| ORDER | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.113 of 09-04-2015 Decided on 01-01-2016 Sukhvir Singh aged about 39 years S/o Karnail Singh S/o Gurdev Singh R/o Kothe Natha Singh Wale (Mehma Swai), Tehsil Goniana Mandi, District Bathinda. ........Complainant Versus 1.HDFC Standard Life Insurance Company Limited, 12th and 13th Floor, Lodha Excelus, Apollo Mill Compound, N.M Joshi Marg, Mahalaxmi, Mumbai, Maharashtra, through its Manager. 2.HDFC Standard Life Insurance Company Limited, E-Meditek (TPA), Services Limited, Plot No.577, Udyog Vihar, Phase-V, Gurgaon, through its Manager. 3.HDFC Standard Life Insurance Company Limited, Ground Floor, Plot No.3038-A, Dalip Singh Walia Complex, Guru Kanshi Marg, National Highway No.15, Bathinda, through its Branch Manager. .......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.M.P Singh Pahwa, President. Smt.Sukhwinder Kaur, Member. Sh.Jarnail Singh, Member. Present:- For the Complainant: Sh.Vikas Gupta, counsel for the complainant. For Opposite parties: Sh.Vinod Garg, counsel for opposite parties. ORDER M. P. Singh Pahwa, President The complainant Sukhvir Singh (here-in-after referred to as complainant) has filed complaint U/s 12 of Consumer Protection Act, 1986 against opposite parties HDFC Standard Life Insurance Company Limited and others (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that in the month of September 2014 he purchased one Health Insurance Policy from HDFC, Life Health Assurance Plan policy for his family, consisting of himself, his wife Chranjit Kaur, son Harkamal Singh and daughter Jaspreet Kaur. Opposite parties issued policy bearing No.90044662 for sum assured of Rs.3 lacs per annum to him. He paid premium of Rs.15,663/- for this policy. It is alleged that unfortunately, in the first week of December 2014, the complainant suffered from Laproscopic and Adhesiolysis disease. He visited Max Super Specialty Hospital, Bathinda and consulted Dr.Vikas Jindal, Laproscopic and General Surgeon. On his advice, the complainant got conducted X-ray on 10.12.2014 whereby 'few small fluid levels' were seen in abdomen and paid an amount of Rs.450/- for X-ray examination. Thereafter as per doctor advice, he also got conducted various tests and was admitted and treated in Max Super Specialty Hospital, Bathinda. It is further alleged that the complainant was suffering from recurrent SAIO for which he had to undergo laproscopic and adhesiolysis surgery on 13.12.2014, which was done by Dr.Vikas Jindal. He paid the total amount of Rs.53,933/- for his treatment to Max Super Specialty Hospital, Bathinda and he was discharged on 15.12.2014. As per complainant, he submitted his claim alongwith medical bills to opposite party No.3 for reimbursement as per insurance policy. Opposite party No.3 asked him to submit the claim alongwith documents to the head office situated at Gurgaon. He sent all the documents alongwith claim to opposite party No.2 at Gurgaon through On-Dot courier vide receipt No.636456661 dated 4.3.2015, but the claim has not been accepted/rejected by opposite parties. On this backdrop of facts, the complainant has alleged deficiency in service on the part of opposite parties. He has claimed reimbursement of Rs.53,933/- in addition to Rs.1 lac as damages and Rs.11,000/- as cost of litigation. Upon notice, opposite parties appeared through their counsel and contested the complaint by filing their joint written version. In written version, opposite parties have raised the legal objections that the intricate questions of law and facts are involved in this complaint, which require voluminous documents and evidence, which is not possible in the summary procedure under 'Act' and appropriate remedy, if any, lies only in the civil court. The complainant has concealed the material facts from this Forum and opposite parties. He is not entitled for any relief. He has concealed the facts that vide letters dated 9.1.2015 and 20.1.2015, he was asked to submit the following documents:- i) History of disease since when the 1st consultation papers certified by treating doctors. Since when is suffering from SAIO. ii) Attested copy of indoor case papers with nursing chart of hospitalization. iii) Provide original X-ray films. Reply of the complainant was not sufficient. Therefore, vide letters dated 27.1.2015 and 3.2.2015, he was asked to submit clarification on reasons for writing diagnosis as recurrent SAIO in discharge papers and past treatment papers related to same for processing and decision of claim, but he did not submit the details of treatment and documents and has filed this complaint, which is premature and is liable to be dismissed. Further legal objections are that this complaint is liable to dismissed for non-joinder of necessary parties. The complainant is not consumer of opposite parties. He has no locus-standi or cause-of-action to file this complaint against opposite parties. The complaint is not maintainable in its present form. On merits also, opposite parties have controverted all material averments. However, it is admitted that the policy bearing No.90044662 was issued to the complainant for sum assured of Rs.3 lacs. Payment of premium is not disputed, but all other material averments are controverted. Opposite parties have reiterated their stand as taken in the legal objections and detailed above. In the end, they prayed for dismissal of complaint. Parties were afforded opportunities to produce evidence. In support of his version, the complainant tendered into evidence documents Ex.C1 to Ex.C16, which includes his own affidavit dated 10.8.2015; photocopy of prescription slip; discharge summary and claim form. In order to rebut the claim of complainant, opposite parties tendered into evidence affidavit of Amit Khanna dated 29.10.2015, (Ex.OP1/1); photocopies of letters (Ex.OP1/2 to Ex.OP1/5) and photocopy of policy, (Ex.OP1/6). We have heard learned counsel for the parties and gone through the file carefully. Learned counsel for complainant has submitted that the material facts are not in controversy. It is not disputed that the complainant got issued policy up to Rs.3 lacs. Payment of premium is not disputed. The complainant has asserted that he got treatment from Max Super Specialty Hospital, Bathinda and submitted claim alongwith documents, this fact is also not disputed. Opposite parties have neither honoured the claim of the complainant nor repudiated it. Opposite parties lingered on the matter without any justification. Of-course, opposite parties have produced copy of letters seeking clarification from the complainant for writing diagnosis as recurrent SAIO in discharge papers and past treatment papers related to same. The complainant has not taken any treatment before treatment in question. He is not supposed to be in possession of past treatment papers. As such, he cannot be asked to submit the same. The attested copy of indoor case papers was already submitted. The complainant is ready to submit original X-ray. Therefore, there is deficiency in service on the part of opposite parties. Complaint be accepted and opposite parties be directed to process the case of the complainant without asking for any further information. On the other hand, learned counsel for opposite parties has submitted that the complaint is premature. Opposite parties have not repudiated the claim of the complainant and claim is pending only on account of default on his part in submitting required documents and information. Opposite parties have placed on record letters, which prove that the complainant was repeatedly asked to submit information. Therefore, the complaint is premature and liable to be dismissed. We have given careful consideration to these submissions. The material facts are not in dispute. It is not disputed that the complainant purchased one insurance policy from opposite parties. It is also not disputed that the complainant got treatment from Max Super Specialty Hospital, Bathinda and submitted claim alongwith documents. The stand of opposite parties is that the complainant has not furnished documents called for vide letters dated 9.1.2015, 20.1.2015, 27.1.2015 and 3.2.2015. A perusal of these letters show that the complainant was asked to provide clarification on reasons for writing diagnosis as recurrent SAIO in discharge papers and past treatment papers related to same. The complainant has not revealed about any past treatment and there is nothing on record to prove that he got treatment earlier to the treatment in question. Therefore, the complainant cannot be expected to furnish past treatment papers. Copy of certificate, (Ex.C3) issued by Dr.Vikas Jindal explained the reasons for writing diagnosis as recurrent. Therefore, clarification sought vide letter dated 3.2.2015 already stands complied with. Of-course, there is nothing to show that the complainant has provided X-ray films. As such, the complainant is liable to provide X-ray films, if not so far provided. Opposite parties have not so far repudiated the claim of the complainant. Therefore, at this stage opposite parties cannot be directed to reimburse the complainant on account of his medical treatment. Certainly, opposite parties are to process the claim of the complainant and only thereafter take the final call on the basis of terms and conditions of policy. For the reasons recorded above, the complaint is partly accepted without any order as to cost against opposite parties with the directions that they will decide the claim of the complainant within one month after receiving X-ray films (if not earlier received) from him. Opposite parties are at liberty to seek any other information/clarification, which is required as per terms and conditions of the policy to process the claim. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 01-01-2016 (M.P Singh Pahwa ) President (Sukhwinder Kaur) Member
(Jarnail Singh) Member
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