Punjab

Sangrur

CC/442/2017

Davinder Kaur - Complainant(s)

Versus

IFFCO TOKIO General Insurance Company Limited - Opp.Party(s)

SH.Nem Kumar

01 Feb 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                      

                                                Complaint No.    442

                                                Instituted on:      05.09.2017

                                                Decided on:       01.02.2018

 

1.Davinder Kaur aged 50 years w/o Pritpal Singh;

2.PritpalSingh aged 52 years son of Ajmer Singh, both R/O Bhawanigarh Road, Village Dhura, Tehsil Dhuri, Distt. Sangrur.

                                                        …Complainant

 

                                Versus

 

1.             IFFCO TOKIO General Insurance Co. Ltd. through its MD, IFFCO Sadan, C-1, District Centre, Saket, New Delhi.

2.             IFFCO TOKIO General Insurance Co. Ltd. through its Servicing Manager, 5C/1, Sheetal Complex, Ground Floor, Rajbaha Road, Patiala.

3.             IFFCO TOKIO General Insurance Co. Ltd. through its Br. Manager, Opposite Bhatta Sahib, Gurudwara, Ropar.

4.             Columbia Asia Hospital through its Manager, Bhupindra Road, Near 22 Number Phatak, Patiala.

                                                        ..Opposite parties.

 

 

For the complainant    :       Shri Nem Kumar, Adv.

For Opp.party No.1to3:       Shri Darshan Gupta, Adv.

For OP No.4              :       Shri Ashi Goyal, Adv.

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

Order by : Sukhpal Singh Gill, President.

 

1.             Smt. Davinder Kaur and Shri Pritpal Singh, complainants (referred to as complainant in short) have preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainants availed the services of the OPs number 1 to 3 by getting a medical insurance policy for Rs.3,00,000/- for the period from 16.8.2016 to 15.8.2017 by paying the requisite premium of Rs.12,540/- vide cheque number 400676 dated 17.8.2016 and the OPs also issued cards bearing ID Number 52665966-1-0 and 52665966-2-0.  The grievance of the complainant number 1 is that on 19.6.2017, she slipped in the stairs at her home and sustained injuries upon her body as such she was taken to village doctor/pharmacist for treatment, however, he advised treatment from hospital having better medical facilities, as such, the agent of the OPs apprised the complainant to approach OP number 4 for treatment under cashless facility. As such, the better complainant approached OP number 4, who charged Rs.450/- as registration and specialist consultation charges to assess if the complainant number 1 is entitled for medical facility under insurance, but thereafter refused to provide the cashless facility. Further case of the complainant is that the amount of Rs.22,113/- was recovered from the complainant as the cashless facility was not provided by the insurer.  Thereafter the complainant lodged the claim for reimbursement of Rs.22,563/- and submitted the medical bills along with cancelled cheque, but the claim of the complainant was repudiated vide letter dated 17.7.2017 on the ground that the claim is not payable as the same has arisen within the two years of the policy.  It is further averred that in case of accident, the claim cannot be denied and the Ops have wrongly repudiated the claim. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.22,563/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             Record shows that the OP number 4 did not appear despite service, as such was proceeded exparte.

 

3.             In reply filed by OPs number 1 to 3, legal objections are taken up on the grounds that the present complaint is totally misconceived, that the complaint is baseless, that the complainant has dragged the Ops into unwanted litigation and that intricate questions of law and facts are involved in the present case. On merits, it is admitted that the complainants had obtained the policy in question for the period from 16.8.2016 to 15.8.2017 for Rs.3,00,000/-, which is subject to the terms and conditions.  It is stated that the complaint is false and baseless and is after thought as it has not been mentioned regarding the alleged accident of the complainant in the cashless request form as well as in the discharge summary of the Columbia Hospital submitted to the insurance company.  As per the discharge summary, the patient has history of LBP, neck pain-5 days, Acute Left sided chest pain, O/E, LS Spine/C spine, PSMS plus ROM P&R, hence, present complaint filed by the complainant is frivolous with an ulterior motive of extracting money from the OPs.  The other allegations levelled in the complaint have been denied in toto and it has been stated that the claim has rightly been repudiated.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-20 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OP number 1 to 3 has produced Ex.OP1to3/1 affidavit along with Annexure R-1 to R-6 and closed evidence.

 

5.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

6.             It is an admitted fact between the parties that the complainants were insured with the Ops number 1 to 3 under medi claim insurance policy for Rs.3,00,000/- by paying the requisite premium for the period from 16.8.2016 to 15.8.2017, as is evident from the copy of the insurance policy on record as Ex.C-5.  It is further an admitted fact that the complainant number 1 slipped from the stairs and suffered internal injuries, as is evident from the affidavits of the complainants Ex.C-1 and Ex.C-2 and further it is supported by the affidavit of Dr. Dharminder Singh Ex.C-3  and his certificate Ex.C-4 . To support this contention, the complainant has produced on record various documents as well as medical bills to show that she suffered injuries by felling from the stairs and spent an amount of Rs.22563/- on her treatment and paid to the OP number 4 as is evident from the receipt issued by OP number 4, which is on record as Ex.C-11.  On the other hand, the learned counsel for OPs number 1 to 3 has contended vehemently that the claim was not payable as the claim arose within the very first year of the policy and the claim is only payable after the expiry of two years of obtaining the insurance policy. But, we are unable to go with the contention of the learned counsel for the OPs number 1 to 3 as the complaint of the complainant is fully maintainable, as she suffered accidental injuries by felling from the stairs as mentioned in the complaint as well as in the affidavits.    In the circumstances, we are of the considered opinion that the Ops number 1 to 3 are deficient in service by not settling the rightful claim of the complainant, which amount was paid by her from own pocket to OP number 4.

 

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

8.             Accordingly, in view of our above discussion, we allow the complaint and direct OP number 1 to 3 to pay to the complainant an amount of Rs.22,563/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 05.09.2017 till realisation.  We further order the OP number 1 to 3 to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.

 

9.             This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        February 1, 2018.

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member