Punjab

Faridkot

CC/17/88

KANWARJIT SINGH - Complainant(s)

Versus

AXIS BANK LTD. - Opp.Party(s)

Gurtaj Sandhu

12 Oct 2017

ORDER

      DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      88

Date of Institution:  20.03.2017

Date of Decision :   12.10.2017

 

1. Kanwarjit Singh aged about 43 years, s/o Mohinder Singh
2. Ramneet Kaur aged about 40 years w/o Kanwarjit Singh s/o Mohinder Singh

Both residents of New Cantt Road, Faridkot.

...Complainants

Versus

1. Axis Bank Ltd, Faridkot through its Branch Manager.
2. Tata AIG General Insurance Company Ltd. 1^st Floor, Dashmesh Complex, SCO 668, Pakhowal Road, Ludhiana through its Manager.
3. Tata AIG General Insurance Company Ltd. Lotus Towers, 1^st Floor, Community Centre, New Friends Colony, New Delhi-110025 through its MD.

.....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Sh P Singla, Member.

 

Present: Sh  Gurtaj Sandhu, Ld Counsel for complainant,

              Sh Neeraj Maheshwary, Ld Counsel for OPs-2 and 3,

              OP-1 Exparte.

ORDER

(Ajit Aggarwal, President)

                                               Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of Rs.39,266/- on account of Mediclaim of complainants and for further directing OPs to pay Rs.50,000/-as compensation for harassment, inconvenience, mental agony besides litigation expenses.

2                                           Briefly stated, the case of the complainant is that on persuasion by OP-1, complainants purchased a Mediclaim insurance policy bearing no.020017493202 valid from 25.05.2016 to 24.05.2017 in the name of complainant no.1 and complainant no.2 and both son and daughter of complainants are also covered under the policy. OPs sent only Mediclaim Policy Schedule and handbook to complainant but did not send any other document pertaining to terms and conditions of the policy. They have been continuously purchasing the said policy since 2013. It is submitted that as per terms and conditions of the policy, if complainants avail any medical treatment, they are entitled to get reimbursement of same upto Rs.2,60,000/-. It is further submitted that during the subsistence of policy in question, wife of complainant i.e complainant no.2 suffered from severe pain in her abdomen and on diagnosis, it was found that she is suffering from Endometrial Polyp and therefore, operation was got conducted upon her. She remained admitted in the hospital from 25.08.2016 to 30.08.2016 and complainants spent Rs.39,226/-for the treatment. After discharge from the hospital, complainants duly informed the OPs regarding this and also submitted their claim for reimbursement alongwith relevant bills and documents to OPs and they also assured that their claim would be processed within 30 days, but they kept lingering on the matter on one pretext and other. Thereafter, they repudiated the claim of complainants on the ground that complainant has not sent requisite documents despite three reminders to them. on receiving the repudiation letter, complainant approached OP-1, and asked about repudiation, but they could not give reply and did not disclose that which documents were not sent by complainants. It is further submitted that complainant completed all the formalities to obtain insurance claim and paid several visits to the office of Ops, but all in vain. Due to non payment of insurance claim by OPs, complainant has been suffering great economic loss and hardships. This act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for accepting the complaint alongwith compensation and litigation expenses. Hence, the present complaint.

3                                                         The counsel for complainant was heard with regard to admission of the complaint and vide order dated 21.03.2017, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                On receipt of the notice, OPs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      filed written statement taking preliminary objections that complaint filed by complainants is false, frivolous and is vexatious. Complaint involves complicated questions of law and facts requiring heavy evidence, which cannot be decided in summary procedure of Consumer Forum. Even complainant has concealed the material facts and documents from Forum as well as from OPs and complainant has not complied with the terms and conditions of the insurance policy in question. It is averred that after treatment, OPs requested complainants to provide original cash paid receipts of final bill and positive investigation on reports supporting the diagnoses, but despite repeated reminders dated 26.10.2016, 5.11.2016 and 15.11.2016, complainants did not supply the requisite documents to OPs and therefore, claim of complainants was repudiated by OPs on 23.12.2016 due to non compliance of documents. Complainants have no cause of action to file the present complaint as they themselves did not supply the requisite information and therefore, Ops were compelled to close the claim of complainant as no claim vide letter dt 23.12.2016 and asserted that there is no deficiency in service on the part of OPs as they have duly processed the claim of complainants, but they did not give required information despite issuance of letter dt 26.10.2016, 5.11.2016 and 15.11.2016 to complainants and therefore, complaint in hand is not maintainable. However, on merits, they have denied all the allegations levelled by complainant being wrong and incorrect and asserted that vide letter dt 26.10.2016, 5.11.2016 and 15.11.2016, complainants were asked to produce original bills and diagnosis report which complainants did not furnish and therefore, claim of complainants was closed and there is no deficiency in service on the part of answering OPs. All the other allegations and allegations with regard to relief sought too were refuted with prayer to dismiss the complaint with costs.

5                                              Notice issued to OP-1 through Process Server, stands served, but despite having sufficient notice of complaint, OP-1 did not appear in the Forum either in person or through counsel, therefore, vide order dated 4.05.2017, OP-1 was proceeded against exparte.

6                                              Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to 12 and then, closed his evidence.

7                               In order to rebut the evidence given by complainant, the ld Counsel for OP-2 and 3 tendered in evidence, affidavit of Mohmd Azhar Wasi as Ex OP-2,3/3 and documents Ex OP-2,3/1 and 2,3/ 2  and then, closed the same on behalf of OPs.

8                                     We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

9                                 From the careful perusal of record and documents produced by parties, it is observed that grievance of complainants is that they were insured with OPs under Floater Family Plan and during the subsistence of insurance policy, complainant no.2 suffered from abdominal pain and she got conducted her operation for Endometrial Polyp and for this purpose she remained admitted in the hospital from 25.08.2016 to 30.08.2016 and spent Rs.39,226/-for the treatment. After discharge from the hospital, complainants duly informed the OPs regarding treatment of complainant no.2 and also submitted their claim for reimbursement alongwith relevant bills and documents to OPs but OPs repudiated the claim of complainants on the ground that complainants have not furnished requisite documents to OPs. In reply, OPs stressed mainly on the point that despite issuance of three reminders dated 26.10.2016, 5.11.2016 and 15.11.2016, complainants were asked to produce original bills and diagnosis report which complainants did not furnish and therefore, claim of complainants was closed and there is no deficiency in service on the part of answering OPs.

10                                   To prove his case complainant has relied upon documents Ex C-4 and C-5 copy of policy schedule wherein it is clearly mentioned that both complainant no.1 and 2 alongwith their wards are insured with OPs under Family Floater Plan and are entitled to avail medical treatment during the subsistence of policy in question. Ex C-6 to 11 are copies of bills that prove the pleadings of complainants that complainant no.1 spent this amount on the treatment of complainant no. 2. Through Ex C-12 copy of Discharge Summary it is clear that complainant no.2 was hospitalized on 25.08.2016 and was discharged therefrom on 30.08.2016. Ex C-3 copy of repudiation letter wherein OPs have clearly stated that claim of complainants is rejected due to non compliance of documents post three reminder though complainant has duly submitted all the requisite documents to OPs.

11                                         After careful perusal of the record available on file and going through the evidence led by parties, it is observed that in the light of documents, there remains no iota of doubt that complainants have not supplied the requisite documents to OPs as sought by them. There is no reason for complainants to hide or withhold those documents, which are necessary for processing the claim and which they have produced on record. Repudiation letter Ex C-3 issued by OPs itself speaks that claim of complainants was rejected on the ground of non compliance of documents post three reminders, but plea taken by OPs that complainants have not furnished requisite documents to them seems inappropriate. Complainants have produced sufficient and cogent evidence to prove their pleadings and these documents can not be doubted. Documents Ex C-6 to 11, are copies of bills and reports the authenticity of which can not be ignored. On the other hand OPs have not produced even copies of letter or reminders dt 6.10.2016, 5.11.2016 and 15.11.2016 vide which they , asked complainants to produce original bills and diagnosis report. Reply given by Ops is contradictory to the evidence produced by them.

12                                    From the above discussion and evidence produced by the complainant, we are of considered opinion that OPs have not made payment on account of Mediclaim of insured complainant no. 2 on false grounds and it amounts to deficiency in service on the part of OPs. Complainants have succeeded in proving their case and hence, complaint case in hand is hereby allowed. OPs are directed to make payment of genuine insurance claim of complainants to the tune of Rs.39,226/- i.e amount spent by complainants on treatment of complainant no. 2 alongwith interest at the rate of 9% per anum from 23.12.2016 i.e the date of repudiation of claim till final realization and Ops are further directed to pay Rs.5,000/- to complainants as consolidated compensation for harassment, mental agony and litigation expenses. Compliance of this order be made within one month of receipt of the copy of the order, failing which, complainants shall be entitled to initiate proceedings under Section 25 and 27 of the Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 12.10.2017       

                                             Member                          President

               (P Singla)                      (Ajit Aggarwal)