BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 128 of 2022
Date of Institution : 09.02.2022
Date of Decision : 28.09.2023
Dinesh Kumar Jindal Advocate, aged about 56 years, son of Sh. Ravi Parkash Jindal, resident of Shiv Chowk, Rori Gate, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Branch Manager, Raksha Health Insurance TPA Pvt. Limited, having its office at C/o Escorts Corporate Centre 15/5, Mathura Road, Faridabad.
2. Branch Manager, Oriental Insurance Company, Janta Bhawan Road, Sirsa, District Sirsa.
3. Branch Manager, Punjab National Bank, Rori Bazar Branch, Sirsa, Tehsil and District Sirsa.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
SH. OM PARKASH TUTEJA……….MEMBER
Present: Sh. Rajinder Bajaj, Advocate for the complainant.
Opposite party no.1 already exparte.
Sh. A. S. Kalra, Advocate for opposite party no.2.
Sh. M.S. Sethi, Advocate for opposite party no.3.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant is having his saving bank account bearing no. 0430000109108417 with op no.3. That as per agreement between op no.3 bank and op no.2, some concession in premium for purchase of insurance policy was to be given to the account holders of op no.3. It is further averred that complainant purchased insurance policy from time to time and lastly he purchased one insurance policy of ops no.1 and 2 vide policy no. 261500/48/2020/500 w.e.f. 11.11.2019 to 10.11.2020 which is under family health plan and accordingly the complainant paid premium to op no.2. That during the period of said policy, wife of complainant namely Anju Jindal suffered from serious problem of cancer and she was fully covered under the said policy. The complainant got treatment of his wife from the concerned hospital. It is further averred that complainant submitted necessary bills and medical certificate to the office of ops for payment of amount of treatment of his wife, but the ops’ company has only paid the amount on account of hospital expenses but has not paid the amount on account of pre-hospitalization expenses and post hospitalization expenses amounting to Rs.3,76,456/- to the complainant despite several requests and demands made by him from time to time. It is further averred that as per requirement of op no.2, the complainant has submitted all the original bills, report of radiologist, films, CT scan films and CDs etc. in their office and has also removed all the objections raised by the company vide letters dated 16.06.2020, 29.08.2020, 14.09.2020 and 23.10.2020 and in this way complainant has told the whole of true position and nothing was withheld by him but still the op no.2 is avoiding payment of aforesaid amount to the complainant. That the complainant also got issued a legal notice dated 26.03.2021 to the ops but an evasive reply to the same was given and as such ops have caused harassment and mental agony to the ops. The complainant is legally entitled to receive the above said amount alongwith interest besides compensation for harassment and litigation expenses. Hence, this complaint.
3. Notice of the complaint was issued to the ops. Op no.1 did not appear despite delivery of notice and as such op no.1 was proceeded against exparte.
4. Op no.2 appeared and filed written statement raising certain preliminary objections that complaint is pre-mature, without any cause of action and complainant is estopped by his own act and conduct to file the present complaint, hence same is liable to be dismissed; that there is no deficiency in service in any manner on the part of company or its officials, rather deficiency and neglect act is on the part of complainant who failed to provide all the relevant prescriptions for claim for medicines, lab test alongwith their original report, films, as amount claimed was more in comparison to the documents submitted by complainant. That clarification on this discrepancy was sought by answering op vide letters dated 11.7.2020, 3.8.2020, 30.9.2020 and by op no.1 vide letters dated 10.3.2021 in claim no. 5562220211115533 pertaining to the period 6.2.2020 to 8.2.2020; further complainant failed to provide treating doctor certificate justifying indication for hospitalization, copy of complete set of indoor case papers and vital charting, original investigation, reports all done during hospitalization dated 15.3.2020, films dated 15.03.2020, original pre-numbered, preprinted duly signed and stamped final bill of the hospital, breakup of main hospital bill on hospitals letter head, reason for delayed submission of claim documents as per policy terms and conditions, reason for no intimation at the time of hospitalization, documents for age proof, original detailed discharge summary, cancelled cheque alongwith NEFT form, doctors advice for admissions/ emergency card or OPD card showing the recommendation for admission 15.3.2020. Besides this some other documents were also demanded/ sought vide letters dated 8.7.2020, 29.7.2020, 14.8.2020 and by op no.1 vide letter dated 10.3.2021 in claim no. 556432021107009 pertaining to the period 15.3.2020/26.5.2020 and complainant also failed to provide documents of other claims despite their letters and due to this reason, the op no.1 was not able to process the claim. As per letter issued by op no.1 to the complainant it was clearly mentioned that conclusion regarding admissibility of amount can only be arrived at, once op will have full set of the requested documents and despite repeated request by op no.1 and answering op complainant failed to assist the company, hence claim of complainant was repudiated vide their letters for want of documents and claim has not been paid due to this very reason. It is further submitted that complainant himself violated the terms and conditions of insurance policy for proceeding further with the claim lodged by him, more particularly when initial claim for cashless has been settled, paid. For afterwards claim the documents are required to be submitted by the claimant/ any individual insured and for further claim requisite record, documents were not submitted by complainant despite repeated letters, hence complaint is not maintainable. It is further submitted that complainant has claimed amount of Rs.3,76,456/- on account of pre and post hospitalization expenses. The complainant and ops are governed by the policy term and conditions. The complainant did not disclose and mention or enclose and supply the record of admission, discharge, medicine, treatment etc. even before this Commission explaining the amount of Rs.3,76,456/- claimed from ops and in absence of all above record, which was sought from complainant by ops no.1 and 2, neither this Commission nor insurance company can decide the claim/ subject matter of present complaint. On merits also, the pleas of preliminary objections are reiterated, contents of complaint are also denied and prayer for dismissal of complaint made.
5. Op no.3 also filed written statement submitting therein that if complainant is policy holder of insurance company, then insurance company is bound to compensate the complainant regarding expenses incurred by him for treatment. Moreover, the matter related to payment of expenses is between the complainant and insurance company and prayer for dismissal of complaint qua op no.3 made.
5. The complainant in evidence has tendered his affidavit Ex. CW1/A, affidavit of his wife Ex. CW2/A and copies of documents Ex.C1 to Ex.C80.
6. On the other hand, op no.2 has tendered affidavit of Ms. Puja, Incharge Legal Hub as Ex.R1 and copies of documents Ex. R2 to Ex.R28. Op no.3 has tendered affidavit of Sh. Ashok Kamboj, Branch Manager as Ex.R29.
7. We have heard learned counsel for the complainant as well as learned counsel for op no.2 and op no.3 and have gone through the case file.
8. According to the complainant he has been purchasing insurance policy from time to time through op no.3 bank and lastly he purchased insurance policy i.e. Family Health Plan of op no.1 vide policy No. 261500/48/2020/500 for the period 11.11.2019 to 10.11.2020. In this regard op no.2 itself has placed on file insurance policy in question as Ex.R28 according to which complainant himself, his wife Anju Jindal, their daughter Jaya Aggarwal and son Anish Jindal were insured for the above said period from 11.11.2019 to 10.11.2020 for the sum insured amount of Rs.5,00,000/-. It is also evident from this policy Ex.R28, that complainant had also purchased insurance policy for the period 11.11.2017 to 10.11.2018 and from 11.11.2018 to 10.11.2019 from the op no.2 for the said sum insured amount of Rs.5,00,000/-. It is further case of complainant that during the period of policy in question, the wife of complainant Anju Jindal suffered from serious problem of cancer and complainant got her treatment for the said disease and has spent huge amount on her treatment. In this regard complainant has also proved on record that his wife was treated in Rajiv Gandhi Cancer Institute and Research Centre, Punjab Cancer Care and Research Centre and Aadhar Health Institute from 25.01.2020 onwards i.e. during the period of policy in question as is evident from various bills/ receipts of the above said hospitals and test reports etc. placed on file by complainant as Ex.C2 to Ex.C80. So, it is proved on record that during the period of policy in question, the insured Smt. Anju Jindal wife of complainant was treated for the said disease of cancer and complainant has spent huge amount on her treatment. According to the complainant he submitted necessary bills and medical certificates to ops alongwith claim form but op no.2 insurance company has only paid amount of hospital expenses but has not paid the amount spent by him on account of pre hospitalization and post hospitalization expenses i.e. amount of Rs.3,76,456/- and accordingly he has claimed said amount of Rs.3,76,456/- from op no.2 insurance company. The complainant has also submitted that he has already removed all the objections raised by insurance company from time to time vide letters sent to op no.2 on different dates i.e. on 16.06.2020, 29.08.2020, 14.9.2020 and 23.10.2020 sent to op no.2 through registered post which were received by op no.2. On the other hand, op no.2 has pleaded that despite demand of above said documents from complainant he failed to submit the same and as such claim of complainant was repudiated vide letters dated 23.2.2021, 25.2.2021 and 25.3.2021 and in this regard ops have also placed on file various letters but however, we are of the considered view that ops had been unnecessarily demanding the documents from the complainant despite the fact that complainant has already been providing documents and has been removing objection of ops’ company from time to time and as such ops’ company was harassing the complainant because ops’ company could also arrange the above said hospital record as well as hospital tariff from the hospitals itself. The ops no.1 and 2 were not justified in demanding above said hospital record, reports and bills etc. from the complainant time and again as complainant was already under mental trauma due to cancer disease of his wife. The copies of bills/ receipts etc. are already placed on file by complainant and during the course of arguments learned counsel for complainant has also placed on file a full set of all the record of pre hospitalization and post hospitalization i.e. copies of prescription slips/ admission card and laboratory test reports, bills and receipts duly stamped and signed by the treating doctors and according to learned counsel for complainant the original of these documents have already been supplied by complainant to the ops no.1 and 2. As such it is proved on record that op no.2 remained deficient in service and was causing much harassment and mental tension to the complainant by not paying genuine claim amount for the treatment of his wife for the disease of cancer and has wrongly and illegally repudiated the claim of the complainant. As such complainant is entitled to reimburse expenses of medical treatment spent by him on the treatment of his wife from op no.2 insurance company. Though complainant has claimed amount of Rs.3,76,456/- from the op no.2 but from the copies of bills/ receipts placed on file as Ex.C2 to Ex.C73, it is evident that complainant has spent total amount of Rs.3,46,356/- on account of pre-hospitalization and post hospitalization expenses and as such complainant is entitled to said amount of Rs.3,46,356/- from op no.2 besides compensation for harassment etc. However, as the maximum liability of op no.2 is of Rs.5,00,000/- i.e. sum insured amount for the period 11.11.2019 to 10.11.2020 and complainant has placed on record total bills of Rs.3,46,356/-, therefore, complainant is entitled to payment of Rs.3,46,356/- during the period of policy in question from op no.2. Since op no.2 is insurer of the insured, therefore, op no.2 only is liable to pay the claim amount to the complainant and as complainant has already submitted his claim to the op no.2 but op no.2 has not entertained the same, therefore, there is deficiency in service on the part of op no.2.
9. In view of our above discussion, we allow the present complaint qua opposite party no.2 insurance company and direct the op no.2 to pay the insurance claim amount of Rs.3,46,356/- to the complainant alongwith interest @6% per annum from the date of filing of present complaint i.e. 09.02.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order, failing which op no.2 will be liable to pay the interest at the rate of @9% per annum on the above said amount of Rs.3,46,356/- for the default period. However, in case it is found that any amount has been paid by op no.2 to the complainant for the treatment of his wife during the period of policy in question i.e. from 11.11.2019 to 10.11.2020, then after deduction of that amount from total sum insured amount of Rs. five lacs, remaining amount will be payable to the complainant against the said amount of Rs.3,46,356/-. We also direct the op no.2 to further pay a sum of Rs.10,000/- as compensation for harassment and also to pay further amount of Rs.10,000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member President,
Dated: 28.09.2023. District Consumer Disputes
Redressal Commission, Sirsa.
