DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH =============== Complaint Case No | : | 599 OF 2011 | Date of Institution | : | 23.12.2011 | Date of Decision | : | 09.07.2012 |
Yogesh Sharma wife of Late Sh. Rakesh Sharma, resident of House No. 641, Sector 41-A, Chandigarh. ---Complainant Vs [1] Iffco Tokio General Insurance, Plot No.2, B&C, 4th Floor, Sector 28-A, Madhya Marg, Chandigarh, through its Manager/ Authorized Representative. [2] Paramount Health Services (TPA) Pvt. Ltd., Elite Auto House, 54-A, Chakala, M. Vasanji Road, Off Andheri- Kurla Road, Andheri (E), Mumbai – 400093. [3] M/s The Ravalgaon Sugar Farm Ltd., 10, Arcade Tower, World Trade Centre, Cuffe Parade, Mumbai, Maharashtra. ---- Opposite Parties BEFORE: MRS.MADHU MUTNEJA PRESIDING MEMBER SH.JASWINDER SINGH SIDHU MEMBER Argued By: Shri Sandeep Bhardwaj, Advocate for the Complainant. Ms. Amarjeet Kaur, Proxy Counsel for Sh. P.M. Goyal, Adv. for OP No.1. Opposite Parties No.2 & 3 ex-parte. PER MADHU MUTNEJA, MEMBER 1. The instant complaint relates to non-payment of insurance claim by the Opposite Parties, due on the death of Sh. Rakesh Sharma deceased husband of the Complainant. Factually speaking, the husband of the Complainant was an employee of Opposite Party No.3 and was insured with a medi-claim policy from Opposite Party No.1, through Opposite Party No.2. The insurance premium was received from the salary account of the husband of the Complainant as it was group medi-claim policy for all the employees of Opposite Party No.3. The relevant period of policy is from 01.10.2010 to 08.11.2011. A card had been issued in the name of the family, wherein treatment for all was allowed, along with room charges and ICU charges. The husband of the Complainant was admitted in the ICU of PGI on 19/20.2.2011. He passed away on 11.03.2011. The Opposite Parties had been duly informed about the admission and treatment. After the death of the husband, the Complainant completed all the formalities required by the Opposite Parties for payment of claim. Certain documents were required as per letter dated 07.04.2011 by the Opposite Parties, which were duly supplied by the Complainant. Surprisingly, the Complainant received a request for the same documents from the Opposite Parties again in June, 2011. The Complainant once again sent the required documents. The Complainant has stated that she did not have any other source of income hence as the amount of insurance was not being released, she issued a legal notice to the Opposite Parties on 19.11.2011. No reply was received. The Complainant thus filed the present complaint claiming a sum of Rs.1,31,611/-, along with interest, besides ICU charges, compensation and costs of litigation. 2. After admission of the complaint, notices were sent to the Opposite Parties. 3. Opposite Party No.1 in reply has stated that there is no deficiency in service on their part, hence, the present complaint is not maintainable. Further, any claim under the policy was subject to terms and conditions upto the limit of Rs.1,00,000/-. The Complainant has claimed Rs.1,20,000/- on which total non payable amount is Rs.15,176/-. Hence, the total payable amount is Rs.1,04,824/-. As the limit of insurance was Rs.1,00,000/-, the claim was settled for Rs.1,00,000/- and this amount was paid to the Complainant, vide Cheque dated 29.2.2012. It was realized on 17.3.2012. Opposite Party No.1 has, therefore, prayed that they have no liability after the payment of claim and have thus, prayed for dismissal of the complaint. 4. Opposite Party No.3 in response to notice has sent a letter dated 7.2.2012. In this letter it has been submitted that the company has already paid the dues in full and final settlement in respect of its ex-employee Late Mr. Rakesh Sharma to his wife Mrs. Yogesh Sharma. The insurance claim, along with requisite documents furnished by Mrs. Yogesh Sharma were submitted by the company on 30.03.2011 to M/s Paramount Health services (TPA) Pvt. Ltd. (Opposite Party No.2), for onward submission to Opposite Party No.1. The settlement of claim is purely the prerogative of Opposite Parties No.1 and 2, as per terms and conditions of the policy. However, Opposite Party No.3 had taken steps on humanitarian grounds to expedite the claim with the other Opposite Parties. Hence, they are not responsible for any delay in settlement of claim. 5. As none appeared on behalf of Opposite Party No.2 and no other reply was received from Opposite Party No.3, they were proceeded against exparte on 30.05.2012. 6. Parties led evidence in support of their contentions. 7. We have heard the learned counsel for the Complainant and Opposite Party No.1 and have perused the record. 8. The grievance of the Complainant is that despite being entitled to an insurance claim, issued by Opposite Party No.1 against a group medi-claim policy taken by Opposite Party No.3 of which her husband was an employee, the Opposite Parties have unnecessarily delayed the payment of claim amount. Opposite Party No.1 in reply has stated that as the due amount has been paid the Complainant is not entitled to any further relief. Opposite Party No.2 has not appeared or given any reply. The reason for the delay in making payment has not been explained by the Opposite Party No.1. It is evident that there has not been any objection to the claim filed as the full amount due as per policy has been paid. 9. A look at the sequence of events shows that the deceased was admitted in hospital in February, 2011, and passed away in March, 2011. The Opposite Parties were informed about the hospitalization as soon as the deceased was admitted. After his death, the claim was filed with them, and all the relevant documents were supplied by the Complainant in April, 2011. The documents were re-submitted in June, 2011. But the payment was actually realized in March, 2012, only; which is one year after the death of the deceased. It is a case of a widow with no other source of income having to face the loss of her husband with two young children to support, and also being made to run to the Opposite Parties again and again, to satisfy their documentary demands for release of her rightful dues. The casual attitude of the employees of Opposite Parties No.1 and 2 is evident in the situation. 10. Hence even though the full amount of insurance claim has been paid to her as per terms and conditions of policy, during the pendency of the complaint, in our opinion, the Opposite Parties No.1 and 2 are liable for deficiency in service for the delay and harassment caused to the Complainant. The claim was released only after she filed a complaint before this Forum. In these circumstances, we deem it appropriate that the Opposite Parties No.1 and 2 must be burdened with payment of interest, costs of litigation and reasonable compensation for the harassment and delay caused by them to the Complainant. 11. In the given situation, we allow this complaint in favour of the Complainant and direct the Opposite Parties No.1 and 2 to pay a consolidated amount of Rs.25,000/- to the Complainant towards compensation and interest. The Opposite Parties No.1 and 2 will be at liberty to recover this money from the employees who are responsible for the delay. Opposite Parties No.1 and 2 shall also pay Rs.10,000/- as costs of litigation. 12. However, as no cause of action against Opposite Party No.3 is made out the complaint against them is dismissed. 13. The above said order shall be complied within 45 days from the date of its receipt, failing which Opposite Parties No.1 and 2 will be liable for an interest @12% per annum on the awarded amount Rs.25,000/-, from the date of this order, till it is paid, besides paying Rs.10,000/- as cost of litigation. 14. Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room. Announced 09th July, 2012. Sd/- (MADHU MUTNEJA) PRESIDING MEMBER Sd/- (JASWINDER SINGH SIDHU) MEMBER
| | MR. JASWINDER SINGH SIDHU, MEMBER | MRS. MADHU MUTNEJA, PRESIDING MEMBER | , | |
