State Consumer Disputes Redressal Commission
The Oriental Insurance Co.Ltd. vs Naveen Kumar Sahu & Ors. on 6 February, 2018
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION,
PANDRI, RAIPUR (C.G).
Appeal No.FA/2017/584
Instituted on : 11.08.2017
The Branch Manager,
The Oriental Insurance Company Limited,
Divisional Office, First Floor, Shivnath Complex,
G.E. Road, Supela,
Bhilai, Tahsil and District Durg (C.G.) .... Appellant (O.P. No.1)
Vs.
01. Naveen Kumar Sahu,
S/o Late Ganpath Ram Sahu,
R/o : 68/7/C, Nehru Nagar (West),
Bhilai ..... Respondent No.1 (Complainant)
2. Manager,
Raksha T.P.A. 15/5,
Mathura Road,
Faridabad ...... Respondent No.2 (O.P. No.2)
3. Insurance Agent,
Nadeem Mohammad,
Maitri Vihar Colony,
Near Dawo Wadha Talab,
Supela, Bhilai (C.G.) .... Respondent No.3 (O.P. No.3)
PRESENT :
HON'BLE SHRI JUSTICE R.S. SHARMA, PRESIDENT
HON'BLE SHRI D.K. PODDAR, MEMBER
HON'BLE SHRI NARENDRA GUPTA, MEMBER
COUNSEL FOR THE PARTIES :
Miss B.S. Kanthi, Advocate for the appellant (O.P. No.1.
Respondent No.1 (complainant) present in person.
None for the respondent No.2 (O.P. No.2).
None for the respondent No.3 (O.P. No.3).
ORDER
DATED : 06 /February/2018 PER :- HON'BLE SHRI JUSTICE R.S. SHARMA, PRESIDENT.
This appeal is directed against the order dated 06.06.2017, passed by District Consumer Disputes Redressal Forum, Durg (C.G.) (henceforth "District Forum") in Complaint Case No. C.C./2017/16. By the impugned order, learned District Forum, has allowed the complaint of the complainant and directed that :-
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(a) The O.P. No.1 will pay remaining a sum of Rs.47,858/- (Rupees Forty Seven Thousand Eight Hundred Fifty Eight) to the complainant within a period of one month to the complainant.
(b) The O.P. No.1 will pay a sum of Rs.20,000/- (Rupees Twenty Thousand) towards compensation for mental agony to the complainant.
(c) The O.P. No.1 will pay a sum of Rs.10,000/- (Rupees Ten Thousand) towards cost of litigation to the complainant.
2. Briefly stated the facts of the complaint of the complainant are that the complainant is policyholder of the mediclaim insurance policy since several years through O.P. No.2 and was regularly every year renewing the mediclaim policy for himself and his family from the O.P. No.1. On 08.12.2015, the O.P. No.2 told the complainant that there is mediclaim insurance policy for minimum Rs.1,00,000/- per person and less than Rs.1,00,000/- mediclaim policy would not be done and complainant fell ill, then the expenses incurred in treatment would be paid by the O.P. No.1 & O.P. No.2, for which the complainant has to pay more premium amount that previously paid. The complainant believed on the version of the O.P. No.2 and paid a premium for Rs.1,00,000/- as per the guidelines of the Insurance Company and obtained insurance policy No.192100/48/2016/2022 for the period from 09.12.2015 to 08.12.2016. The complainant had to go to Ganga Ram Hospital, New Delhi for treatment of Piles disease. Before going to New Delhi for treatment, the complainant send intimation to the O.P. No.1 and O.P. No.2 Raksha T.P.A. that the expenditure incurred during the treatment in the hospital would be paid by the Insurance Company, but prior to undergoing operation, the complainant contacted the O.P. No.1 & O.P. No.2 several time, but even then, they did not make payment // 3 // of the expenses and also did not give reply. The complainant himself paid the entire expenses of the hospital in cash and came back, whereas the above policy is Insurance (Cashless) Policy, but even then the O.P. No.1 did not pay the amount and the O.P. No.2 agent, appointed by the O.P. No.1 had not paid the mediclaim amount to the Hospital. After coming back after taking treatment, the O.P. No.2 obtained entire original documents from the complainant in its office situated at Risali Azad Market by saying that within 7 to 15 days, the mediclaim amount would be deposited in complainant's account. The complainant believed on the version of the O.P. No.2 and waited for 15 days and contacted several time and after near about 45 to 50 days, a sum of Rs.50,000/- was deposited in the account of complainant through RTGS, whereas in the treatment a sum of Rs.97,857.64 was incurred. When the complainant sought information in this regard then it was informed that only 50% amount would be paid, whereas the premium amount was taken for Rs.1,00,000/-. Thus, the O.P. No.1 and O.P. No.2 have committed deficiency in service. Hence the complainant filed the instant complaint and prayed for granting reliefs as mentioned in the relief clause of the complaint.
3. The O.P. No.1 filed its written statement and averred that since many years, the complainant is not a mediclaim policy holder. But the actual fact is that the complainant had purchased Individual Mediclaim Policy in the year 2013 vide policy No.192100/48/2014 commencing from 09.12.2013 to 08.12.2014. The O.P. No.1 would not pay the medical expenses if the sum assured is increased in comparison to the previous policy. It appears from the documents filed by the complainant is that the complainant had been suffering with piles (fistula) since several years and the complainant had obtained estimate from doctors for // 4 // undergoing operation for fistula. While renewing the policy No.192100/48/2015/1743 valid from 09.12.2014 to 08.12.2015 the complainant had enhanced the sum assured from Rs.50,000/- to Rs.1,00,000/- as he was aware about the expenses which would be incurred if he undergoes operation for fistula. The O.P. No.1 had issued renewal Policy 192100/48/2016/2022 valid from 09.12.2015 to 08.12.2016. In the said policy, sum insured is Rs.1,00,000/-. Basing on the medical prescription of AIMMS Hospital, Raipur, the complainant was treated on 22.01.2016 for Fistula. On 20.06.2016, the complainant had approached Dr. B.C. Jain and undergone treatment for fistula. Then finally the petitioner had undergone operation for fistula at Ganga Ram Hospital at New Delhi. The claim is settled by Third Party Administrator in every Mediclaim Policy issued by the O.P. No.1 subject to terms and conditions mentioned in the policy conditions attached to the Mediclaim Policy. The treatment expenses for fistula is payable after 2 years of completion of policy without any break in the policy. As the sum assured is Rs.50,000/- in the two previous policies vide Policy No.192100/48/2015/1743, the complainant would be entitled upto Rs.50,000/- only. The complainant had not approached the O.P. No.1 several times requesting to settle his claim. The complainant's claim was settled basing on the sum insured as mentioned in the Policy No.192100/48/2015/1743. The Third Party Administrator (O.P. No.2) had paid an amount of Rs.50,000/- directly to the treating hospital. After due official process of procuring the entire medical record and bills from the concern treating hospital claim was settled. The complainant had enhanced sum insured from Rs.50,000/- to Rs.1,00,000/- during the policy period commencing from 09.12.2015 to 08.12.2015 vide policy No.192100/48/2016/2022. As the disease for which complainant had undergone treatment is covered after two years of continuity of // 5 // policy, the claim was payable basing on the sum insured in the two previous policies. The sum insured was Rs.50,000/- in policy No.192100/48/2014/1686 and Policy No.192100/48/2015/1743 as such the complainant was entitled upto Rs.50,000/- the TPA had paid the entire amount of Rs.50,000/- which is equal to the total sum insured as per Policy No.192100/48/2014/1686 and Policy No.192100/8/2015/1743. Therefore, the term deficiency in service will not attract against the O.P. No.1 because the claim was settled without any delay. There is no cause of action raised against the O.P. No.1 in filing the complaint. The complainant was admitted in Ganga Ram Hospital on 24.08.2016 and discharged on 25.08.2016. After procuring all the original documents from the concern hospital and from the complainant, claim was paid on 18.10.2016. As such there is no cause of action raised in filing this complaint, therefore, the complaint is liable to be dismissed with cost payable to the O.P. No.1. Unless the original documents relating to prescriptions and treatment are submitted to the TPA or the Insurance Company, the claim settlement process cannot be proceeded with. Therefore, the TPA and Insurance Company had taken immediate steps for settling the claim of petitioner and during the process of settlement of claim it was observed that the complainant had undergone treatment for fistula during the policy period 09.12.2015 to 08.12.2016 vide policy No.192100/48/2016/2022. The complainant had enhanced sum insured from Rs.50,000/- to Rs.1,00,000/- in the policy in which the claim was raised. As the enhanced sum assured is not payable for any treatment undergone during the running policy, the claim was settled basing on the sum insured in the two previous policies. Therefore, the complainant is not entitled for any relief as claimed for. As such the complaint is liable to be dismissed in toto. M/s Meditex Insurance TPS Limited is the TPA authority and the TPA authority // 6 // directly pays the claims to the treating hospital subject to terms and conditions of policy. The O.P. No.1 is a public related company and is always at the services of the public. Every customer / policy holder is explained about the advantages and disadvantage of policy and terms and conditions of each and every policy are explained in detail prior to issuing of policy. Every insured person is provided policy schedule attached with policy conditions and it is also explained to the insured that in case of any further queries, he can go through the website. The O.P. No.1 had explained to the complainant while issuing the policy No.192100/48/2016 that if sum insured is enhanced under the current policy, for a further claim for the same disease during the current policy, the earlier limit of sum insured shall be applicable and not the enhanced sum insured. The O.P. No.1 had not acted in adverse to terms and conditions of policy. The actual facts of the case are suppressed by the complainant and complaint is filed before the District Forum with all false and frivolous allegations, which deserves to be dismissed. As the claim is settled, there is no question of deficiency in services, therefore, the complaint is liable to be dismissed. The complainant had unnecessarily dragged the O.P. No.1 into the litigation without any cause of action for which the O.P. No.1 had to spend huge amounts for defending the case. Therefore, it is prayed that the District Forum may be pleased to award cost of Rs.50,000/- payable to the O.P. No.1. The complaint is liable to be dismissed.
4. Though, the O.P. No.2 appeared before the District Forum, but did not file written statement.
5. The O.P. No.3 did not appear before the District Forum inspite of service of notice and also did not file written statement.
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6. The complainant has filed documents. Annexure A-1 is letter dated 12.09.2016 sent by the complainant to M/s Raksha T.P.A. Raipur, Annexure A-2 is letter dated 28.09.2016 sent by the complainant to M/s Raksha TPA Pvt. Ltd., Raipur (C.G.), Annexure A-2 is Mediclaim Insurance Policy (Individual) Policy Schedule of Policy No.192100/48/2016/2022 for the period from 09.12.2015 to 08.12.2016, Annexure A-4 is letter dated 08.08.2016 sent by the complainant to the Manager, The Oriental Insurance Co. Ltd., Mediclaim Branch, Bhilai, District Durg (C.G.), Annexure A-5 is Request for Cashless Hospitalisation for Medical Insurance Policy, Annexure A-6 are Bill Cum Receipt, Bills etc. issued by Sir Ganga Ram Hospital, Annexure A-7 is Mediclaim Insurance Policy (Individual) Policy Schedule in respect of Policy No.192100/48/2016/2022 for the period from 09.12.2015 to 08.12.2016.
7. The O.P. No.1 has filed documents. Annexure NA-1 is Claim Settlement Voucher, Annexure NA-1 (2) is Claim Status Details, NA-1(3) is Policy Condition relating to Individual Mediclaim Policy, Annexure NA-1 (4)(a)(b) are Xerox Copy of Policy Schedule from 09.12.2013 to 08.12.2014, Annexure NA-1(5)(a) (b) are Xerox copy of Policy Schedule from 09.12.2014 to 08.12.2015.
8. The O.P. No.2 & O.P. No.3 have not filed any documents.
9. Learned District Forum, after having considered the material placed before it by the parties, has allowed the complaint and directed the O.P. No.1 to pay amounts to the complainant, as mentioned in para 1 of this order.
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10. Miss. B.S. Kanthi, learned counsel appearing for the appellant (O.P. No.1) has argued that the respondent No.1 (complainant) was not obtaining Mediclaim Policy since many year, actually the complainant had purchased Individual Mediclaim Policy, for the first time in the year 2013 having policy No.192100/48/2014/1686 for the period from 09.12.2013 to 08.12.2014. The sum insured is Rs.50,000/-, but the complainant enhanced the sum insured from Rs.50,000/- to Rs.1,00,000/-. The complainant was aware that he was suffering from Fistula before obtaining first policy and it was also renewed by the O.P. for the period from 09.12.2013 to 08.12.2014. The complainant has filed prescription AIMMS Hospital, Raipur dated 22.01.2016 for fistula. Thereafter the complainant approached Dr. B.C. Jain and had taken treatment for fistula and finally the complainant had undergone operation for Fistula at Sir Ganga Ram Hospital, New Delhi. The expenses for treatment for Fistula is payable after two years of completion of policy without any break in the policy. As the sum insured is Rs.50,000/- in the two previous policies vide policy No.192100/48/2014/1684 and policy No.192100/48/2015/1743, the complainant would be entitled upto Rs.50,000/- only. A sum of Rs.50,000/- was paid to the complainant and the complainant is not entitled for the remaining amount because the expenses for treatment for fistula is payable after two years of completion of policy without any break in the policy. The O.P. No.1 did not commit any deficiency in service. The impugned order passed by the District Forum, is erroneous and is liable to be set aside. The appeal filed by the appellant (O.P. No.1) may be allowed.
11. The respondent No.1 (complainant), who is present in person has argued the complainant is policyholder of the mediclaim insurance policy since several years // 9 // through O.P. No.2 and it was renewed every year. Previously the sum insured is Rs.50,000/- thereafter it was enhanced to Rs.1,00,000/-. The insurance policy was valid for the period from 09.12.2015 to 08.12.2016. The complainant had undergone treatment for piles and his operation for Fistula was conducted in Sir Ganga Ram Hospital, New Delhi. The above policy is Cashless Policy, but even then the appellant (O.P. No.1) did not pay the amount to the complainant. After coming back from taking treatment, the O.P. No.2 obtained entire original documents from the complainant in its office situated at Risali Azad Market by saying that within 7 to 15 days, the mediclaim amount would be deposited in complainant's account. The complainant believed on the version of O.P. No.2, but only a sum of Rs.50,000/- was deposited in the account of the complainant through RTGS whereas in the treatment a sum of Rs.97,857.64 was incurred. Therefore, learned District Forum has rightly awarded remaining amount of Rs.47,858/-, Rs.20,000/- towards compensation for mental agony and Rs.10,000/- towards cost of litigation to the complainant. The impugned order passed by the District Forum, is just and proper and does not suffer from any infirmity, irregularity or illegality, hence does not call for any interference by this Commission. The appeal filed by the appellant (O.P.No.1) may be dismissed.
12. None appeared for the respondent No.2 (O.P. No.2) and respondent No.3 (O.P. No.3) on 29.01.2018 when the case was fixed for final hearing.
13. We have heard learned counsels appearing for the parties and have also perused the record of the District Forum as well as the impugned order.
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14. It is admitted fact that the respondent No.1 (complainant) initially purchased Mediclaim Policy from the appellant (O.P. No.1) for sum insured Rs.50,000/-. According to the complainant since several years he had taken mediclaim policy and enhanced the sum insured on 08.12.2015 from Rs.50,000/- to Rs.1,00,000/. According to the O.P. No.1, the complainant purchased the Mediclaim Policy for the first time in the year 2013 vide policy No.192100/48/2014/1684, which was effective for the period from 09.12.2013 to 08.12.2014 and thereafter it was renewed for the period from 09.12.2015 to 08.12.2016 and the sum insured was enhanced from Rs.50,000/- to Rs.1,00,000/-.
15. The appellant (O.P. No.1) has filed copy of terms and conditions of Mediclaim Insurance Policy (Individual), in which at internal page No.11, it is mentioned thus :-
"4.3 The expenses on treatment of following ailments / diseases / surgeries, if contracted and / or manifested after inception of first policy (subject to continuity being maintained), are not payable during the waiting period specified below :-
..........................
Note : If the continuity of the renewal is not maintained then subsequent cover will be treated as fresh policy and clauses 4.1, 4.2, 4.3 shall apply afresh, unless agreed by the Company and suitable endorsement passed on this policy, by the duly authorised official of the Company. Similarly, if the sum insured is enhanced subsequent to the inception of the first policy, the exclusion 4.1, 4.2 and 4.3 will apply afresh for the enhanced portion of the sum insured."
16. According to the terms and conditions of the policy, if the continuity of the renewal is not maintained then subsequent cover will be treated as fresh policy, but in the instant case, in para 4 of its written statement, the O.P. No.1 pleaded that the O.P. No.1 had issued renewal policy No.192100/48/2016/2022 valid from // 11 // 09.12.2015 to 08.12.2016. According to the O.P. No.1, the first Mediclaim policy was issued in the year 2013 and thereafter the policy was issued for the period from 09.12.2014 to 08.12.2015 and 09.12.2015 to 08.12.2016. It shows that the complainant had taken the Mediclaim Policy from the O.P. No.1 prior to undergoing operation of Fistula and the same was renewed by the O.P. No.1 in the year 2014 and 2015. It means the policy was continued policy, therefore, the contention of the O.P. No.1 that initially the sum insured was Rs.50,000/- and when the sum insured was enhanced, the policy had not completed period of two years, therefore, the complainant is only entitled for Rs.50,000/- is not acceptable.
17. According to the O.P. No.1, the complainant suffered disease of Fistula prior to obtaining Mediclaim Insurance Policy, but the O.P. No.1 has not filed any document to prove that the complainant had suffered Fistula disease prior to 2013 or 2014. Document Annexure A-6 is Bill Cum Receipt dated 24.08.2015 issued by Sir Ganga Ram Hospital, New Delhi. It shows that the operation of the complainant was conducted in Sir Ganga Ram Hospital, New Delhi in the month of August, 2016. The complainant pleaded that for the first time he went to Sir Ganga Ram Hospital, New Delhi for treatment of Piles. The O.P. No.1 pleaded that the complainant suffered from fistula and he went to AIMMS Hospital, Raipur for treatment and was treated on 22.01.2016 for fistula. On 20.06.2016, the complainant approached Dr. B.C. Jain and undergone treatment for fistula. Then finally the complainant had undergone operation for fistula at Ganga Ram Hospital at New Delhi. It has further been pleaded by the O.P. No.1 that the treatment expenses for fistula is payable after 2 years of completion of policy without any break in the policy.
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18. The O.P. No.1 has filed copy of Individual Mediclaim Policy Schedule for Policy No.192100/48/2014/1686 which was effective for the period from 09.12.2013 to 08.12.2014 [Annexure NA-4(a)] In the above document it is mentioned thus :-
"Warranted that in case the person covered under the policy has lodged any claim under the previous policy and the sum insured is enhanced under the current policy, for a further claim for the same disease during the current policy, the earlier limit of Sum Insured shall be applicable and not the enhanced sum insured.
Warranted that in case of dishonor of premium cheque (s) the Company shall not be liable under the policy and the policy shall be void abinitio (from inception)
19. The O.P. No.1 has filed copy of Individual Mediclaim Policy Schedule for Policy No.192100/48/2015/173 which was effective for the period from 09.12.2014 to 08.12.2015 [Annexure NA-5(a)] . The same conditions are mentioned in the above policy.
20. Looking to the above policies, it is proved that the complainant without any break, continuously taken Mediclaim Policy. The O.P. No.1 has not filed any document to prove that the complainant had enhanced the sum insured only for obtaining cover amount from the O.P. No.1.
21. The Mediclaim Policy was continuously renewed by the O.P. No.1, the sum insured under it was ultimately enhanced upto to Rs.1,00,000/- and the complainant had incurred a sum of Rs.97,857.64 in his treatment, therefore, the complainant is entitled for the above amount, which was incurred in the treatment. Therefore, learned District Forum, has rightly directed the O.P. No.1 to pay the remaining amount of Rs.47,858/- to the complainant.
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22. The learned District Forum, has awarded a sum of Rs.20,000/- (Rupees Twenty Thousand) towards compensation for mental agony to the complainant, which is just and proper looking to the facts and circumstances of the case. So far award of cost of litigation Rs.10,000/- is concerned, it is on higher side. Looking to the facts and circumstances of the case, it is just and proper to award a sum of Rs.3,000/- (Rupees Three Thousand) as cost of litigation instead of Rs.10,000/- to the complainant.
23. Therefore, the appeal filed by the appellant (O.P. No.1) is partly allowed. It is held that :-
(i) The Sub-para (a) & (b) of Para 22 of the impugned order are confirmed.
(ii) So far as Sub Para (c) of Para 22 is concerned which is regarding cost of litigation, it is modified and it is directed that the appellant (O.P. No.1) will pay a sum of Rs.3,000/- (Three Thousand) to the respondent No.1 (complainant), instead of Rs.10,000/-.
(iii) No order as to the cost of this appeal.
(Justice R.S. Sharma) (D.K. Poddar) (Narendra Gupta)
President Member Member
06/02/2018 06 /02/2018 06/02/2018