Punjab

Faridkot

CC/17/126

Makhan Singh - Complainant(s)

Versus

Branch Manager Canara Bank - Opp.Party(s)

Gurwinder Brar

19 Sep 2017

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      126

Date of Institution:  17.04.2017

Date of Decision :   19.09.2017

 

Makhan Singh Sran aged about 67 years s/o Maghar Singh r/o Balmiki Chowk, Kotkapura, Tehsil Kotkapura District Faridkot.

...Complainant

Versus

1. Canara Bank, Branch Kotkapura through its Branch Manager.
2. Apollo Munich Health Insurance Company Ltd 2^nd and 3^rd Floor, ILABS Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon-122016 (Haryana) through its MD.                    

.....OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum:     Sh. Ajit Aggarwal, President,

                   Sh P Singla, Member.

 

Present:       Sh  Gurwinder Brar, Ld Counsel for complainant,

Sh Dildeep Singh,  Ld Counsel for OP-1,

                   Sh Varun Gupta, Ld Counsel for OP-2,

ORDER

(Ajit Aggarwal, President)

                                                       Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to them to make payment of insurance claim of Rs.27,614/-and for further directing OPs to pay Rs.25,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses.

2                                               Briefly stated, the case of the complainant is that on persuasion of Op-1, complainant purchased a Health Insurance Policy from OP-2 and at that time, OP-1 took signatures of complainant on various blank papers and debited the premium from the account of complainant. Thereafter, Ops issued copy of certificate of health insurance to complainant and did not provide any other document to him. It is submitted that during the subsistence of policy, complainant suffered from fever and cough and when despite taking medicines, complainant did not get relief, then on advice of doctor, he was admitted in Dr Pirthi Pal Memorial Hospital and Heart Centre for treatment of non allergic bronchia asthma on 31.08.2016 and was discharged from there on 6.09.2016. Complainant showed his card to concerned doctor, but he told him to pay in cash and his expenses would be reimbursed by OPs. Thereafter, complainant completed all formalities and sent relevant documents regarding his treatment to OPs and requested them to reimburse the amount of Rs.27,614/-spent by him as medical treatment expense, but Ops kept lingering on the matter on one pretext or the other. In October, 2016 on demand of Ops for requisite documents through letter, complainant submitted all the requisite documents to them and again prayed for processing his claim, but all in vain. Complainant made several requests to OPs to make payment of his insurance claim, but all in vain. All this amounts to deficiency in service and trade mal practice on the part of Ops and it has caused harassment and mental agony to complainant for which he has prayed for directions to OP to pay Rs.25,000/- as compensation alongwith cost of litigation besides the  medical insurance claim. Hence, the present complaint.

3                                             The counsel for complainant was heard with regard to admission of the complaint and vide order dated 21.04.2017, complaint was admitted and notice was ordered to be issued to the opposite party.

4                                          On receipt of the notice, OP-2 filed written statement taking preliminary objections that this Forum has no jurisdiction to hear and try the present complaint. It is asserted that there is no deficiency in service on the part of OPs. Complainant purchased the policy in dispute after fully understanding its terms and conditions and no cause of action arises in favour of complainant. Complainant has violated the terms and conditions of Policy and he has not come to the Forum with clean hands. Complainant failed to submit the requisite documents for processing the claim and therefore, present complaint is premature and is liable to be dismissed. Ops are still ready to reopen the case of complainant on submission of requisite documents by him. It is averred that complainant did not provide Investigation Reports to them to align the treatment for hospitalization as these documents are very important to ascertain the admissibility of claim. Complaint involves complicated questions of law and facts requiring voluminous evidence, which is not possible in summary procedure of this Forum and moreover, complainant has no locus standi to file the present complaint and he is stopped by his own act and conduct to file the present complaint. It is based on false and frivolous allegations and is liable to be dismissed.  However, on merits, OP-2 has denied all the allegations of complainant and reiterated that there is no deficiency on the part of OP-2. It is admitted that complainant purchased the policy in question to ensure his health against any kind of risk and it is also admitted that complainant got treatment for bronchia asthma, but they have denied other allegations of complainant being incorrect stating that required documents are not provided by complainant and complaint is premature. Documents sought by answering Ops are most important to align the treatment for hospitalization. Complainant himself is at fault in not providing requisite documents to them for processing the claim and therefore, complaint is premature and therefore, he is not entitled to relief sought. All the other allegations have been refuted with prayer to dismiss the complaint with costs.

5                                         Earlier OP-1 did not appear in the Forum despite service of summons and therefore, vide order dated 15.06.2017, OP-1 was proceeded against exparte, but lateron , when case was at the stage of evidence, OP-1 appeared in the Forum and on giving no objection by complainant counsel, OP-1 was allowed to join the proceedings.        

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 C-16 and then, closed his evidence.

7                                     In order to rebut the evidence of the complainant, ld counsel for OP-1 tendered in evidence affidavit of Deepak Mehra as Ex OP-1/1 and closed the same on behalf of OP-1

8                                        OP-2 tendered in evidence, affidavit of Deepti Rustogi as Ex OP-2/1 and document Ex Op-2/2 and then,  evidence of OP-2 was closed by order of this Forum as OP-2 did not tender any evidence despite availing several opportunities.

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

10                           From the careful perusal of record and documents placed on record by parties, it is observed that grievance of complainant is that complainant purchased Health Insurance Policy from OP-2 through OP-1 and they issued only copy of certificate of health insurance to complainant and did not provide any other document to him. During the subsistence of policy, complainant suffered from fever and cough and when despite taking medicines, he did not get any relief, then on advice of doctor, he was admitted in Dr Pirthi Pal Memorial Hospital and Heart Centre for treatment of non allergic bronchia asthma on 31.08.2016 and was discharged from there on 6.09.2016. Complainant showed his card to concerned doctor, but he told him to pay the expenses in cash and later on he would get reimbursement from OPs. After that, complainant completed all formalities and sent relevant documents regarding his treatment to OPs and requested them to reimburse the amount of Rs.27,614/-spent by him as medical treatment expense, but Ops kept lingering on the matter  and in October, 2016 on demand of Ops for requisite documents through letter, complainant submitted all the requisite documents to them and again prayed for processing his claim, but all in vain. Complainant made several requests to OPs to make payment of his insurance claim, but all in vain. Despite several requests, OPs did not make any payment of genuine mediclaim on account of treatment of his own, which amounts to deficiency in service and it has caused harassment and mental agony to complainant. He has prayed for accepting the present claim alongwith compensation and litigation expenses.  In reply, OP-2 have denied all the allegations of complainant being incorrect and wrong and asserted that there is no deficiency on the part of OP-2 though it is admitted by them that complainant purchased the policy in question from them to ensure his health against any kind of risk. It is also admitted that complainant got treatment for bronchia asthma, but denied other allegations being incorrect stating that required documents are not provided by complainant and complaint is premature. Op-2 stressed mainly on the point that documents sought by them are most important and vital to align the treatment for hospitalization. To ascertain the admissibility of claim sought by complainant, requisite documents are very necessary. Complainant himself is at fault in not providing requisite documents to them for processing the claim and therefore, complaint is premature and therefore, he is not entitled to relief sought. Ld Counsel for OP-1 has denied all the allegations levelled by complainant being wrong and incorrect and asserted that there is no deficiency in service on the part of answering OP.

11                  In the light of documents Ex C-6, it is clear that complainant was admitted in said Pirthi Pal Hospital for treatment of bronchia asthma on 31.08.2016 and was discharged therefrom on 6.09.2016. Ex C-3 is the diagnosis certificate issued by concerned doctor clearing explaining the trouble of bronchia asthma to complainant. from the document Ex C-6 which is a copy of Detailed Discharge Summary, it is clearly mentioned at Sr No. 7  that complainant suffered from this bronchia asthma for last 15 days and it clears that he has no prior history for this problem. Moreover, at serial no. 11, it is further justified that complainant has no past medical history for any kind of disease.

12                                      It is observed that documents furnished by complainant are sufficient to process the claim sought by him. Demand of those documents regarding prior history of bronchia asthma from complainant, which complainant does not have, amounts to deficiency in service. Complainant has no prior history of said disease and OP-2 should not insist for calling those documents pertaining to particular disease from which never suffered earlier. Moreover, at the time of purchasing the policy, particulars filled by complainant do not reveal that complainant was suffering from any problem of respiration or bronchia asthma. It seems that OP-2 is using delaying tactics to escape its liability of making payment of medical expenses incurred by complainant on his treatment during the subsistence of said policy. As complainant was ensured with OP-2 and this fact is admitted by them, therefore, as per rules and regulations of policy in question, complainant is entitled for reimbursement of mediclaim expenses spent by him.

13                                    From the above discussion and evidence produced by the complainant, we are of considered opinion complainant has produced sufficient and cogent evidence to prove his pleadings. Action of OP-2 for insisting upon procuring a document pertaining to prior history of bronchia asthma from which complainant did not suffer earlier does not seem appropriate. OP-2 has not made payment on account of Mediclaim of insured complainant on false grounds and it amounts to deficiency in service on the part of OP-2. Complainant has succeeded in proving his case and hence, complaint case in hand is hereby allowed. OP-2 is directed to make payment of genuine insurance claim of complainant to the tune of Rs.27,614/- i.e amount spent by complainant on his treatment alongwith interest @ 9% per anum from 17.04.2017 i.e from the date of filing the present complaint till final realization and OP-2 is further directed to pay Rs.5000/- to complainant as compensation for harassment and mental agony suffered by them besides Rs.3000/-as 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. It is also observed that there is no role of OP-1 in non reimbursement of claim to complainant, therefore, complaint against Op-1 stands hereby dismissed. 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 : 19.09.2017           

             

Member                        President                             (P Singla)                     (Ajit Aggarwal)

 

 

                 

                 cc-126-/17

     Makhan Singh Vs Canara Bank

 

 

 

 

Present:       Sh  Gurwinder Brar, Ld Counsel for complainant,

Sh Dildeep Singh,  Ld Counsel for OP-1,

                   Sh Varun Gupta, Ld Counsel for OP-2,

                   Arguments heard. Vide our separate detailed order of even date, complaint in hand is hereby allowed against OP-1 and stands dismissed against OP-1. 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 : 19.09.2017                

                                               

 Member                        President