DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/184/2019

Date of Institution : 29.10.2019

Date of Decision : 25.08.2020

1. Asha Rani wife of Suresh Kumar son of Gian Chand resident of # 1807, Ward No. 16, Lakhi Colony, Barnala, Tehsil and District Barnala.

2. Suresh Kumar son of Gian Chand resident of # 1807, Ward No. 16, Lakhi Colony, Barnala, Tehsil and District Barnala. …Complainants

Versus

1. Iffco-Tokio General Insurance Co., Registered Office: Iffco Sadan, C1, District Centre, Saket, New Delhi-110017 Through its Branch Manager/ Authorized Signatory. 

2. Iffco-Tokio General Insurance Co. Ltd., Servicing Office, 5C/1, Sheetal Complex, Ground Floor, Rajbaha Road, Patiala-147001 Through its Branch Manager/Authorized Signatory.

3. Bhim Nursing Home, Handiaya Bazaar, Barnala-148101 Through its Doctor Bhim Sain.

…Opposite Parties

Complaint Under Consumer Protection Act, 1986.

Present: Sh. Gagandeep Garg counsel for complainants.

Sh. AK Jindal counsel for opposite parties No. 1 and 2.

Sh. Mohit Garg counsel for opposite party No. 3.  

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

(ORDER BY KULJIT SINGH, PRESIDENT):

    The complainants namely Asha Rani and another have filed the present complaint under the Consumer Protection Act, 1986 (as amended up to date)  against Iffco-Tokio General Insurance Company Limited, New Delhi and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainants earlier filed a complaint under the same title but later due to some technical defect withdraw the same with permission to file a fresh complaint, so present complaint has been filed by the complainants. The complainant has purchased one medical insurance policy from the opposite parties their agent Rajinder Kumar Singla under the plan Family Health Protector Policy vide policy No. 52791482 and paid the premium of Rs. 8,303/- on 25.5.2017 to valid till 24.5.2018 for sum assurance of Rs. 3 lacs at Barnala. Further, as per plan the spouse of policyholder also covered under the policy, so complainant and her husband covered under the said policy for one year. 

3. It is further alleged that on 16.10.2017 the complainant and her husband felt ill and were got admitted to the opposite party No. 3 where both were diagnosed with dengue and received treatment from the opposite party No. 3. The complainant remained there till 24.10.2017 and husband of the complainant remained there till 23.10.2017 and after the said dates both discharged from the hospital after paying all the amount in cash of medical treatment, doctor's fee, lab test and any other charges to the opposite party No. 3. During the said period the complainants spent an amount of Rs. 47,000/- in cash to the opposite party No. 3 for their treatment for dengue which includes laboratory test and hospitalization and medicines charges. After that complainants sent the documents including the claim form for reimbursement of claim amount through courier on 2.11.2017 which were received by the opposite parties. But in the earlier complaint the opposite parties have taken objection that complainants have not submitted the documents so on the orders of this Forum now commission dated 15.7.2019 the complainant submitted all the required documents with the opposite party No. 2 on 26.7.2019. But opposite party No. 3 refused to cooperate with the complainants and Agent of the opposite parties No. 1 and 2 namely Agham returned back because of denial and mal practice of opposite party No. 3. The complainants approached the opposite party No. 3 many times for meeting with the insurance Agent but he lingered on the matter on one pretext or the other and ultimately refused to do so. Further, the complainants also many times approached the opposite parties No. 1 and 2 for their genuine claim and opposite party No. 3 to clear the query of opposite parties No. 1 and 2 but opposite party No. 3 not cooperated with the complainants. But due to bad service of opposite party No. 3 complainants are not able to get the insurance claim from the opposite parties No. 1 and 2. The complainant also got served a legal notice on 19.1.2018 to the opposite parties but to no effect which amounts to deficiency in service and unfair trade practice on the part of the opposite parties. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite party No. 3 may be directed to clear every query of opposite parties No. 1 and 2 and opposite parties No. 1 and 2 may be directed to pay the claim of Rs. 47,000/- with interest at the rate of 18% per annum from the date of discharge till realization.  

2) To pay Rs. 35,000/- on account of compensation for mental torture, agony and  harassment.             

3) To pay Rs. 15,000/- as litigation expenses.  

4) If the opposite party No. 3 fails to clear the query of opposite parties No. 1 and 2 then opposite party No. 3 may be directed to pay the amount of Rs. 47,000/- alongwith interest at the rate of 18% per annum from the date of discharge till realization alongwith Rs. 35,000/- as compensation for mental torture and harassment and Rs. 15,000/- as litigation expenses.

4. Upon notice of this complaint, the opposite parties No. 1 and 2 filed written reply taking preliminary objections on the grounds that the complaint is baseless and groundless. Further, complainant has no locus standi to file the present complaint and this Forum has no jurisdiction to decide the present complaint. Further, complainant has not approached the Forum now Commission with clean hands and concealed material fact as the present complaint has been filed without submission of complete documents with the answering opposite parties and arranging meeting with the doctor as per order dated 15.7.2019 passed by this Forum now Commission in earlier complaint. The complainants and opposite party No. 3 have not complied with the directions of this Forum now Commission so the answering opposite parties unable to process the claim of the complainants as per terms and conditions of policy. The opposite parties have a right to decide the claim of the complainants as and when requisite documents are submitted and meeting with the treating doctor is arranged by the complainants. 

5. On merits, it is admitted that complainant has purchased Family Health Protector Policy vide policy No. 52791482 with the insurance company for the duration of 25.5.2017 to 24.5.2018 also covering her husband namely Suresh Kumar for an amount of Rs. 3,00,000/- alongwith a cumulative bonus of Rs. 15,000/- subject to certain conditions and exclusions. Further, after scrutiny of documents submitted by the complainants the representative of opposite parties visited the opposite party No. 3 to verify some facts and to collect the necessary information from the treating doctor which were essential for processing of the claim. But he was not able to meet the treating doctor. So, the opposite parties issued letters dated 8.1.2017 and 16.1.2017 to the complainant requested them to fix appointment with the treating doctor regarding the information about details of condition of the patients on first consultation, to verify registration certificate, lab register and ID proof of pathologist, to collect registration certificate of treating doctor, original discharge summary and reason for discrepancy mentioned in date of admission in hospital admission file and final bill from the treating doctor. But the said meeting was not arranged by the complainants so vide letter dated 20.3.2018 the said claim was repudiated under General definitions No. 6 of the policy for not any clarify the queries raised by the opposite parties. In this way, claim was rightly repudiated being premature and within the terms and conditions of the insurance policy. Lastly, they prayed for the dismissal of the present complaint with costs. 

6. The opposite party No. 3 also appeared and filed written reply taking preliminary objections on the grounds of groundless complaint, no jurisdiction, baseless and no locus standi to file the present complaint.

7. On merits, the opposite party No. 3 submitted that the entire record is already with the complainant which was submitted with the opposite parties No. 1 and 2. The allegations against opposite party No. 3 about refusal to cooperate are baseless and complainant not met with the answering opposite party. It is denied that complainants approached the opposite party No. 3 for meeting with the Insurance Agent and he refused for the same. It is admitted that opposite party No. 3 received the payment of Rs. 47,000/- from the complainants for the treatment and allied costs. Rest of the averments of the complaint are denied by the opposite party No. 3 and last prayed for the dismissal of the present complaint with costs. 

8. In support of their complaint, the complainants tendered into evidence copy of withdrawal order Ex.C-1, copy of policy Ex.C-2, affidavit of complainant Ex.C-3, copy of treatment bills of complainant Ex.C-4 to Ex.C-22, copy of discharge summary Ex.C-23, copy of treatment bills of husband of the complainant Ex.C-24 to Ex.C-45, copy of discharge summary Ex.C-46, copy of claim form Ex.C-47 and Ex.C-48, copy of order dated 15.7.2019 Ex.C-49, copies of letters of submission of claim documents Ex.C-50 and Ex.C-51, copy of legal notice Ex.C-52, copies of postal receipts Ex.C-53 and Ex.C-54, copies of repudiation letter Ex.C-55 and Ex.C-56, copy of Agent Identity Card Ex.C-57 and closed the  evidence.   

9. To rebut the case of the complainant, the opposite parties No. 1 and 2 copy of policy alongwith terms and conditions Ex.OP-1.2/1, copy of letter dated 8.1.2018 Ex.OP-1.2/2, copy of letter dated 16.1.2018 Ex.OP-1.2/3, copy of letter dated 20.3.2018 Ex.OP-1.2/4, copy of order dated 15.7.2019 Ex.OP-1.2/5, copy of investigation report Ex.OP-1.2/6, copy of certificate alongwith copy of affidavit of Asha Rani and all medical bills   Ex.OP-1.2/7, copy of letter Ex.OP-1.2/8, affidavit of Agam Kumar Ex.OP-1.2/9, affidavit of Mridul Ranjan Ex.OP-1.2/10 and closed the evidence. The opposite party No. 3 tendered in evidence affidavit of Dr. Bhim Sain Ex.OP-3/1 and closed the evidence. 

10. We have heard the learned counsel for the parties and have gone through the record. Written arguments filed by the complainants.

11. It is admitted fact between the parties the complainant Asha Rani purchased the Family Health Protector insurance policy Ex.C-2 from the opposite parties No. 1 and 2 for the period from 25.5.2017 to the midnight of 24.5.2018 for the sum assured of Rs. 3,15,000/- which covered the complainant No. 1 herself alongwith her spouse Suresh Kumar. It is not denied by the opposite parties No. 1 and 2 that the complainants have taken the treatment from the opposite party No. 3 within the validity period of the insurance policy i.e. from 16.10.2017 to 24.10.2017. The opposite party No. 3 also admitted that he has received the amount of Rs. 47,000/- from the complainants for their treatment for dengue. It is also admitted by the opposite parties No. 1 and 2 that they have repudiated the claim of the complainants vide letter dated 20.3.2018 Ex.C-55 for not arranging the meeting with the treating doctor even after repeated requests. 

12. The first objection of the opposite parties No. 1 to 2 for repudiating the claim of the complainants is that the complainants have not submitted the required documents as per the orders of this Forum now Commission dated 15.7.2019 but from letters dated 26.7.2019 Ex.C-50 and Ex.C-51 the complainants proved on the file that they have submitted the required documents with the opposite parties No. 1 and 2 as per the orders dated 15.7.2019 of this Forum now Commission. Further, in the repudiation letter dated 20.3.2018 Ex.C-55 it is mentioned that we have examined the documents submitted by the complainants also proved that the complainants already submitted the required documents with the opposite parties No. 1 and 2. So, this objection of the opposite parties No. 1 and 2 is of no force.

13. The second objection of the opposite parties No. 1 and 2 is that as the complainants have failed to arrange the meeting of the Agent of the Insurance company with the treating doctor i.e. opposite party No. 3, so the opposite parties cannot process of the claim of the complainants and due to this reason repudiated the same. On the other hand the opposite party No. 3 mentioned in his affidavit Ex.OP-3/1 that the complainant never approached him for the meeting with the Agent of the insurance company. 

14. To meet this objection of the opposite parties we consider the affidavit of Agam Kumar Ex.OP-1.2/9 who is the Insurance Agent of the opposite parties No. 1 and 2 and this affidavit is most important document of the present complaint. In this affidavit Agam Kumar Insurance Agent of the opposite parties deposed that he investigated the reimbursement case of Asha Rani complainant. He further deposed that he met the hospital owner/ treating doctor Dr. Bhim Sain Garg on 16.8.2019 at 11.00 AM in his hospital. So, this objection of the opposite parties that the complainants have failed to arrange the meeting of the Insurance Agent of the opposite parties with the treating doctor i.e. opposite party No. 3 is also of no force. However, in affidavit of Agam Kumar Ex.OP-1.2/9 he further deposed that the opposite party No. 3 firstly provide the ICP of both the cases to him but many discrepancies found. He further deposed that finally the treating doctor Dr. Bhim Sain Garg accept the treatment of patient Suresh Kumar but he does not accept the treatment of the patient Mrs. Rani. But Agam Kumar not cleared in his affidavit nor cleared that Mrs. Rani who is complainant or someone else. Thereafter, the opposite party No. 3 never met with the insurance Agent of the opposite parties. From this affidavit one thing is proved on the file that the Insurance Agent of the opposite parties met with the treating doctor i.e. opposite party No. 3 so the opposite parties cannot repudiate the claim of the complainants on the ground that the complainants failed to arrange the meeting with the opposite party No. 3. 

15. The opposite party No. 3 admitted in his version that he has treated both the complainants in his hospital and received the amount of Rs. 47,000/- for their treatment. Further, from the treatment bills of complainant Ex.C-4 to Ex.C-22 and copy of discharge summary of Asha Rani Ex.C-23 it is proved on the file that she has taken the treatment from the opposite party No. 3 for dengue within the validity period of the insurance policy so the objection of the opposite parties that complainant Asha Rani has not taken the treatment from the opposite party No. 3 is false and baseless. Further, cutting in the discharge summary of Suresh Kumar Ex.C-46 in our view is a clerical mistake as the policy was valid from 25.5.2017 to 24.5.2018 so complainants have not taken any benefit of this cutting and it is only a clerical mistake. In this way, the complainants have proved their case beyond any doubt and repudiation of the genuine claim of the complainants is clear cut deficiency in service and unfair trade practice on the part of the opposite parties No. 1 and 2. 

16. The Hon'ble Punjab and Haryana High Court at Chandigarh in case titled New India Assurance Company Limited Versus Smt. Usha Yadav and others 2008(3) RCR (Civil) Page-111 held as under.-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs. 5,000/- for luxury litigation being rich.”

This citation is also fully applicable to the facts of present case as in the present matter also the opposite parties earned premium of Rs. 8,303/- from the complainants but at the time when complainants lodged insurance claims then opposite parties repudiated the claim on false and baseless grounds which is clear cut deficiency in service and unfair trade practice on their part.

17. As a result of our above discussion, the complaint of the complainant is partly allowed against the opposite parties No. 1 and 2. Accordingly, the opposite parties No. 1 and 2 are directed to pay Rs. 47,000/- to the complainants in equal share on account of their insurance claims. The opposite parties No. 1 and 2 are also directed to pay Rs. 5,000/- to the complainants in equal share as consolidated amount of compensation on account of mental tension, harassment and litigation expenses. The opposite parties No. 1 and 2 are also directed to deposit Rs. 5,000/- as costs in the Consumer Legal Aid Account maintained by this Commission.  Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order, failing which the opposite parties No. 1 and 2 are directed to pay the above mentioned amount of Rs. 47,000/- to the complainants in equal share  alongwith interest at the rate of 6% per annum from the date of order till actual realization. The opposite parties No. 1 and 2 jointly and severally liable to comply with this order. Copy of this order be supplied to the parties free of costs. The file be consigned to the records after its due compliance.  

ANNOUNCED IN THE OPEN COMMISSION:

        25th Day of August 2020

 

 

 

            (Kuljit Singh)

            President

              

(Tejinder Singh Bhangu)

Member