State Consumer Disputes Redressal Commission
Mohinder Singh vs National Insurance Company Limited on 3 January, 2014
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UNION TERRITORY, CHANDIGARH First Appeal No. 487 of 2013 Date of Institution 08.11.2013 Date of Decision 03.01.2014 Sh. Mohinder Singh son of Late Sh. Bhutu Ram R/o H.No.1150, Sector 40-B, Chandigarh. Appellant/Complainant. Versus National Insurance Company Limited through its Senior Branch Manager, SCO-305-306, Sector 35-B, Chandigarh. ..Respondent/Opposite Party. BEFORE: JUSTICE SHAM SUNDER (RETD.), PRESIDENT SH.DEV RAJ, MEMBER
Argued by:Sh. Rohit Goswami, Advocate for the appellant.
Sh. Sandeep Suri, Advocate for the respondent.
PER DEV RAJ, MEMBER This appeal is directed against the order dated 08.10.2013, rendered by the District Consumer Disputes Redressal Forum-I, UT, Chandigarh (hereinafter to be called as the District Forum only) vide which it dismissed the complaint filed by the complainant (now appellant).
2. In brief, the facts of the case, are that the complainant got a National Swasthya Bima Policy No.420101/48/9/8500000111 (Annexure C-1), from the Opposite Party, which was valid for the period from 16.7.2009 to 15.7.2010, and the sum insured, under this Policy, was Rs.2 Lacs. The terms and conditions as also the exclusions were not supplied to the complainant. It was further stated that during the currency of said Policy, the wife of the complainant suffered acute pain in ovarian cyst near uterus, for which she was rushed to PGIMER, Chandigarh on 09.07.2010, where she was admitted and after surgery, she was discharged on 10.7.2010 (Annexure C-2). It was further stated that the complainant intimated this fact to the Opposite Party, through letter dated 14.3.2011 and submitted the necessary documents i.e. claim form, medical bills of Rs.13,544/- alongwith the prescription slips etc. to the Opposite Party (Annexure C-3 Colly). It was further stated that the complainant was intimated by the T.PA. vide letter (Annexure C-4) about rejection of his claim, on the ground, that he submitted incomplete documents with the claim form and also directed him to submit the necessary documents within 7 days. It was further stated that on 04.8.2011, the complainant again sent the necessary documents alongwith the claim and medical bills through speed post vide letter (Annexure C-5). It was further stated that the complainant also sent previous insurance certificates (Annexure C-7) issued by the Opposite Party and also explained that there was no gap between the said Policies. It was further stated that on 28.9.2011, the Opposite Party again issued letter (Annexure C-6), wherein it informed that the documents provided by the complainant were still incomplete and there was a gap in the Policy for the period i.e. 28.6.2009 to 15.7.2009. It was further stated that when after so many requests and representations, the Opposite Party failed to settle the claim, the complainant sent a legal notice dated 25.1.2013 (Annexure C-8) to the Opposite Party, which was replied to by it, vide letter dated 8.2.2013 (Annexure C-10). It was further stated that on 22.2.2013, the Opposite Party again sent a reply (Annexure C-11) to the legal notice, wherein it was mentioned that due to non-submission of the documents within the stipulated time, the TPA had closed the claim file of the complainant on 5.7.2012. It was further stated that on 26.3.2013, the complainant made a representation (Annexure C-12), wherein it was mentioned that there was a typographical error while mentioning the Policy number and again requested the Opposite Party to settle the claim but to no avail. It was further stated that the aforesaid acts of the Opposite Party, amounted to deficiency, in rendering service and indulgence into unfair trade practice. When the grievance of the complainant was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed seeking directions to the Opposite Party to pay Rs.13,554/- (in fact Rs.13,544/-) alongwith interest @12% per annum; Rs.40,000/- as compensation for mental agony and physical harassment besides Rs.11,000/- as cost of litigation.
3. Opposite Party, in its written version, admitted the issuance of Insurance Policy, in question, subject to the terms, conditions, exclusions and limitations of the same. It was stated that the complainant lodged the claim pertaining to the reimbursement of expenses on the alleged hospitalization of the wife under the Insurance Policy, in question. It was further stated that the said claim was processed by the TPA i.e. Alankit Health Care TPA Ltd. of the Opposite Party and the said TPA sent letter dated 27.7.2011 to the complainant informing that the claim could not be processed/settled without compliance of the requirements as mentioned in the said letter (Annexure R-2). It was further stated that the TPA also sent another letter dated 15.9.2011 (Annexure R-3) to the complainant informing him to supply the requisite documents and information, to enable them to process the claim further. It was further stated that the TPA sent a final reminder vide letter dated 28.9.2011 (Annexure R-4) to the complainant informing him to supply the requisite documents, within 7 days of receipt of the said letter. It was further stated that considering the reply dated 4.8.2011 of the complainant, received on 6.8.2011, which was incomplete and as the claim fell under Clause 5.3 of the Policy, as the complainant failed to submit the claim documents within 30 days, from the date of discharge from the hospital and also fell under Section 11 of the Mediclaim Policy, as the claimant failed to give intimation within 7 days from the date of admission and moreover, when there was a gap in the renewal of the policy from 28.6.2009 to 15.7.2009, , the claim was closed as No Claim vide letter dated 01.10.2011 (Annexure R-5). It was further stated that neither there was any deficiency, in rendering service, on the part of the Opposite Party nor did it indulge into unfair trade practice. The remaining averments, were denied, being wrong.
4. The Parties led evidence, in support of their case.
5. After hearing the Counsel for the parties, and, on going through the evidence and record of the case, the District Forum, dismissed the complaint as stated above, in the opening para of the instant order.
6. Feeling aggrieved, the instant appeal, has been filed by the appellant/complainant.
7. We have heard the Counsel for the parties and have gone through the evidence and record of the case, carefully.
8. The Counsel for the appellant/complainant submitted that the Insurance Policy was valid from 16.7.2009 to 15.7.2010. It was further submitted that the wife of the appellant/complainant was admitted to PGIMER on 9.7.2010, underwent surgery and was discharged on 10.7.2010. The treatment taken was during the currency of the Insurance Policy. It was further submitted that the appellant/complainant had submitted complete claim documents to the respondent/Opposite Party. TPA of the respondent/Opposite Party was also intimated regarding the treatment. It was further submitted that at the time of taking the said Policy, the complainant was never informed regarding any terms and conditions or exclusion clause that the intimation regarding any claim was to be given within a specific period. It was further submitted that it was specifically averred in Para 2 of the complaint that the said Policy was not accompanied with any terms and conditions. It was further submitted that the appellant/complainant submitted necessary documents i.e. claim form, medical bills of Rs.13,544/- alongwith prescription slips to the respondent/Opposite Party (Annexure C-3 Colly.).
9. The Counsel for the respondent/Opposite Party submitted that the appellant/complainant never asked for the terms and conditions of the Insurance Policy. It was further submitted that even in the legal notice, the appellant/complainant did not mention that the terms and conditions of the Insurance Policy were not received by him. It was further submitted that the claim of the appellant/complainant fell under Clause 5.3 of the Insurance Policy as the appellant/complainant failed to submit the claim documents within 30 days from the date of discharge and there was delay of 65 days. It was further submitted that the appellant/complainant also failed to give intimation within 7 days from the date of admission.
10. Issuance of BOI National Swasthya Bima Policy No.420101/48/9/8500000111 (Annexure C-1), valid for the period from 16.7.2009 to 15.7.2010 for Rs.2 Lacs, to the appellant/complainant is an admitted fact. The appellant/complainant submitted necessary documents, claim form and medical bills vide letter dated 14.3.2011 (Annexure C-3) through speed Post. The submission of appellant/complainant, in Para 3 of the complaint, is with regard to medical claim on account of treatment of his wife in PGI from 9.7.2010 to 10.07.2010. Out of total amount of Rs.13,544/-, the following bills included in the claim do not pertain to the aforesaid period:-
Sr. No. Bill/Receipt No. Date Amount (Rs.) Page No. of District Forum file.1
48489 9.6.2010 805-00 22 2 10337 5.9.2010 370-00 22 3 2567
11.6.2010 120-00 29 4 49981 1.8.2010 380-00 24 5 180525124 7.7.2010 150-00 36 6 180525126 7.7.2010 100-00 30 7 180525125 7.7.2010 15-00 30 Total 1940-00
11. It is also evident from the record that vide letter dated 27.07.2011 (Annexure R-2), Alankit Health Care TPA Ltd., in reference to the claim papers received by it on 04.04.2011, asked the appellant/complainant to submit the required documents viz. original discharge summary and all previous policies copies, which he (complainant) submitted vide letter dated 0.4.08.2011 (Annexure C-5). The claim of the appellant/complainant was closed as NO CLAIM by the said TPA vide letter dated 01.10.2011 (Annexure R-5) on the ground that the required documents were not submitted within 30 days.
12. Clause 5.3 of the Insurance Policy (Annexure R-1), being relevant is extracted below:-
5.3 All supporting documents relating to the claim must be filed with TPA within 30 (thirty) days from the date of discharge from the hospital. In case of Post-hospitalization, treatment (Limited to 60 days). All claim documents should be submitted within 30 (thirty) days after completion of such treatment.
Note:Waiver of this Condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the physical circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time-limit.
13. The appellant/complainant has specifically stated in Para 2 of the complaint that the Insurance Policy was not accompanied with any terms and conditions. Perusal of the Insurance Policy (Annexure C-1), attached by the appellant/complainant, and, Annexure R-1, attached by the Opposite Party, reveals that the Insurance Policy Document contained two pages only as is mentioned on the top of Annexures C-1 and R-1. No doubt, the Opposite Party, with Annexure R-1, has attached the terms and conditions, running into 05 pages, which allegedly form part of the Policy. It, however, did not adduce any evidence that the same were sent to the appellant/complainant and, if so, through which mode.
14. In M/s Modern Insulators Ltd. Vs Oriental Insurance Co. Ltd., I (2000) CPJ 1 (SC), the principle of law, laid down, was to the effect, that it is the fundamental principle of Insurance law, that utmost good faith, must be observed by the contracting parties, and good faith forbids either party, from non-disclosure of the facts, which the parties knew. The insured has a duty to disclose all the facts, and similarly it was the duty of the Insurance Company, and its agents, to disclose all the material facts, in their knowledge, as obligation of good faith applies to both equally. It was, thus, the duty of the Insurance Company to disclose all the facts and circumstances, relating to the insurance cover, to the complainant. It was also required of it, to apprise the complainant of the benefits of insurance, exclusion clauses, contained therein, and the warranties referred to, in the same. It was, under these circumstances, the utmost duty of the insurer to supply the Insurance Policy and the terms and conditions thereof, to the insured, so as to enable him (complainant) to go through the same and understand the clauses contained therein. Not only this, it was also the duty of the Insurance Agent or Insurance Advisor to explain the terms and conditions of the Insurance Policy, including the exclusion clauses, contained therein. However, in the instant case, respondent/Opposite Party, as stated above, failed to prove that the terms and conditions of the Insurance Policy were supplied to the appellant/complainant. In United India Insurance Co. Ltd. & Anr. Vs S.M.S. Tele Communications & Anr., III (2009) CPJ 246 (NC), it was observed that being aware of the existence of the policy, is one thing, and being aware of the contents and meaning of the clauses of the policy, is another. The principle of law, laid down, in the aforesaid cases, is fully applicable to the facts of the instant case. Since the terms and conditions of the Insurance Policy were not supplied to the complainant, it was neither aware of the exclusions, nor was bound by the same.
15. Thus, closure of the claim, when there is no evidence that the terms and conditions of the Insurance Policy (Annexure C-1) were supplied to the appellant/complainant, was illegal and the same, amounted to deficiency, in rendering service and indulgence into unfair trade practice on the part of respondent/Opposite Party. In this view of the matter, respondent/Opposite Party, is liable to pay Rs.11,604/- (i.e. Rs.13,544/- minus Rs.1,940/-) to the appellant/complainant, spent by him, on the treatment and medicines during treatment of his wife in PGI, Chandigarh on 9.7.2010 and 10.07.2010.
16. No other point, was urged, by the Counsel for the parties.
17. For the reasons recorded above, the appeal filed by the appellant/complainant is accepted with costs. The order of the District Forum is set aside. The complaint is partly accepted and the respondent/Opposite Party is directed in the following manner:-
(i) to pay Rs.11,604/- to the appellant/complainant, which he had spent on the treatment/medication of his wife in the P.G.I on 9th & 10th July, 2010, alongwith interest @9% per annum from the date of filing the complaint;
(ii) to pay cost of litigation, to the tune of Rs.5,000/- to the appellant/ complainant;
18. This order shall be complied with, by respondent/Opposite Party, within a period of 30 days, from the date of receipt of its certified copy, failing which, it shall be liable to pay the amount, mentioned in Clause (i) of Para No.17 alongwith interest @12% p.a. from the date of default, till the date of actual payment to the appellant/complainant, besides paying the litigation costs, as aforesaid.
19. Certified copies of this order, be sent to the parties, free of charge.
20. The file be consigned to Record Room, after completion.
Pronounced.
January 3, 2014.
Sd/-
[JUSTICE SHAM SUNDER (RETD.)] PRESIDENT Sd/-
[DEV RAJ] MEMBER Ad/-
STATE COMMISSION (First Appeal No.487 of 2013) Argued by:Sh. Rohit Goswami, Advocate for the appellant.
Sh. Sandeep Suri, Advocate for the respondent.
Dated the 3rd day of January, 2014.
ORDER Vide our detailed order of the even date, recorded separately, the appeal has been accepted, with costs. The order impugned, passed by the District Forum, has been set aside. Consequently, the complaint has been partly accepted (DEV RAJ) MEMBER (JUSTICE SHAM SUNDER (RETD.)) PRESIDENT Ad