Complainant Meharvan Singh through his father Sh.Pardeep Singh being his next friend has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has sought issuance of necessary directions to the opposite parties to make payment of mediclaim policy and also to pay Rs.50,000/- as compensation on account of mental and physical harassment suffered by him from the hands of the opposite parties, in the interest of justice.
2. The case of the complainant in brief is that he is an account holder of the opposite party no.1 for his saving account and every month he is depositing money with the opposite party no.1 and availing its services. Opposite party no.1 has tied collaboration with the opposite party no.2 for the purpose of medical claim insurance and the maximum Mediclaim for the family, the opposite party no.1 doing is of Rs.8 lacs. He purchased a policy of Mediclaim from the opposite party no.1 for Rs.2 lacs Insurance which included parents and one child for which he paid Rs.3500/- as yearly premium to the opposite party no.1 through his father’s Saving Account No.68006588240 but they did not issue him policy letter. He is continuing the Mediclaim Policy from the opposite party no.2 for the last 3 years and in the year 2014, the policy was renewed through the opposite party no.1, as the opposite party no.2 has collaboration with the opposite party no.1 for the purpose of mediclaim. He has further pleaded that in the year 2014, he was operated for Gall Bladder Stone from Navpreet Hospital, Amritsar. The opposite party no.1 was informed in Black and White regarding operation of his Gall Bladder through Laparoscopy by his father. He filled up the Form with the opposite party no.1 for reimbursement of the amount of Rs.25,000/- spent on the operation of the Gall Bladder at Navpreet Hospital, Amritsar and submitted all the original bills to the opposite party no.1 duly countersigned by the Navpreet Hospital, Amritsar. The opposite party no.1 after receiving the original bills and reimbursement form duly signed by the Consultant Doctor of Navpreet Hospital, Amritsar forwarded the file to the opposite parties no.2 and 3 for issuance of cheque or Draft of the amount spent on the operation of his Gall Bladder, but till date the opposite parties no.2,3 & 4 has withheld the cheque of the insured amount which he is entitled for reimbursement of Mediclaim as per the policy and instructions of the Mediclaim insurance policy without any sufficient and reasonable cause which is deficiency in service on the part of the opposite parties. The opposite parties have caused mental agony and harassment to him by withholding the cheque/draft of the insured amount. It is also an unfair practice by the opposite parties. Hence this complaint.
3. Upon notice, the opposite party no.2 appeared and filed its written reply through the counsel by taking the preliminary objections that the complaint is not maintainable against opposite party no.2, because there is no contract of insurance between the complainant, alleged to be a consumer of the opposite parties and the opposite party no.2. If at all, it is established that there exists a policy of insurance, in that case too it is to be ascertained whether it is an indemnity policy or liability policy. In case of indemnity policy, any award or payment pertaining to the case will have to be borne by opposite party no.1. However on the final disposal of the case, the insurance Company shall certainly reimburse the amount subject to the terms and conditions of the policy of insurance and the policy of insurance has not been made available or neither filed by the opposite party no.1 nor by the complainant. In the absence of original policy of insurance it is not possible to accept or deny the insurance. The opposite party however reserves the rights to amend the written statement if so required after examining the policy once it is produced. On merits, it was submitted that as per information received from opposite party no.3, the claim is pending for want of following documents, for which the complainant has been requested many times to supply the same but it has not been done so far.
(a) Original discharge summary with details of operative procedure and treatment given.
(b) Hospital Registration certificate and or Form C.
© Investigation report supporting the diagnosis.
- Original prescription corresponding to the submitted pharmacy bills.
- Reasons for delay in claim submission.
(f) Copy of policy of insurance for the year 2013-14.
All other averments made in the complaint have been denied and lastly the complaint has been prayed to dismiss with costs.
4. Notice to the opposite parties no.1, 3 and 4 have not been received back. Case called several times, but none has come present on their behalf, therefore, they were proceeded against exparte vide order dated 10.3.2015.
5. Sh.Pardeep Singh father of Meharvan Singh minor has tendered into evidence his own affidavit Ex.C1, alongwith other documents Ex.C2 to Ex.C6 and closed the evidence.
6. Sh.Pardeep Singh Sr.Branch Manager of opposite party no.2 tendered into evidence his own affidavit Ex.OP-2/1, alongwith other document Ex.OP2/2 and closed the evidence.
7. We have carefully gone through the pleadings of the parties; arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the purpose of adjudication of the present complaint
8. We have carefully examined and thoroughly considered the evidence and other documents as available on the records of the proceedings while adjudicating the present complaint. We observe that the complainant had purchased the Medi-claim Policy (in question) as professed by the OP2 insurers through their ‘tied-up’ associates/agents the OP1 Bank with whom the complainant and his other family members were maintaining the Bank accounts. The non-appearance of the OP1 Bank in spite of the due service of summons/notices to present/produce its defense before the Forum gives rise to the judicial presumption that it does not have any defense to plead. Further, the OP2 insurers have pleaded that in the absence of the related ‘Policy’ and/ or its details etc., its nature/type could not be ascertained to facilitate settlement of the ‘claim’ and moreover the OP3 TPA (Third Party Administrators) advises them that the related documents (for settlement of claim) have not been submitted to them; whereas the complainant states having submitted all these papers to the OP1 Bank who did not even hand him over the insurance Policy. Under the circumstances, we find the OP1 Bank responsible for ‘non-settlement’ of the legal and valid insurance claim and also for the resulting ‘delay’ and thus hold them guilty of ‘deficiency in service’ as envisaged under the Act.
9. In the light of the all above, we partly allow the present complaint and ORDER the OP1 Bank to settle and pay to the complainant the insurance claim amount as ‘capped’ for the gall-bladder’ surgery under the related Policy along with Rs.3,000/- as compensation besides Rs.2,000/- as litigation expenses within 30 days of the receipt of the copy of these orders otherwise the total award amount shall attract interest @ 9% PA from the date of the orders till actually paid. The OP1 Bank shall however, be at liberty to recover the amount of the ‘paid claim’ from the OP2 insurers in terms of their mutually ‘tied-up’ arrangement/agreement.
10. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (Jagdeep Kaur)
August 26, 2015 Member.
*MK*
