Punjab

Ludhiana

CC/21/402

Balwinder Kaur - Complainant(s)

Versus

Health Insurance TPA of India - Opp.Party(s)

R.K.Maurya

10 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:402 dated 01.09.2021.                              Date of decision: 10.12.2024.

 

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 Insurance TPA of India, 2^nd Floor, Mjestic Omnia Building A-110, Sector 4, NOIDA, Uttar Pardesh-201301, through its Claim Manager/Authorized Representative.
2. Central Bank of India, Branch Bhai Wala Chowk, through its Regional Manager.                                                                                                                                                                          …..Opposite parties 

Complaint Under section 35 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                         :         None.

 

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, having employee code PF No.22970, 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 leaving behind the complainants as his legal heirs. The insured Sh. Vijay Kumar Singla raised claims with OP2, who forwarded the same to OP1 but the same were not settled. According to the complainants, Sh. Vijay Kumar Singla submitted the claims i.e. claim vide quote bank INTC-935 (Claim No.181.100235359) dated 25.12.2018 of Rs.1,75,394/-, claim of Rs.1,65,242/- dated 16.02.2019, claim vide quite bank INTC-935 (claim No.181.100235359), dated 19.03.2019 of Rs.1,64,496/-, claim No.19110009840 dated 26.04.2019 of Rs.27,288/- in all Rs.5,32,420/- before OP2 along with documents, which was further forwarded to OP1. The insured many times requested the OPs to settle the claim but to no avail. Even legal notice dated 31.10.2019 was served upon the through Sh. R.K. Maurya, Advocate but no reply was received.

                   The complainants further stated that Sh. Vijay Kumar Singla during his life time filed another claim dated 10.12.2019 submitted on 26.12.2019 of amount of Rs.91,285/- and claim of amount of Rs.25,840/- submitted on 26.12.2019 and the same were paid by OP2. Sh. Vijay Kumar Singla died on 29.02.2020 and due to Covid-19 lockdown was imposed. They filed complaint on 21.12.2020 but the same was withdrawn on 22.07.2021 due to technical grounds. Later on the complainants filed the present complaint. In the end, the complainants have prayed for issuing directions to the OPs to pay Rs.5,32,420/- 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  02.12.2021.

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 have already filed a complaint against it on the same ground, in which OP2 appeared and filed written statement. OP2 further stated that it has nothing to do with the claim of the claimants. OP2 is not liable for any alleged damages, harassment, mental pain, agony etc. 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 vide employee code No.22970, the group insurance of Sh. Vijay Kumar Singla was issued by OP1. Claim regarding illness of Sh. Vijay Kumar Singla was sent to OP2, which OP2 forwarded to OP1 without any delay vide letter reference no.LUDH:HRD:2019 20:88 dated 10.04.2019. 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 legal notice dated 31.10.2019, Ex. C3 is the copy of letter dated 02.01.2019 written by Vijay Kumar Singla, Ex. C4/1, Ex. C4/5 to Ex. C4/14, Ex. C4/16  to Ex. C4/46, Ex. C5/3 and Ex. C5/4 are the copies of bills/receipts etc., Ex. C4/6 is the copy of letter dated 16.02.2019 written by Vijay Kumar Singla, Ex. C4/15 is the copy of letter dated 19.03.2019 written by Vijay Kumar Singla, Ex. C5/1 is the copy of letter dated 15.11.2018 written by Vijay Kumar Singla, Ex. C5/2 is the copy of claim form, Ex. C6 is the copy of death certificate of Vijay Kumar Singla, Ex. C7 is the copy of Aadhar Card of Balvinder Kaur, Ex. C8 is the copy of Aadhar Card of Pardeep Singla,  Ex. C9 is the copy of Aadhar Card of Raman Kumar Singla, Ex. C10 is the copy of Aadhar Card of Neha Jindal, Ex. C11 to Ex. C11/4 are the copies of passbook of Central Bank of India and closed the evidence.

5.                OP2 did not tender any evidence despite sufficient opportunities including last chance and imposition of costs of Rs.200/-. Even none has been appearing on behalf of OP2 since 22.10.2024 for concluding evidence as well as for depositing costs.

6.                None turned up for the complainant today also. We have heard the arguments of the counsel for the complainant and also gone through the complaint, affidavit and annexed documents and written reply produced on record by both the parties. We proceed to decide the case on merits.    

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 expired on 29.02.2020. During his life time, he remained hospitalized for different ailments and on 07.09.2018 he lodged five claims with OP2 i.e. first claim of Rs.1,64,788.50/- vide letter dated 15.11.2018 Ex. C5/1, second claim of Rs.1,75,394/- vide letter dated 02.01.2019, third claim of Rs.1,65,242/- vide letter dated 16.02.2019 Ex. C4/6, fourth claim of Rs.1,64,496/- vide letter dated 19.03.2019, fifth claim of Rs.27,288/- vide claim form Ex. C5/2. Sh. Vijay Kumar Singla submitted documents along with said letters to OP2 bank for all his said claims for its onward transmission to OP1, who is a Third Party Administrator (TPA) of “undisclosed insurance company”.

OP2 bank has claimed that it has forwarded all the claims with OP1 for settlement. However, OP2 along with written statement submitted one document dated 10.04.2019 vide which they submitted only one claim of Rs.1,64,496/-. No record was produced by OP2 bank to show that the documents of remaining four claims were also forwarded to OP1. Despite the service of legal notice dated 31.10.2019 (Ex. C2), all the 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 four claims of Rs.1,75,394/-, Rs.1,65,242/-, Rs.1,64,496/- and Rs.27,288/-  (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. However, as far as claim of Rs.1,64,788.50/- is concerned, regarding said claim, the complainants have already filed a complaint No.366 dated 21.12.2020, which was decided vide order dated 15.07.2024 by directing OP1 to consider and settle the claim of Rs.1,64,788/- along with another claim of Rs.1,74,108/-. As such, the matter regarding the said claim of Rs.1,64,788.50 has already been decided and now the complainants cannot raise reimbursement of said claim again and again.

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.1,75,394/-, Rs.1,65,242/-, Rs.1,64,496/- and Rs.27,288/- (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:10.12.2024.

Gobind Ram.