State Consumer Disputes Redressal Commission
New India Assurance Co. Ltd. vs Dr. Renu Bidani & Others on 24 November, 2015
Daily Order FIRST ADDITIONAL BENCH STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB SECTOR 37-A, DAKSHIN MARG, CHANDIGARH. First Appeal No.783 of 2013 Date of Institution: 19.07.2013 Date of Decision: 24.11.2015 New India Assurance Company Ltd., Divisional Office, Ferozepur City, Ferozepur, through its Divisional Manager. Now represented through the authorized signatory of Chandigarh Regional Office, SCO No.36-37, Sector 17-A, Chandigarh. ...Appellant/Opposite Party no.1 Versus 1. Dr. Renu Bidani, w/o Sh.Kanwal Dhuria, R/o Parnami Mandir Street, Fazilka, Tehsil & District Fazilka ...Respondent no.1 /Complainant 2. Vipul Med Corp TPA Pvt. Ltd., 515, Udyog Vihar, Phase 5, Gurgaon (Haryana) through its Managing Director. ..Respondent no.2/Opposite party no.2 First Appeal against order dated 25.03.2013 passed by the District Consumer Disputes Redressal Forum, Ferozepur Quorum:- Shri J. S. Klar, Presiding Judicial Member.
Shri. H.S. Guram, Member Present:-
For the appellant : Sh. Nitin Gupta, Advocate For the respondent no.1 : Sh.Yogesh Kumar Aneja, Advocate For the respondent no.2 : Ex-parte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J.S KLAR, PRESIDING JUDICIAL MEMBER :-
The appellant of this appeal (the opposite partyno.1 in the complaint) has directed this appeal against the respondent no.1 of this appeal (the complainant in the complaint) and respondent no.2 of this appeal (the opposite party no.2 in the compalaint), challenging order dated 25.03.2013 of District Consumer Disputes Redressal Forum Ferozepur, accepting the complaint of the complainant by directing the OPs to pay a sum of Rs.60,855/- along with interest @ 9% per annum from the date of filing the complaint till its realization, besides Rs.2,000/- as compensation and Rs.2,000/- as litigation expenses. The instant appeal has been preferred against the same by the OP no.2 now appellant.
2. The complainant Dr. Renu Bidani has filed the complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OPs, on the averments that on 10.03.2009, she took a "Hospitalization Benefit Mediclaim Policy" bearing no.36070234071100000178 for herself as well for her family members against premium of Rs.7500/- from OP No.1. Term of the said policy was from 12.03.09 to 12.03.10. Cover note-cum-duplicate schedule no.148677 was issued to her exclusively. On 19.05.09, due to colicky pain/crohn's disease, she was admitted at Dayanand Medical College & Hospital Ludhiana for her treatment till 21.05.09. She was later on admitted at Sir Ganga Ram Hospital New Delhi from 03.09.09 to 4.09.09 with regard to her above disorder. Many tests were conducted upon her and in this way, she spent Rs.60855/- on her treatment. She submitted insurance claim to OPs for reimbursement of the expenses incurred by her on her treatment. The OPs perplexed her by sending repudiation letter dated 13.07.10 printed on 21.07.10, which was received by her on 19.11.2011 with regard to repudiation of her claim. It has been mentioned in the repudiation letter that clause no.3 and 4 of the insurance policy excluded the claim of the complainant. The OPs repudiated the genuine claim of the complainant wrongly, which is deficiency in service on their part. The complainant has alleged that she has developed cause of action on 19.11.10 and again in the month of May 2011 to file the complaint against OPs. The complainant has, thus, filed the complaint directing the OPs to pay the amount of Rs.60,855/- along with interest @ 2% per month from 4.09.09 till its actual payment, Rs.20,000/- as compensation for mental harassment, besides Rs.11,000/- as cost of litigation.
3. Upon notice, OP no.1 appeared and filed written reply by raising preliminary objections that complainant had undergone endoscopy on day care basis, which cannot be considered as per clause 3.4 of the terms and conditions of the insurance policy, therefore, the OP repudiated the claim of the complainant rightly. The complaint is alleged to be barred by time, because the claim has been repudiated on 21.07.2010 by the OP and the present complaint has filed by the complainant on 16.11.2012, after more than two years period. The complex questions of facts and law are involved in this case, which cannot be adjudicated in summary manner by the Consumer Forum. The locus standi of complainant and cause of action to file the complaint was disputed. The maintainability of the complaint was also questioned by OP No.1 On merits, it was denied that complainant had to admit herself at DMC Ludhiana or at Sir Ganga Ram Hospital, New Delhi during the period, as pleaded by her. It was denied that she spent Rs.60855/- on her treatment. It was asserted by OP No.1 that the insurance claim of the complainant has been rightly repudiated, in view of clause 3.4 of the terms and conditions of the policy. OP No.1 prayed for dismissal of the complaint.
4. OP No.2 was set exparte before District Forum, vide order dated 16.01.2013.
5. The complainant tendered in evidence, her affidavit Ex.C-1 along with copies of documents Ex.C-2 to Ex.43. As against it; OP no.1 tendered in evidence affidavit of Ashwani Kukkar Divisional Manager Divisional Office New India Assurance Company Ex.R-1 along with copies of documents Ex.R-1 to Ex.R-4. On conclusion of evidence and arguments, the District Forum Ferozepur, accepted the complaint of the complainant by directing OPs to pay the amount of Rs.60,855/- along with interest @ 9% per annum from the date of filing the present complaint i.e.16.11.2012 till its realization, besides Rs.2000/- as compensation and Rs.2,000/- as costs of litigation. Dissatisfied with the order of the District Forum Ferozepur dated 25.03.2013, the OP no.1 now appellant has preferred this appeal against the same.
6. We have heard learned counsel for the parties and have also examined the record of the case.
7. The District Forum granted relief to the complainant, on the ground that terms and conditions of the insurance policy were not conveyed to the complainant by the OPs. We have to primarily explore this point with the aid of evidence on the record, as to whether terms and conditions of the insurance policy were supplied to complainant or not. The complainant specifically pleaded in para no.1 of the complaint that exclusively a cover note-cum-duplicate schedule no.148677 was issued to her. The complainant also filed her affidavit Ex.C-1 on the record stating on oath that cover note-cum-schedule no.148677 was issued to her. OP No.1 filed written reply and corresponding to para no.1 of the written reply to the above averments of the complainant which may be examined. OP No.1 has stated in para no.1 of the written statement on merits that it is matter of record. There is no specific denial by OP No.1 to the above plea of the complainant regarding non-supply of the terms and conditions of the policy documents to her. The OP No.1 should have specifically denied this fact in the pleadings. There is no denial in corresponding paragraph of the written reply to para no.1 of the complaint by the complainant to the effect that only cover note and duplicate schedule was supplied to her. OP No.2 has been set exparte before District Forum. Affidavit of Ashwani Kukkar Divisional Manager Ex.R-1 on behalf of OP No.1 is on the record. We have examined this affidavit and evidence on the record. There is no denial of this specific plea of the complainant regarding non-supply of the terms and conditions of the policy. Leaving aside the above pleas, we have to examine evidence on the record, as to whether there is any proof regarding supply of the terms and conditions of the insurance policy by the OPs to the complainant. Ex.C-2 is discharge summary of the complainant by DMC Ludhiana. Ex.C-3 to Ex.C-6 are endoscopy reports. Ex.C-8 is treatment record of the complainant by Sir Ganga Ram Hospital New Delhi. Discharge summary Ex.C-11 is on the record to the effect that she complained of abdomen pain and capsul endoscopy was done to alleviate her affliction. Ex.C-12 is histopathology report. Ex.C-13 is record of DMC Ludhiana. Ex.C-14 to Ex.C-21 are copies of the various bills. There are also reports of various tests Ex.C-22 to Ex.C-27 on the record. Paying clinic report of DMC Hospital, Ludhiana Ex.C-28. Ex.C-29 is findings of the doctors. Ex.C-30 is copy of bill. Ex.C-31 is discharge summary of DMC Hospital Ludhiana. Ex.C-32 is repudiation letter. Ex.C-33 is mediclaim policy. Ex.C-34 is letter addressed to the Branch Manger of OP/Company by complainant. Ex.C-35 is copy of claim form. Ex.C-36 is certificate issued by Dr. Anil Arora. We have also examined the other documents Ex.C-37 to Ex.C-43.
8. To refute this evidence, OP no.1 tendered in evidence affidavit Ashwani Kukkar Divisional Manager Divisional Office Ex.R-1, in which it is nowhere recorded on oath that the terms and conditions of the policy were supplied to the complainant. Ex.R-2 to Ex.R-3 are mediclaim policies. Ex.R-4 is repudiation letter of claim of the complainant on the record. There is nothing on the record that the OPs conveyed the terms and conditions of the policy either through courier or through post to the complainant. Neither there is any such letter or receipt of dispatch or receipt of courier or postal receipt of Postal Authorities to prove this fact. In view of the matter, the District Forum has rightly observed that terms and conditions of the insurance policy were not conveyed to complainant. As such, terms and conditions, were never supplied to the complainant or got signed from her. The terms and conditions of the mediclaim policy produced by OP No.1 as Ex.R-3 are Mediclaim Policy (2007), whereas the mediclaim policy in question was for the period from 12.03.09 to 12.03.2010. Therefore, the OPs were not justified in repudiating the claim of the complainant on the basis of above-referred clause 3.4 of the mediclaim policy in question. The complainant clearly pleaded in her complaint and deposed in her affidavit Ex.C-40 that repudiation letter was received by her only on 19.11.2010 and this fact has been admitted by OP no.1. In this case cause of action for filing the complaint arose to the complainant on 19.11.2010 and as per provisions contained in Act, the complaint is well within limitation, as it was filed on 16.11.2012. '
9. In view of these circumstances, we are of the opinion that the OPs repudiated the claim of the complainant wrongly and illegally and the complainant is entitled to the insurance claim. Accordingly, we do not find any illegality or material infirmity in the order passed by the District Forum Ferozepur.
10. As a result of our above discussion, the appeal of the appellant is dismissed and the order of the District Forum is affirmed.
11. The appellant has deposited an amount of Rs.25,000/- with this Commission at the time of filing the appeal. This amount with interest, if any, accrued thereon, be refunded by the registry to the complainant by way of crossed cheque/demand draft after the expiry of 45 days. Remaining amount as per the order of the District Forum shall be paid by the appellants to the complainant within 45 days from the receipt of copy of this order.
12 Arguments in this appeal were heard on 20.11.2015 and the order was reserved. Copies of the order be communicated to the parties as per rules.
13. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(J. S. KLAR) PRESIDING JUDICIAL MEMBER (H.S.GURAM) MEMBER November 24, 2015 (ravi)