Complainant Mrs. Jyoti has filed the present complaint against the opposite parties U/S 35 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to make the payment of amount spent on her treatment as mentioned in her claim in terms of the Insurance Policy in question alongwith interest @ 18% P.A from the date of due till actual realization. Opposite parties be further directed to pay Rs.50,000/- as compensation on account of mental agony, physical harassment and deficiency in service alongwith Rs.5,000/- as litigation expenses, in the interest of justice.
2. The case of the complainant in brief is that she got insurance policy on 11.3.2019 from the opposite parties bearing No.21256000-HDFC Life Sanchay and (Main Policy & Rider Policy) for a term of 10 years and premium of this policy was Rs.15,000/- P.A. Total value of the insured amount is Rs.3 lakh. As per terms and conditions of the abovesaid policy, it is also one of the rider covered under Rider Policy that various serious and critical diseases are also covered under the rider policy for a sum of Rs.2,43,475/- and for this purpose the opposite party have also included separate premium of requisite amount in this regard from her. Unfortunately, she suffered from heart problem and to got her treatment from Holy Heart Hospital Super Specialty Centre, Near Taranwala Bridge, Amritsar on 24.04.2019 and after heart surgery she was discharged from the abovesaid hospital on 04.05.2019. She spent an amount of Rs.2,55,000/- on her treatment. Requisite intimation was given by her to the opposite party regarding her illness and agents/representatives of the opposite parties also visited hospital in order to inquiry about her medical treatment. Thereafter, she submitted her claim for the reimbursement of the amount alongwith all requisite documents, reports, bills etc. to the opposite parties. She extended her full cooperation to the opposite parties from time to time, but they have failed to pay the claim amount to her. As per terms and conditions of rider policy, she is legally entitled for the amount spent by her on her treatment, but till today the opposite parties have not paid the amount claimed by her intentionally and willfully, despite the repeated requests. She also served legal notice dated 15.01.2021 upon the opposite parties with a request to make payment of the amount but all in vain. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.
3. Notice of the complaint was issued to the opposite parties who appeared through their counsel and filed their written reply taking the preliminary objections that the complainant has no cause of action and locus standi to file the present complaint. There is no deficiency in service on the part of the insurance company. Actually, the complaint is pre-mature. No claim has ever been filed by the complainant. Even no claim number or any claim form has been produced by the complainant on the file and this fact clearly shows that she never filed any complaint and it is the complainant who is at fault and failed to fulfill her part of obligation. As no claim has been filed so no question of deciding the claim arises and the complaint is liable to be dismissed being premature. On merits , it was submitted that no claim has been filed and the applicant shall consider these facts only after filing the complaint by the complainant. The complaint is totally pre-mature. It was further submitted that no such intimation has ever been given by the complainant and even no claim has ever been filed. The complainant has not mentioned any complaint in her complaint and this fact clearly shows that she has not filed any claim and she is making false story. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
4. Complainant tendered into evidence her own affidavit Ex.CW-1/A and copies of documents Ex.C-1 to Ex.C-24 and closed the evidence.
5. Ld.counsel for the opposite parties tendered into evidence affidavit of Sh.Gurpreet Singh Deputy Manager Legal Ex.OP-1,2/1/A and copies of relevant documents Ex. OP-2 to Ex.OP-16 and closed the evidence.
6. Written arguments not filed by both the parties.
7. We have carefully gone through the pleadings of counsel for the complainant; oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the complainant for the purposes of adjudication of the present complaint.
8. In the said complaint, the complainant Jyoti had purchased a HDFC Life Sanchay policy with rider issued on 11.3.2019 (Ex.C-1/9) for a premium of Rs.15,803/-. Further the complainant had sought treatment for Heart Disease at Holy Heart Hospital, Amritsar, during the period 24.4.2019 to 4.5.2019. Complainant has further claimed that she spent Rs.2,55,000/- on her treatment. Complainant has claimed that the bills for this treatment were submitted to opposite party, but has failed to produce on record any evidence in support of the claim. The preliminary objection taken up by the opposite party in the reply that the complainant had not submitted the claim to the Company i.e. HDFC Life and has neither placed on record any proof of such submission.
9. Following the due process as agreed upon at the time of purchase of policy the said claim needs to be lodged with the opposite party in the first instance. The application is disposed of with the directions to the complainant to submit her claim in the office of opposite party and opposite party is directed to settle the claim within 15 days from the receipt of documents. No order as to costs.
10. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
11. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned.
(Naveen Puri)
President
Announced: (Ragbir Singh Sukhija)
August 10, 2022 Member
*MK*
