DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FAZILKA.
Complaint No. CC/116/2023
Date of Institution: 30.10.2023
Date of Decision : 25.07.2024
Bimla Rani wife of Chiman Singh, Resident of Village Chak Arainwala, Fazilka.
………..Complainant
Versus
1. Bajaj Finance Limited, 511, Acme Plaza, Andheri Kurla Road, Andheri East, Mumbai-400059, through its authorized signatory.
2. Niva Bupa Health Insurance (M/s MAX Health Plus), S.C.F. 135, Second Floor, Opposite Three Cinema, Near Improvement Trust Office, G.T. Road, Bathinda-151001.
......Opposite Parties
Complaint under section 35 of Consumer Protection Act, 2019.
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Quorum: Sh.Vishal Arora, President.
Sh.Raghbir Singh Sukhija, Member.
Smt.Tajinder Kaur, Member.
Present: Sh.Karamjeet Handa, Advocate, Counsel for Complainant.
Opposite Party no.1 Exparte.
Sh. Harish Chawla, Advocate, Counsel for opposite party no.2.
ORDER
(Vishal Arora, President):
Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against opposite parties for seeking directions to the opposite parties to pay Rs.6,00,000/- alongwith interest besides Rs.1,00,000/- as compensation for mental pain/harassment and litigation expenses to the tune of Rs. 22,000/-.
2. Briefly stated, the case of complainant is that husband of complainant Chiman Singh S/o Beka Singh during his life time had purchased Group Master Policy from the opposite parties bearing policy no.50102900202000 dated 26.12.2020 which was valid upto 03.06.2022 and covers accidental death upto Rs.6,00,000/- in which complainant Bimla Rani
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being wife of Chiman Singh has been cited as nominee. Unfortunately, husband of complainant died in road side accident on 18.9.2021 and Rapat no. 024 dated 24.09.2021 was also lodged with Police Station City, Fazilka. The police has conducted necessary proceedings in this regard and also recorded the statements. The post mortem on the dead body of husband of complainant was conducted by Dr.Gayatri Pujara, Medical officer, Civil Hospital, Fazilka, having P.M.R no.GP/11/2021/FZK/PMR. All the requisite information regarding the death alongwith documents has already been sent to the opposite parties, but till date, the claim of complainant to the tune of Rs.6,00,000/- has not been settled so far. The complainant had also issued legal notice dated 22.12.2022, but of no use. The aforesaid act and conduct on the part of the opposite parties caused grave mental tension, pains, financial loss and sufferings to the complainant for which they are liable to compensate the complainant. Pleading deficiency in service and unfair trade practice on the part of opposite parties, the complainant has prayed for acceptance of the present complaint.
3. The counsel for complainant was heard with regard to admission of the complaint and vide order dated 07.11.2023, the complaint was admitted and notice was ordered to be issued to the opposite parties.
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4. As per the office report, notice was sent to the opposite party no.1 on 04.01.2024 through Regd. Post but the RC was not received back. By presuming the service of notice within 7 days from the date of sending the notice, it was served upon the opposite party no.1 on 11.01.2024. But nobody appeared on behalf of opposite party no.1 either in person or through counsel on 30.01.2024, 01.02.2024, 05.02.2024, 12.02.2024 and 19.02.2024. Therefore, opposite party no.1 was proceeded against Ex-parte vide order dated 19.02.2024.
5. Upon notice, the opposite party no. 2 has appeared and filed written reply to the complaint raising certain preliminary objections interalia to the effect that the present complaint is pre-mature and till date, no claim has been submitted by the complainant. The complainant has not filed any documents which proves that he has submitted the claim form and related documents. The opposite party no.2 through the present complaint came to know that the insured member died in a road accident on 18.09.2021 but opposite party no.2 till date has not received any claim regarding the same from the complainant. The complainant has not submitted any document, death certificate, F.I.R, post-mortem report or any other documents relating to the incident. Therefore, the alleged claim has neither been accepted nor
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rejected by opposite party no.2. The claim along with required documents are essential for processing and settling claim of the policy holder. After receiving the claim and required documents, the same are scrutinized in order to decide whether to admit the claim or not. In the present case, the complainant has jumped the entire process and directly approached the Commission without providing opportunity to opposite party no.2 to decide the claim. Since pre authorization request was also declined as liability could not be established, the said claim can also be decided only after receipt of reimbursement claim. The complainant has not submitted any bills, discharge summary or medical reports relating to his treatment and the alleged claim has neither been accepted nor rejected by opposite party no.2. On merits, the preliminary objections have been reiterated and the other allegations of the complaint have been denied with a prayer for dismissal of the present complaint.
6. The complainant along with the present complaint has placed on record, Copies of, Certificate of Insurance Ex. C-1, Post Mortem Examination Report Ex.C-2, Legal notice Ex.C-3, Postal Receipt Ex.C-4, Rapat Ex.C-5. Per contra, counsel for opposite party No.2 tendered into
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evidence, Affidavit of Sudhakar Anand, Manager Legal of Insurance Company Ex. OP-2/1, Copy of Policy Ex.OP-2/2 and closed evidence.
7. We have heard the Ld. counsel for the parties have also very carefully gone through the record. The Learned counsel for complainant and opposite party no.2 have argued on the same lines as per their respective pleadings.
8. The main plea put forward and argued by the Ld.counsel for the opposite party no.2 is that the present complaint is pre-mature and till date, no claim has been submitted by the complainant. The complainant has not filed any documents which proves that he has submitted the claim form and related documents. The opposite party no.2 through the present complaint came to know that the insured member died in a road accident on 18.09.2021 but opposite party no.2 till date has not received any claim regarding the same from the complainant. The complainant has not submitted any document, death certificate, F.I.R, post-mortem report or any other documents relating to the incident. Therefore, the alleged claim has neither been accepted nor rejected by opposite party no.2. The claim along with required documents are essential for processing and settling claim of the policy holder. After
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receiving the claim and required documents, the same are scrutinized in order to decide whether to admit the claim or not. In the present case, the complainant has jumped the entire process and directly approached the Commission without providing opportunity to opposite party no.2 to decide the claim. Since pre authorization request was also declined as liability could not be established, the said claim can also be decided only after receipt of reimbursement claim. The complainant has not submitted any bills, discharge summary or medical reports relating to his treatment and the alleged claim has neither been accepted nor rejected by opposite party no.2.
Perusal of the file reveals that the complainant has not placed on record any documentary evidence to prove that any claim along with requisite documents has been lodged by the complainant with the opposite party no.2.
9. In view of what has been discussed above, the present complaint stands disposed off being premature with a direction to the complainant to lodge the claim with the opposite party no.2 along with the requisite documents against proper receipt. And on receipt thereof, the opposite party no.2 will decide the admissibility of the claim of the
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complainant within a period of 45 days including conducting of investigation and demand of documents, if any. In case, the admissibility of the claim is not decided within the stipulated period of 45 days, then opposite party no.2 shall be liable to pay to the complainant Rs.300/- per day for the period of delay. If the complainant is dissatisfied with the decision taken by the Insurance company, the complainant shall be at liberty to file a fresh complaint on the same cause of action. The present complaint is disposed off accordingly. Copies of order be supplied to the parties free of costs under the rules. File be indexed and consigned to the record room.
ANNOUNCED IN THE OPEN COMMISSION:
25th Day of July, 2024
(Vishal Arora)
President
(Raghbir Singh Sukhija)
Member
(Tajinder Kaur )
Member
