BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.122 of 2015

Date of Instt. 25.03.2015

Date of Decision :11.09.2015

Som Nath aged about 48 years son of Swaran Dass R/o Village Mahuwal, Post Office & Tehsil Nakodar, District Jalandhar.

..........Complainant Versus

1. HDFC Standard Life Insurance Company Ltd, 5th Floor, The IL & FS Financial Centre, Plot No.C-22, G Block, Bandra Khurla Complex, Bandra(E), Mumbai-400051, through its Manager/M.D./ CEO/ Authorized Person.

2. HDFC Standard Life Insurance Company Ltd., Ramon House, HT Parekh Marg, 169, Backbay Reclamation Churghgate, Mumbai-400020 through its Manager/MD/CEO/Authorized Person.

3. HDFC Standard Life Insurance Company Ltd, Ground Floor, SCO-139-140, Sector 9-C, Madhya Marg, Chandigarh-160017 through its Manager/Authorized Person.

4. HDFC Standard Life Insurance Company Ltd, Shoppers Square Branch, Ist & 2nd Floor, Gupta Chambers, Opposite Commissioner Office, Civil Lines, Jalandhar City-144001, through its Branch Incharge/ Authorized person.

.........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.AK Verma Adv., counsel for complainant.

Sh.Prince Tayal Adv., counsel for opposite parties.

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 is serving as Assistant Sub Inspector in Punjab Police, Jalandhar and has additionally availed the benefit of insurance from the opposite parties after paying the subscription fee and resultantly health card bearing policy No.90048272 with client ID No.71970907, which was valid from 18.10.2014 was issued by the opposite parties. Unfortunately, within the insurance time the complainant suffered coronary artery disease Unstable Angina and resultantly the complainant had to undergo for coronary artery bypass surgery from Tagore Hospital and Heart Care Centre (P) Ltd., at Banda Bahadur Nagar, Mahavir Marg, Jalandhar on 24.11.2014 and has been discharged from the hospital on 1.12.2014 as the complainant was admitted in the hospital on 22.11.2014. The total bill paid by the complainant for the said surgery is Rs.1,94,500/- out of total bill of Rs.2,07,000/-, it is specifically stated that Rs.12,500/- was discounted from the original bill amount of Rs.2,07,000/-. It is specifically made clear that as per the terms of the insurance company, for which the premium has been paid by the complainant, the limit of sum assured was Rs.3,00,000/-. The complainant had paid the amount of Rs.1,94,500/- from his own pocket with great difficulties. The complainant even after undergoing the surgery and suffering from this serious disease, has requested number of times by personally visiting the office of opposite party No.4, which was also in the knowledge of other opposite parties. It is specifically made clear that the original bills were deposited by the complainant with the opposite party No.4 and it is further specifically stated that the representatives of the opposite parties also visited the hospital and verified the facts from the hospital. Even then for the reasons best known to the opposite parties, till date the opposite parties did not give a single penny qua his claim to him, who is facing physical and mental harassment and agony at the hands of the opposite parties. On such like averments, the complainant has prayed for directing the opposite party insurance company to pay the medical expenses of Rs.1,94,500/-. He has also claimed compensation and litigation expenses.

2. Upon notice, opposite parties appeared and filed a written reply, inter-alia, pleading that so far the opposite parties have not received the complete papers/complete information from the complainant and therefore, the opposite parties are unable to process the claim of the complainant. It is further submitted that vide letter dated 20.1.2015, 2.3.2015 and 24.4.2015, the complainant was asked to submit the various documents to enable the opposite parties to process his case but the complainant has failed to supply the same, therefore, the claim of the complainant is still pending with the opposite parties. It is further submitted that as the opposite parties have not so far repudiated the claim of the complainant, therefore, the present complaint is premature hence, the same is liable to be dismissed being premature. They denied other material averments of the complainant.

3. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C7 and closed evidence.

4. On the other hand, learned counsel for the opposite parties has tendered affidavit Ex.OPA alongwith copies of documents Ex.OP1 to Ex.OP6 and closed evidence.

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

6. Without going into the other details, according to the own version of the opposite parties, they have not decided the claim of the complainant so far and same is still pending with it. According to the opposite parties, the complainant has not submitted various documents to enable them to process his case. Since the opposite party insurance company has not decided the claim of the complainant on merits so far, so, we feel that opposite party insurance company should be given an opportunity to decide the claim of the complainant on merits.

7. In view of above discussion, the present complaint is partly accepted and complainant is directed to submit any further document in respect of his claim which he may desire to the opposite party insurance company within 15 days from the date of receipt of copy of this order and thereafter the opposite parties shall positively decide the claim of the complainant within two months on the basis of documents already submitted by the complainant and on the basis of documents produced by him in evidence during the trial of the present complaint and on the basis of document, if any, which he may further submit to the insurance company. In case the opposite party insurance company fails to decide the claim of the complainant within aforesaid period of two months then the claim submitted by him shall be deemed to have been accepted by it. The insurance company shall decide the claim of the complainant one way or other i.e either to accept it or reject it irrespective of the fact that complainant may not submit any further document to the insurance company within above said period of 15 days. In the circumstances of the case, there shall be no order as to cost. 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

11.09.2015 Member Member President