Punjab

Ludhiana

CC/20/366

Balwinder Kaur - Complainant(s)

Versus

Health India Insurance TPA Services Pvt.Ltd. - Opp.Party(s)

R.K.Maurya

15 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:366 dated 21.12.2020.                                                         Date of decision: 15.07.2024.

 

1. Balwinder Kaur W/o. Late Sh. Vijay Kumar Singla, aged about 64 years
2. Pardeep Singla S/o. Sh. Vijay Kumar Singla, aged about 45 years,
3. Raman Singla S/o. Sh. Vijay Kumar Singla, aged about 44 years, both R/o.1005, Phase II, Dugri, Urban Estate, Ludhiana.’
4. Neha Jindal W/o. Sachin Jindal, D/o. Vijay Kumar Singla, aged about 38 years R/o. B-9, 1675, Near Gud Mandi, Mandi Bagh Khajanchiya, Ludhiana, all through their special power of attorney Pardeep Singla son of Sh. Vijay Kumar Singla.                                                                                                                                            ..…Complainants

                                                Versus

1. Health India Insurance TPA Services Pvt. Ltd., Office No.406-12, 4^th Floor, Neelkanth Corporate Park, Kirol Road/Village Vidya Vihar Society, Vihar West, Mumbai-400086 through its Claim Manager/Authorized Representative.
2. Central Bank of India, Branch Bhai Wala Chowk, through its Regional Manager.                                                                                                                                                                     …..Opposite parties 

Complaint Under section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants            :         Sh. R.K. Maurya, Advocate.

For OP1                         :         Exparte.

For OP2                         :         Sh. S.K. Chawla, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainants are legal heirs of Vijay Kumar Singla, who being an employee of OP2 Central Bank of India, was covered under group insurance scheme to get benefit after his retirement. The insured remained under regular treatment due to some health problem for about 2 years and ultimately he died on 29.02.2020. The complainants raised claims of Rs.1,64,788.50 and Rs.1,74,108/- in all Rs.3,38,896.50 before OP2 along with documents, which was further forwarded to OP1. The complainants many times requested the OPs to settle the claim but to no avail. Even the complainant sent legal notice dated 31.10.2019 to the OPs through Sh. R.K. Maurya, Advocate but no reply was received. In the end, the complainants have prayed for issuing directions to the OPs to pay Rs.3,38,896.50 being medical expenses incurred on treatment of the complainant and also to pay compensation of Rs.50,000/- besides litigation expenses of Rs.15,000/-.

2.                Notice through registered post was sent to OP1, but none turned up for OP1 despite service of notice and as such, OP1 was proceeded against exparte vide order dated 06.07.2021.

3.                Upon notice, OP2 appeared and filed written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability; concealment of material facts; lack of jurisdiction and cause of action etc. OP2 stated that the complainants are not entitled to any compensation as it has not adopted any unfair trade practice or deficiency in service. The complainants have filed this complaint to grab money from OP2.

                   On merits, OP2 reiterated the crux of averments made in the preliminary objections. OP2 averred that Sh.Vijay Kumar Singla was their employee and as per the policy of the bank, the group insurance of Sh. Vijay Kumar Singla was issued by OP1. Claim regarding illness was sent to OP2, which OP2 forwarded to OP1 without any delay. OP2 further stated that it is OP1 to settle the claim and OP2 has nothing to do with the same. OP2 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

4.                In support of their claim, complainant No.2 Sh. Pardeep Singla tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainants also tendered documents Ex. C1  is the copy of Special Power of Attorney, Ex. C2 is the copy of death certificate of Vijay Kumar Singla, Ex. C3 is the copy of letter dated 15.11.2018 written by Vijay Kumar Singla, Ex. C4 to Ex. C7, Ex. C9 to Ex. C14, Ex. C16 are the copies of bills/receipts etc., Ex. C8 is the copy of letter dated 02.01.2019 written by Vijay Kumar Singla, Ex. C15 is the copy of report of CT Scan, Ex. C17 is the copy of legal notice, Ex. C18 and Ex. C19 are the copies of postal receipts and closed the evidence.

5.                On the other hand, counsel for OP2 tendered affidavit Ex. RA of Ms. Neena Sood, Senior Manager of Central Bank of India, Sarabha Nagar branch, Ludhiana along with documents Ex. R1 is the copy of claim forwarding letter dated 10.04.2019 and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties. We have also gone through written arguments submitted by OP2.

7.                One Vijay Kumar Singla, husband of complainant No.1 and father of complainant No.2 to 4 was an employee of OP2 bank having employee code  PF No.22970. Unfortunately, he died on 29.02.2020. During his life time, he remained hospitalized for different ailments and on 07.09.2018 he lodged two claims with OP2 i.e. first claim of Rs.1,64,788/- and second claim of Rs.1,74,108/-. Thereafter, on 15.11.2018 vide letter Ex. C3, he submitted original documents Ex. C4 to Ex. C7 to OP2 bank for his first claim of Rs.1,64,788/- for its onward transmission to OP1, who is a Third Party Administrator (TPA) of “undisclosed insurance company”. Similarly, Vijay Kumar Singla vide letter dated 02.01.2019 Ex. C8 submitted original documents Ex. C9 to Ex. C16 for his second claim of Rs.1,74,108/-. OP2 bank has claimed that the claim was forwarded to OP1 for its settlement but perusal of Ex. R1 shows that on 10.04.2019 vide Ex. R1, the documents as well as request for settlement was forwarded with regard to first claim only. No record was produced by OP2 bank to show that the documents of second claim were also forwarded to OP1. Despite the service of legal notice dated 31.10.2019 (Ex. C18), both claims remained unsettled.

8.                This Commission is constraint to observe that the pleadings and affidavits of both the parties are vague, sketchy and are lacking in material particulars. Even the name of the insurance company has not been mentioned or disclosed throughout the proceedings before this Commission. At the time of arguments, their respective counsels were not in a position to render  effective assistance in the absence of any documented inputs received by them from the complainant or the OPs. It is also rather shocking that the officials of the OP bank are signing written version and swearing affidavit without examining to the record. Faced with this situation, this Commission has no option but to issue direction to OP1 to consider and settle the both claims of Rs.1,64,788/- and Rs.1,74,108/-  (if not settled earlier) regarding hospitalizations of Vijay Kumar Singla within 30 days from the date of receipt of copy of this order. Further OP2 being a corporate agent of said undisclosed insurance company will proactively assist the complainant in processing and settlement of the claim.

9.                As a result of above discussion, the complaint stands disposed of with direction to OP1 to consider and settle the both claims of Rs.1,64,788/- and Rs.1,74,108/-  (if not settled earlier) regarding hospitalizations of Vijay Kumar Singla within 30 days from the date of receipt of copy of this order. Further OP2 being a corporate agent of said undisclosed insurance company will proactively assist the complainant in processing and settlement of the claim. Keeping in view the peculiar circumstances of the case there is no order as to costs and compensation.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                                (Sanjeev Batra)

Member                                                President         

 

Announced in Open Commission.

Dated:15.07.2024.

Gobind Ram.