BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAPURTHALA.
Complaint No. 75 of 2019
Date of Instt. 05.08.2019
Date of Decision:10.01.2020
Kartar Singh aged about 86 Years son of Mehar Singh R/o Village Padri Makhu, Tehsil Zira, District Ferzepur through attorney Heera Singh son of Kartar Singh employee of Shiromani Gurudwara Prabhandak Committee at present appointed at Gurudwara Sri Ber Sahib, Sultanpur Lodhi, District Kapurthala.
….....Complainant
Versus
1. Bajaj Allianz General Insurance Co. Ltd. Regd. At Head Office GE Plaza, Airport Road, Yerwada, Pune 4110006.
2. Bajaj Allianz General Insurance Company, Ranjit Avenue K. K. Tower at Amritsar through its Manager.
3. Bajaj Allianz General Insurance Company Pvt. Ltd 2F09, Second Floor GMD Galleria, Sector 48, Sohana Road, Gurgaon.
4. Shiromani Gurudwara Prabhandak Committee (SGPC) Through Manager Gurudwara Sri Ber Sahib Sultanpur Lodhi, District Kapurthala. .........Opposite parties
Complaint under section 12 of Consumer Protection Act
Quorum: Before: S. Karnail Singh (President)
Mrs.Rajita Sareen (Member)
Present: Sh. Rahul Sharma, Adv. Counsel for the Complainant.
Sh. Varun Kumar, Adv. Counsel for the OPs No.1 to 3.
Sh. Raghav Dhir, Adv. Counsel for the OP No.4.
Order
S.Karnail Singh (President)
1. The instant complaint has been filed by the complainant Kartar Singh through his attorney i.e. Heera Singh.
2. The brief facts of the complaint are that the complainant Kartar Singh is 86 years old and suffering from various diseases and is unable to walk and as such, the instant complaint has been filed by him through his son Heera Singh being attorney. The son of the complainant Heera Singh is the employee of Shiromani Gurudwara Prabhandak Committee, who is OP No.4 in the instant complaint and the said employer of Heera Singh purchased a Group Insurance for its employee including Heera Singh and ID Card number of Heera Singh is GMG-19111330029-SBSSLK119 and the said policy is valid upto 29 March 2019, the whole dependents/family members are covered there under. The complainant is having his health and wellness bearing ID Card No.GMC-19111330029/SBSSLK119/D through policy issued to the son of the complainant namely Heera Singh.
3. That the complainant Kartar Singh suffered from sudden attack of Hemiprigia and Sapticmaig and was got admitted in Algon Hospital, VPO Algon Kothi Tehsil Patti, District Tarn Taran on 08.05.2018 at 11:00 PM and remained admitted in the said hospital under treatment of Dr. Vainder Rampal MBBS, Registration NO.9066 and was discharged on 17.05.2018 at about 03:30 PM and his medical expenses for his treatment to the amount of Rs.29,115/- were borne by the complainant and his son/attorney Heera Singh. Thereafter, all the original bills of medicines and treatment alongwith claim form were handed over to the Manager Bajaj Allianz General Insurance Company. Thereafter, no such claim was accepted by the OPs of the complainant as per policy issued in the name of Heera Singh under which the complainant is also insured being dependent. The complainant and his son visited number of times to the office of OPs No.1 to 3, but all in vain and thereafter the complainant sent a legal notice to the OPs, but no reply has been filed. Inspite of submission of original bills of treatment and other required documents, the claim of the complainant has not been settled, whereby the complainant has faced harassment, mental tension and financial loss caused to the complainant and accordingly, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the amount of Rs.29,115/- to the complainant as expenditure of medical treatment alongwith interest @ 9% per annum from the date of medical treatment till its actual realization and OPs be further directed to pay compensation of Rs.50,000/- towards mental tension, harassment, agony and damages and further OPs be directed to pay Rs.15,000/- as litigation expenses.
4. Notice of the complaint was given to the OPs and accordingly, OPs No.1 to 3 filed joint written reply, whereby contested the complaint by taking preliminary objections that the present complaint is not maintainable and further averred that the complainant has portrayed an entirely concocted story for creating right to file the complaint and for recovery of money where there are none. The answering OP submits that the complainant has filed the captioned complaint with evil intention of harassing the OPs and further submitted that the complainant has concealed and suppressed the true and material facts, as such, the complainant is not entitled to any relief from the Forum and the complaint deserves to be dismissed with special cost. It is further alleged that the complainant has miserably failed to submit original final hospital bill with paid receipts with revenue stamps and seal of Algon Hospital for hospitalization period 8th May to 17 May 2018. The original final hospital bill with paid receipts with revenue stamps and seal of Algon Hospital has not been provided to the OPs No.1 to 3 despite of several reminders, hence the claim stands closed and further submitted that the policy cover was subject to terms and condition, exceptions and endorsements of the policy. On merits, it is admitted that the policy was issued to the complainant as well as his son, who is employee of the OP No.4 and further, it is not denied that the complainant remained admitted in the hospital and submitted the insurance claim rather alleged that the complainant himself failed to submit the complete document as required and for want of document, the claim closed and intimation was given to the complainant. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
5. OP No.4 filed its separate written reply, whereby admitted that the son of the complainant namely Heera Singh is working at Gurudwara Sri Ber Sahib Sultanpur Lodhi and a group insurance was obtained by the employer i.e. OP No.4 for its employee including the son of the complainant and further submitted that the OPs No.1 to 3 are required to pay the amount as demanded by the complainant.
6. Complainant filed rejoinder to the written statement of OPs No.1 to 3, whereby reasserted the entire facts as detailed in the complaint and denied those of the written statement. Rejoinder to the written statement of OP No.4 not filed.
7. Both the parties produced on the file their respective documents, in support of their version, at the time of filing their pleadings i.e. complaint as well as replies.
8. We have heard the argument from the learned counsel for the respective parties and have also gone through the case file very minutely.
9. There is no dispute that a group insurance was issued by the OPs No.1 to 3 to the employee of the OP No.4 i.e. Shiromani Gurudwara Prabhandak Committee, wherein the son of the complainant namely Heera Singh is also one of the member of the insurance company being employee of the OP No.4 and liability of complainant Kartar Singh is also covered being he is dependent upon his son Heera singh. Further the factum in regard to submission of insurance claim of the complainant is not denied by the OPs No.1 to 3 rather the OPs No.1 to 3 alleged that some required documents i.e. original final hospital bill etc. were not supplied by the complainant at the time of submission of claim and accordingly, the claim of the complainant was closed on 29.08.2019.
10. We have considered the plea taken by the OPs No.1 to 3 that some documents i.e. original bill of the hospital alongwith revenue stamps were not supplied by the complainant and due to that reason, the claim was closed, but this version of the OPs No.1 to 3 is not acceptable because whenever any such like medical claim is submitted, then insurance complaint is usually appointed Investigator, whose duty is to visit the hospital and to verify whether the insured was remained admitted or not, whether he get treatment there-from or not and also to collect all relevant documents in order to ascertain whether there is any previous ailment insured or not, for that purpose, the OPs No.1 to 3 must have appointed investigator in the instant case and who has required to collect all the documents instead of demanding the same from the complainant. We find the OPs No.1 to 3 are pretending to not supply the document and on the basis of this sole ground illegally closed the claim of the complainant, whereas the OPs itself bound to get relevant document from the concerned hospital not to demand the same from insured. So, with these observations, we are of the opinion that the OPs No.1 to 3 has illegally and wrongly closed the claim of the complainant and thereby caused mental tension and harassment to the complainant and as such, we hold that the complainant is entitled for the relief claimed.
11. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs No.1 to 3 are directed to pay medical treatment amount of Rs.29,115/- to the complainant with interest @ 9% per annum from the date of filing complaint i.e. 05.08.2019, till its realization and further, OPs No.1 to 3 are directed to pay compensation to the complainant for causing mental tension and harassment, to the tune of Rs.25,000/- and further, OPs No.1 to 3 are directed to pay litigation expenses of Rs.10,000/-. Compliance of the order be made within one month from the date of receipt of copy of the order. This complaint could not be decided within stipulated time frame due to rush of work. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Rajita Sareen Karnail Singh
10/01/2020 Member President
