Punjab

Faridkot

CC/17/22

Bipan Pal Sharma - Complainant(s)

Versus

HDFC ERGO General Insurance Co. Ltd - Opp.Party(s)

Jaswant Singh

17 Jul 2017

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     22

Date of Institution: 10.01.2017

Date of Decision :   17.07.2017

 

Bipan Pal Sharma aged 43 years, s/o Nageen Chand Sharma, r/o New Harindra Nagar, Street No. 1, House No. B-II/273, Faridkot, Tehsil and District Faridkot, State Punjab.

                                                                                        ...Complainant

Versus

 

1. HDFC Ergo General Insurance Company Ltd, 5^th Floor, Tower 1, Steller IT Park, C-25, Sector 62, Noida-201301, through its Managing Director.
2. HDFC Ergo General Insurance Company Ltd, 6^th Floor, MBC Tower, Old No. 90, New No.199, Luz Church Road, Mylapore, Chennai-600004(Tamil Nadu), through its Manager.
3. HDFC Ergo General Insurance Company Ltd, SCO 124-125 Sector 8, Madhya Marg, Chandigarh-16008 (Punjab) through its Manager.

                                                                              .......Ops

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

                Sh P Singla, Member.

 

Present: Sh Jaswant Singh, Ld Counsel for complainant,

              Sh Atul Gupta, Ld Counsel for OPs.

 

ORDER

(Ajit Aggarwal, President)

                                          Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of insurance claim worth Rs. 4 lacs pertaining to mediclaim insurance policy bearing no.2828200917687500000 and for further directing OPs to pay Rs 50,000/- as compensation for harassment, inconvenience, mental agony and litigation expenses of Rs.15,000/-.

2                                            Briefly stated, the case of the complainant is that complainant purchased a mediclaim insurance policy bearing number 2828200917687500000 on 28.11.2014 and as per policy, OPs are liable to pay Rs.4 lacs for treatment in case of accident/illness. It is submitted that on 8.12.2015, complainant met with an accident and FIR to this effect was also got registered by him at City Police Station, Faridkot under Sections 279, 337, 338 and 427 IPC and thereafter, complainant remained admitted in Amandeep Hospital and Clinic, Amritsar from 8.12.2015 to 16.12.2015 and from 21.12.2015 to 24.12.2015 and even today he is under treatment. Complainant had paid an amount of Rs.8 lacs on his treatment and medicines. Complainant submitted his claim alongwith original bills and documents with OP-2 in February, 2016 for Rs.4 lacs  and he has been supplying documents required by OPs from time to time. Even after a period 10 months, OPs have not paid a single penny for treatment. Complainant also served a legal notice dt 13.12.2016 to Opposite parties but all in vain. All this amounts to deficiency in service and trade mal practice on the part of OPs and has caused harassment and mental agony to him. He has prayed for directions to Ops to pay the insurance claim and Rs.20,000/- as compensation besides Rs.11,000/- as cost of litigation. Hence, the present complaint.

3                                             The counsel for complainant was heard with regard to admission of the complaint and vide order dated 17.01.2017, complaint was admitted and notice was ordered to be issued to the opposite party.

4                                            On receipt of the notice, OPs filed reply taking preliminary objections that complaint is not maintainable in the present form as complicated questions of law and facts are involved in it and it can not be decided in summary proceedings. Complainant has not come to the Forum with clean hands and has concealed the material fact that his claim is closed due to non submission of original documents, which are sought from complainant, but instead of submitted the requisite original documents, complainant has filed the present complaint. Complaint filed by complainant is premature as claim of complainant is closed for want of documents sought from him. OPs admitted that complainant was insured under the policy of OPs and he remained admitted in Amandeep Hospital for his treatment. It is averred that claim intimation documents were sought from complainant and despite issuance of several letters and reminders, complainant did not submit the original documents to them, rather he kept sending Ops Xerox copies of original documents. Complainant is required to submit Discharge Summary, Final Bill, Advance and final payment receipts and investigation reports against submitted bill and all these documents are required in original and not the photocopies. However, on merits, they have denied all the allegations of complainant being wrong and incorrect. It is further averred that there is no deficiency in service on the part of OPs and all the other allegations levelled have been denied being wrong and incorrect and prayed that complaint deserves to be dismissed with costs.

5                                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-161 and then, closed his evidence.

6                                   In order to rebut the evidence of the complainant, the opposite party tendered in evidence, affidavit of Pankaj Kumar as Ex OP-1, documents Ex OP-2 to 20 and then evidence of OPs was closed by order dt 14.07.2017 of this Forum.

7                                  We have heard the arguments addressed by all the parties and have also gone through the evidence and documents led by the parties.

8                                From the careful perusal of record and going through the affidavits, evidence and pleadings of the parties, it is observed that grievance of complainant is that he was insured under the policy of Ops for a sum of Rs. 4,00,000/- and during the validity of insurance period, he met with an accident and underwent indoor treatment at Amandeep Hospital, Amritsar and he is still under outdoor treatment. He has spent about Rs.8 lacs on his treatment and he submitted his claim alongwith bills and documents to OPs, but they have not made any payment on account of expenses incurred by him on his treatment. In reply, Ops admitted that complainant insured with OPs under the policy in question and it also not denied that he undertook treatment and he submitted his claim with them. OPs stress mainly on the point that complainant has not supplied them with original documents required by them despite repeated letters and issuance of reminders to him. They have pressed only for original documents namely: Discharge Summary, Final Bill, Advance and final payment receipts and investigation reports against submitted bills. They want to complainant to submit all these documents in original and not Xerox thereof.

9                                             We have carefully gone through the file and from the  above discussion, we come to the conclusion that there is no dispute about the insurance claim as it is admitted fact of Ops that complainant was insured under their insurance policy for Rs.4,00,000/- and they have themselves admitted in their written statement as well as before the Forum that they are ready to pay the insurance claim to complainant subject to submission of original Discharge Summary, Final Bill, Advance and final payment receipts and investigation reports against submitted bills. Ops have sought all these documents in original. It is observed that complaint is premature and therefore, complaint in hand stands disposed off being premature. Complainant is directed to submit all the documents namely Discharge Summary, Final Bill, Advance and final payment receipts and investigation reports against submitted bills in original to OPs within 15 days of receipt of the copy of this order and OPs are directed to process and clear the claim of complainant within 45 days of submission of original documents sought by them from complainant. Compliance of this order be made within prescribed period, failing which complainant shall be at liberty to file it afresh on the same cause of action. Copy of order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 17.07.2017                 

 

  Member                            President

                                                  (P Singla)                      (Ajit Aggarwal)