BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.436 of 2014

Date of Instt. 11.12.2014

Date of Decision :20.05.2015

Inderjit Singh Rehal son of Gurpal Singh R/o 321, New Jawahar Nagar, Jalandhar.

..........Complainant

Versus

1. Dr.Amarjit C/o Dr.Amarjit Clinic R/o 457, Lajpat Nagar Market, near Post Office, Guru Nanak Chowk, Jalandhar City.

2. National Insurance Company through its Manager, Branch Office-II, 89 Mahavir Marg, Jalandhar.

.........Opposite parties

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.Anup Gautam Adv., counsel for complainant.

Sh.JS Uppal Adv., counsel for OP No.1.

Sh.Ramana Sharma Adv., counsel for OP No.2.

Order

J.S Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite parties on the averments that the complainant was to get the operation of Umbilical Hernia and for that reason he visited the hospital of opposite party No.1 in the first week of January, 2014. He personally met opposite party No.1 and informed him that he has a mediclaim policy from National Insurance Co.Ltd. The said policy was shown to him at that time. Opposite party No.1 assured the complainant that he has got all the requisite requirements which are required in case of mediclaim policy i.e 10 bedroom facility etc and opposite party No.1 also showed the complainant a certificate showing 10 bedroom facility issued by Pollution Control Board, Regional Office, Jalandhar. Opposite party No.1 also told the complainant that the said certificate is valid upto 31.3.2014. Believing the version of opposite party No.1, the complainant got himself admitted in his hospital on 6.1.2014 and the operation was performed and the complainant was discharged on 8.1.2014. Thereafter the complainant sent his manager Satnam Singh to the hospital of opposite party No.1 several times for collecting the medical bills relating to the complainant as the same were required for the mediclaim policy but opposite party No.1 only provided him with the discharge certificate, medicine bills and a simple cash receipt bearing No.799 dated 6.1.2014 for Rs.31,000/-. Opposite party No.1 knew very well that he was duty bound to provide the complainant with the medical bills but he started dilly dallying in this regard. The complainant went to the office of opposite party No.2 for the purpose of mediclaim but they refused to give any claim to the complainant and stated that he should get a medical bill from opposite party No.1. Thereafter the complainant visited the hospital of opposite party No.1 several times and also sent his manager to the hospital of the opposite party No.1 several times, but in vain. The officials of opposite party No.2 are also hand in glove with opposite party No.1. When the complainant goes to opposite party No.1, he told him that all the papers which are necessary for the mediclaim policy have already been given by him and that the complainant should approach the opposite party No.2 and when the complainant goes to opposite party No.2 then they say that the papers are not complete and that he should again go to opposite party No.1. In this way the complainant has been harassed by the opposite parties. On such like averments the complainant has prayed for directing the opposite parties to pay him Rs.20 Lacs as compensation.

2. Upon notice, opposite parties appeared and filed their written replies. In its written reply, opposite party No.1 pleaded that no defect or deficiency has been pointed out against opposite party No.1 during operation and after operation care and advice. The operation has been successful in every respect and there is no allegation of any defect or deficiency in the operation. Complainant was operated upon for umbilical hernia on 6.1.2014 and was discharged from the hospital on 8.1.2014 after giving proper instructions for follow-up, medicines and normal care to be taken during recuperation period. The discharge certificate, bill for medicines and a cash receipt for Rs.31,000/- bearing No.799 dated 6.1.2014 as well as other relevant papers regarding the operation, room rent, anesthetist etc were also handed over to the representative of the complainant, on the very first instance, when he came to the hospital. It is specifically denied that the complainant or his representative was made to come to the hospital several times, as alleged. A detailed bill prepared on the letter head of the hospital duly signed and stamped personally by the opposite party No.1 was handed over to the complaint on the very first instance, when the came for the same. It denied other material averments of the complainant.

3. In its separate written reply opposite party No.2 insurance company pleaded that on receipt of claim papers submitted by the complainant, it was observed that the complainant had submitted bill for Rs.31,000/- on letter head of Dr.Amarjit Clinic and receipt of payment was also on the letter head. The complainant was asked vide letter dated 25.7.2014 to submit proper numbered bill from the treating doctor and cash receipt No.1499 dated 1.6.2014 issued by the hospital for processing the claim but the complainant did not supply the same. The answering opposite party No.2 once again giving the reference of previous letter dated 25.7.2014, vide letter dated 29.8.2014 asked the complainant to submit the required documents within 10 days, otherwise the claim of the complainant shall be filed as "No Claim" but the complainant again did not respond and the complainant vide letter dated 8.10.2014 was informed that the opposite party No.2 will close the file as "No Claim". There is neither any deficiency in service nor any negligence on the part of the opposite party No.2 in handling the claim nor there is any unfair trade practice, it is the complainant himself or the opposite party No.1 who are at fault by not supplying the requisite documents for processing the settlement of the claim, as such the complaint against the opposite party No.2 is liable to be dismissed. It denied other material averments of the complainant.

4. In support of his complaint, learned counsel for complainant has tendered into evidence affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to Ex.C5, Ex.C4/1 to Ex.C4/4 and closed evidence.

5. On the other hand, learned counsel for opposite party No.1 has tendered affidavit Ex.RW1/A alongwith copies of documents Ex.R1 to Ex.R10 and closed evidence. Further learned counsel for opposite party No.2 has tendered affidavit Ex.OP2/A alongwith copies of documents Ex.OP2/1 to Ex.OP2/4 and closed evidence.

6. We have carefully gone through the record and also heard the learned counsels for the parties.

7. The facts involved in the present case are not much disputed. It is not disputed that the complainant was having mediclaim policy from opposite party No.2 insurance company and during validity of the policy, he under went operation for Hernia in the hospital of opposite party No.1 and after operation, he was discharged. The complainant lodged claim with opposite party No.2 insurance company but the opposite party No.2 insurance company closed the case of the complainant as "No Claim" vide letter dated 8.10.2014 for want of supply of certain documents by the complainant. The opposite party No.2 insurance company asked the complainant to submit bill for Rs.31,000/- which was on letter head of opposite party No.1 on numbered bill form etc. Counsel for the complainant contended that whatever documents were supplied by opposite party No.1 were submitted to the opposite party No.2 insurance company. Counsel for the opposite party No.1 contended that bill for Rs.31,000/- has been issued by opposite party No.1 on its letter head which is duly signed by opposite party No.1 and also bears his signatures and further in the bill details of the charges have also been mentioned. He further contended that cash receipt No.799 dated 6.1.2014 is from printed receipt book. He further contended that medicines bills Ex.C4/1 to Ex.C4/4 are also on printed form. We have carefully considered the version of all the parties. The insurance company has not decided the claim of the complainant on merits and it has simply closed the claim case as "No Claim" for want of submission of certain documents. In these circumstances, we feel that insurance company should be given an opportunity to decide the claim of the complainant one way or another.

8. Consequently, the present complaint is disposed off with the directions to the complainant to submit any further documents which he may desire to the insurance company within 15 days from the date of receipt of copy of this order and after the expiry of said period of 15 days, the opposite party No.2 insurance company shall positively decide the claim of the complainant within two months on the basis documents already submitted by him and further the documents, if any which he may further submit to the insurance company and also on the basis of documents produced by the complainant during the trail of the present complaint. In case the opposite party No.2 insurance company fails to decide the claim of the complainant within aforesaid period of two months then the claim of the complainant shall be deemed to have been accepted by opposite party No.2 insurance company in toto. However, in the circumstances of the present case, there shall be no order as to cost or compensation. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

20.05.2015 Member Member President