BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 65 of 2019
Date of Institution : 06.02.2019
Date of Decision : 10.09.2019
Suresh Kumar son of Shri Jagdish Rai, resident of House No. 53, C-Block, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
- E-Meditek (EMSL), Corporate Office, Plot No. 577, Udyog Vihar, Phase-5, Gurgaon, through its Managing Director/ Medical Manager.
- HDFC Life Insurance Company, Near Sangwan Chowk, Dabwali Road, Sirsa, District Sirsa, through its Branch Manager.
- HDFC Bank Limited, Sandoz House, 2nd Floor, Shiv Sagar Estate, Dr. Annie Besant Road, Worli Mumbai, Maharashtra- 400 018, through its Managing Director.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA………………. ……PRESIDENT.
SH. ISSAM SINGH SAGWAL……..MEMBER
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. A.S. Kalra, Advocate for opposite party no.2.
Opposite parties no.1 and 3 exparte.
ORDER
The case of the complainant, in brief, is that complainant obtained a life insurance policy from the HDFC Life Insurance Company vide insurance policy No.90057447 with details as proposal date 24.12.2014, policy term whole life subject to payment of annual premium, plan type family floater, plan option silver, sum insured Rs.5,00,000/- and annual limit of Rs.5,00,000/-. It is further averred that ops have deducted premium amount of Rs.20,811/- from the complainant on 22.12.2014 and assured that this insurance shall be commenced
from 22.12.2014 and this insurance has been continued up to 1.3.2016 on payment of Rs.21,208/- as premium. It is further averred that complainant suffered serious heart pain and he was admitted in Medanta Hospital from 11.5.2015 to 14.5.2015 and stent was inserted in the body of complainant and he spent huge amount of more than Rs.2,60,000/- besides the expenses of transportation and on the medicines which are still taken by complainant as per advice of doctors. The complainant submitted claim to the op company for disbursement of above said amount of medical expenses. The complainant approached and requested the ops to pay the above said amount. The ops have demanded the documents pertaining to the treatment and bills from the complainant, which were sent to the op company without any delay but only to harass and humiliate him, the ops sent final reminder to the complainant by making totally false demand against the complainant and now the ops are avoiding to make the payment of treatment to the complainant with malafide intention and are harassing him. The act and conduct of the ops comes under the ambit of deficiency in service as well as unfair trade practice. It is further averred that complainant also served a legal notice dated 29.8.2016 upon the ops but all in vain. That earlier, the complainant had filed an application under Section 22C of the Legal Services Authority Act before the Permanent Lok Adalat, Sirsa, however, same was withdrawn on 22.11.2018 with liberty to file fresh case before the competent court of law/ Forum. The complainant also filed a complaint before this Forum against the ops which was also withdrawn on 15.1.2019 due to some technical defect with permission to file fresh complaint on the same cause of action after curing the technical defect. Hence, this complaint.
2. On notice, opposite party no.2 appeared and filed reply raising certain preliminary objections. It is submitted that complainant lodged claim with the answering op on 25.5.2015 and received by answering op no.2 on 26.5.2015 for the treatment taken for Coronary artery disease. After receiving of the claim, the answering op raised a requirement for further documents vide letter dated 30.11.2015, besides previous many reminders and as per the letter dated 30.11.2015 sent by op no.2 to the complainant, he was required to submit the following documents for the settlement of the claim:
(i) Provide clarification from the treating doctor regarding
manipulating H/O HTN in indoor case papers,
(ii) Provide all past treatment papers related to obesity, since as per
Dr. M.M. Talwar patient is suffering from obesity since 2 years.
It is further submitted that vide the said letter, the complainant was further informed that as per the above requirements, the claim is not admissible under the terms and conditions and provisions of the policy on account of unavailability of the required documents and therefore no amount is payable against the policy. It was also informed that if he wishes to represent his claim, he can do so within 30 days of the receipt of this letter at the given address, but the said requirements raised by answering op no.2 were not complied with, as such the claim of complainant is in the closed status. The complaint is pre-mature and liable to be dismissed. It is further submitted that complainant has not come to this Forum with clean hands. The complainant has lodged the claim with answering op firstly on 30.11.2016 and received by op no.2 on 1.12.2016 for the treatment taken for Chikungunya with hypertension with old IHD from Talwar Nursing Home. After receiving of the claim, the answering op raised a requirement of further documents vide letter dated 27.9.2017 besides previous many reminders. It is further submitted that complainant has sent a reply but the said reply was not sufficient and as per letter dated 27.9.2017, he was required to submit the following documents for the settlement of the claim:
- Attested copy of indoor case papers with nursing chart of hospitalization with doctor notes.
- TPR charting
- Past history with duration of the ailment certified by the treating doctor of hypertension, IHD with all past treatment papers.
- All investigation reports in support of final diagnosis of chikungunya (PCR-Chikungunya).
- The first consultation paper when hypertension, IHD were diagnosed for the first time certified by the treating doctor with supporting investigation report.
It is further submitted that said requirements were not complied with and as such claim is in the closed status. With these averments, dismissal of complaint prayed for.
3.On notice, none appeared on behalf of ops no.1 and 3 and therefore, ops no.1 and 3 were proceeded against exparte.
4.It is pertinent to mention here that alongwith the complaint, an application under Section 24(A) of the Act for condonation of delay was also filed, reply to which was filed on behalf of op no.2 and said application was allowed vide separate detailed order dated 24.5.2019.
5.The parties then led their respective evidence.
6.We have heard learned counsel for the parties and have perused the case file carefully.
7.The complainant in order to prove his case has furnished his affidavit Ex.C1 in which he has deposed and reiterated all the averments made in the complaint. He has also furnished copies of documents Ex.C2 to Ex.C32. On the other hand, op no.2 has furnished affidavit of Sh. Gurpreet Singh, Deputy Manager Legal as Ex.R1 in which he has deposed and reiterated the version of written statement and op no.2 has also furnished copies of documents Ex.OP1 to Ex.OP6.
- During the course of arguments, Sh. A.S. Kalra, learned counsel for op no.2 has submitted that complainant has not supplied the required documents which were necessary for the settlement of the claim. In case the documents are supplied by the complainant, the ops may consider and settle the claim of complainant as per terms and conditions of the policy.
On the other hand, learned counsel for complainant submitted that complainant is ready to furnish the documents as required by the op insurance company for settlement of the claim.
- In view of above, we partly allow the present complaint and direct the complainant to supply copies of the documents as per letter dated 27.09.2017 within 15 days from the date of receipt of copy of this order and thereafter theopposite party(s) insurance company is directed to re-open the closed file and consider the same alongwith documents submitted by complainant and thereafter to settle and pay the claim of complainant, if same is payable as per terms and conditions of the policy within further period of 45 days. No order as to costs. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced in open Forum. Member Member President,
Dated:10.09.2019. District Consumer Disputes
Redressal Forum, Sirsa.
