Punjab

Fatehgarh Sahib

CC/64/2016

Des Raj - Complainant(s)

Versus

ICICI Lombard General Insurance - Opp.Party(s)

Sh Gian Singh Saini

27 Oct 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

Consumer Complaint  No. 64 of 2016

                                           Date of institution : 16.06.2016                                                 

                                           Date of decision    : 27.10.2017

Des Raj son of Sh. Ram Chand resident of village Nalina, Tehsil and District Fatehgarh Sahib.

……..Complainant

Versus

1. ICICI Lombard General Insurance, Kunal Towers Ludhiana.
2. DGP Cum CGHG and Director Civil Defence Punjab, Sector 17, 17 Bays Building, Chandigarh.
3. District Commander, Punjab Home Guards, Fatehgarh Sahib.

…..Opposite Parties

Complaint Under the Consumer Protection Act.                                                  

Quorum

Sh. Ajit Pal Singh Rajput, President                                       

Sh. Inder Jit, Member

Present :  Sh.G.S.Saini, Adv. counsel for the complainant.                                      

               Sh. Sumit Gupta, Adv.Cl. for OP No.1.

               Sh. Rajesh Kumar, representative of OPs No. 2 & 3.

 

ORDER

 

Ajit Pal Singh Rajput, President.

            Complainant, Des Raj son of Sh. Ram Chand resident of village Nalina, Tehsil and District Fatehgarh Sahib, has filed this complaint against the Opposite Parties ( hereinafter referred to as the OPs) under the Consumer Protection Act. The brief facts of the complaint are as under:

2.         The complainant, who was an employee of OPs No. 2 & 3, got a membership of Group Insurance Scheme launched by the OPs. During his service he fell ill and his right leg was amputated by the doctors of Civil Hospital, Fatehgarh Sahib. The medical expenses of Rs.11,261/- incurred on his treatment were borne by him. The complainant paid the premium and was covered under the Group Insurance Scheme of the OPs. But the OPs failed to pay the insured amount to the tune of Rs.4,00,000/-, being 60% disability, and further failed to pay the claim for the medical expenses to the tune of Rs.11,261/- incurred by the complainant on his treatment.  The complainant also served a legal notice upon the OPs but in vain. The act and conduct of the OPs amounts to deficiency in service on the part of the OPs. Hence, this complaint for giving directions to the OPs to pay Rs.11,261/- as medical expenses incurred by the complainant on his treatment, Rs.4 lakhs as insured amount and Rs. 3 lakhs as compensation for pain, agony, physical suffering, loss of future prospect etc along with interest.

3.                   The complaint is contested by the OPs. In reply to the complaint OP No.1 raised certain preliminary objections, inter alia, that the present complaint is not maintainable as no claim was lodged with OP No.1 by the complainant; the present complaint is false, frivolous, vague and vexatious in nature and the complainant has concealed and suppressed the material and relevant facts of the case. As regards the facts of the complaint, OP No.1 stated that it issued Group Insurance Policy bearing No. 4005/76698784/02/000 in the name of DGP cum CGHG and Director Civil Defense Punjab, Chandigarh for the period from 23.12.2014 to 22.12.2015 subject to its terms and conditions. As per the policy, the claim is payable only in the event of death + loss of limb+ loss of eyes+ permanent total disability caused due to accident.  Under the said policy 13119 persons were insured as per the list provided by OP No.2. It is further stated that no claim was lodged by the complainant with OP No.1. Moreover, the injury on account of accident is covered as per the policy.  No claim is payable as the complainant stated that his leg was amputated due to illness and not due to accident. There is no deficiency in service on its part. After denying the other averments made in the complaint, OP No.1 prayed for dismissal of the complaint.

4.                   In reply to the complaint, OPs No. 2 & 3 raised preliminary objection that the complainant has no cause of action to file the present complaint. As regards the facts of the complaint, OPs No.2 & 3 stated that the payment of insurance claim, if, at all, lies to the complainant, is a subject matter of Insurance Company and OPs No. 2 & 3 have nothing to do with it. So far as, reimbursement of Medical Bill of the complainant is concerned, the medical bill submitted by the complainant was duly considered as per Punjab Home Guards( Welfare & Benevolent) Fund Rules, 1993. But the same was dis-approved as the reimbursement of medical expenses is allowed only to those volunteers who get injuries while performing duty. The right leg of the complainant was amputated due to Diabetes and not due to injury. There is no deficiency in service on the part of OPs No. 2 & 3. After denying the other averments made in the complaint, they prayed for dismissal of the complaint.

5.                   In order to prove his complaint, the complainant tendered in evidence his affidavit Ex. C-1, true copies of documents i.e. legal notice Ex. C-2, original postal receipts Ex. C-3 to Ex. C-5, notice dated 01.01.2016 Ex. C-6, insurance policy Ex. C-7, disability certificate Ex. C-8, discharge certificate Ex. C-9, certificate Ex. C-10, copy of pass book Ex. C-11, approval Ex. C-12, reimbursement certificate Ex. C-13, application to OP No.3 Ex. C-14, reply to legal notice Ex. C-15 and closed the evidence. In rebuttal OP No.1 tendered in evidence affidavit of Karan Nangla, Legal Manager, Ex. OP-1, true copies of documents Ex. OP-2 to OP-4 and closed the evidence.  OPs No.2 & 3 tendered in evidence affidavit of Rai Singh Dhaliwal, District Commander, Ex.OP2/1, copy of policy Ex. OP2/2 and closed the evidence.

6.                    Learned counsel for the complainant submitted that complainant was covered under the Group Insurance Scheme issued by the OPs. He pleaded that the OPs failed to pay the insured amount to the tune of Rs.4,00,000/-, being 60% disability, and further failed to pay the claim for the medical expenses to the tune of Rs.11,261/- incurred by the complainant on his treatment. Learned counsel argued that the OPs had repudiated the claim in an arbitrary and illegal manner, as it is evident from the material placed on record by the complainant.

7.                   On the other hand, the Learned counsel for OP No.1 has submitted that the complainant is not entitled to any reimbursement, as the said policy was Accident Insurance Policy and not medical insurance. He pleaded that as per the policy, the claim was payable only in the event of death + loss of limb+ loss of eyes+ permanent total disability caused due to accident. Learned counsel argued that the complainant had never lodged his claim with OP No.1, thus there was no question of deficiency in service on the part of the OP no.1.

8.                   Learned representative of OPs No.2 & 3 pleaded, that reimbursement of medical bills submitted by the complainant was duly considered as per Punjab Home Guards( Welfare & Benevolent) Fund Rules, 1993. He further pleaded that the same was dis-approved as the reimbursement of medical expenses was allowed only to those volunteers, who had suffered injuries while performing duty. He stated that the right leg of the complainant was amputated due to Diabetes and not due to injury as it is established from the medical record of the complainant.

9.          After hearing the Learned Counsel for the parties and going through the pleadings, evidence produced by the parties and the oral arguments and written submissions, we find that there is force in the  submissions made by the OPs. It is well established from the material placed on record i.e Discharge Certificate, Certificate issued by Doctor Ex.C-10 and Medical Reimbursement Certificate Ex.C-13, that the right foot of the complainant was amputated due to diabetic disease. Further complainant has failed to place on record any material to prove that he had filed his claim with OP No.1. We have pursued the terms and condition of the Group Personal Accident Insurance Policy Ex.OP-3(colly) under the said policy,  reimbursement of medical expenses was only allowed/entitled to those volunteers, who had suffered injuries while performing duty. Thus the complainant was not entitled to receive reimbursement.

10.                 Accordingly, in view of our aforesaid discussion, we find that complainant was not entitled to reimbursement as his right leg was amputated, due to diabetic disease. We also find that the OPs had not committed any deficiency in service, as the reimbursement of medical bills had been rejected keeping in view the terms and conditions of the Group Accident Insurance Policy. Hence the present complaint is hereby dismissed being devoid of any merits.    

11.                  Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated:27.10.2017

(A.P.S.Rajput)                       

  President

 

(Inder Jit)                      

Member