Punjab

Sangrur

CC/637/2016

Pankaj Garg - Complainant(s)

Versus

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

SHri Sonam Mohinder

03 Mar 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                          

                                                Complaint No.  637

                                                Instituted on:    01.11.2016

                                                Decided on:       03.03.2017

 

Pankaj Garg aged 19 years son of Prem Garg, H.No.734, Guru Nanak Colony, Block-D, Opposite Sarvhitkari School, Sangrur, Tehsil and District Sangrur.

                                                        …Complainant

                                Versus

1.             IFFCO TOKIO General Insurance, SCO -65, 2^nd and 3^rd Floor, New Leela Bhawan, Patiala 147001 through its authorised signatory.

2.             IFFCO TOKIO General Insurance, registered office: IFFCO Sandan, C-1, District Center, Saket, New Delhi-110 017 through its authorised signatory.

                                                        ..Opposite parties.

 

For the complainant  :       Shri Sonam Mohinder, Adv.

For OPs                    :       Shri Darshan Gupta, Adv.

 

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Pankaj Garg, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that he purchased a policy number 13/GHI-M/15 52541543 from the OPs with ID number 15-00650339-00 under Group Insurance scheme.  It is further averred that the complainant is a student at PEC Universities of Technology at Patiala.  Further case of the complainant is that during the subsistence of the insurance policy on 18.5.2016 the complainant met with a minor accident by falling from the stairs resulting from a fall leading to laceration of pinna due to ear injury, as such the complainant was got admitted into Dr. Kapoor’s Plastic Cosmetic Laser & Hair Transplant Centre at Patiala and the surgery was done on 18.5.2016 itself and advised the complainant for follow ups dressings, as such the complainant spent an amount of Rs.14,989/- on the treatment.  Thereafter, the complainant approached the OPs for reimbursement of the claim amount, and as such on 22.6.2016 the complainant received mail from the Ops asking for registration certificate of the hospital along with infrastructure details of the hospital like number of beds, ICU etc, as such the same were sent to the Ops.  Thereafter the Ops again required various documents, which were provided. But, the Ops did not settle the claim without assigning any reason.  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 insurance claim amount of Rs.29,978/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by OPs, legal objections are taken up on the grounds that the complaint is false, frivolous and that the complaint is not maintainable and that the complainant has not come to the Forum with clean hands.  The territorial jurisdiction of this Forum has also been disputed.  On merits, issuance of the insurance policy for the period from 18.9.2015 o 17.9.2016  by the OPs on the request of the PEC University of Technology for the benefit of the students is admitted. It is further stated that the complainant was admitted in Dr. Kapoor’s plastic, laser and hair transplant centre on 18.5.2016 with the complaint of laceration pinna and was discharged on 19.5.2016 and it is further admitted that the complainant submitted claim to the insurance company on 7.6.2016 for reimbursement of Rs.14,989/- and on scrutiny of the claim documents, it was found that some essential information/documents are required in order to process the claim, therefore, the OP intimated the complainant for some essential documents, but the same were not submitted. It is stated further that the claim of the complainant is still pending due to non submission of the essential document in order to process his claim as per the terms and conditions of the policy.  It has been stated that the OP had received a claim form along with medical bills for an amount of Rs.14,989/-, but the complainant did not submit the complete sets of essential documents.  As such, any deficiency in service on the part of the Op has been denied. 

       

3.             The learned counsel for the complainant has produced Ex.C-1 affidavit of Bhupinder Singh, Ex.C-2 affidavit of Pankaj Garg, Ex.C-3 copy of ID card of the policy, Ex.C-4 copy of claim form, Ex.C-5 to Ex.C-8 copies of bills, Ex.C-9 copy of discharge slip, Ex.C-10 and Ex.C-11 copies of OPD slips, Ex.C-12 copy of slip dated 19.5.2016, Ex.C-13 to Ex.C-44 copies of emails and postal receipts etc. and closed evidence. On the other hand, the learned counsel for the Ops has produced Ex.OP-1 copy of letter dated 26.7.2016 and Ex.OP-2 affidavit and closed evidence.

 

4.             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.

 

5.             It is an admitted fact that the complainant had purchased the policy in question and was insured under the same for the period from 18.09.2015 to 17.09.2016 and it is further an admitted fact between the parties that the complainant was admitted in Dr. Kapoor’s Plastic, Laser and Hair Transplant Centre on 18.5.2016 with the complaint of Laceration Pinna and was discharged on 19.5.2016. It is further an admitted fact of the Ops that the complainant submitted the claim form to the Ops on 7.6.2016 for reimbursement of Rs.14,989/-, but on scrutiny of the documents it was found that there are some discrepancies in the documents as such, some documents were called upon from the complainant for submission.  Further case of the Ops is that the complainant was requested to provide the copy of registration certificate of the hospital and infrastructure details and further to provide a copy of indoor case papers duly signed and stamped by the hospital head.  We may mention that the complainant has produced on record the copy of the renewal certificate of registration issued by Punjab Medical Council in favour of the treating doctor, which is shown valid upto 24.09.2018, Ex.C-29 and further Ex.C-30 is the copy of certificate issued by Dr. Ajata Shatru Kapoor, M.S. M.Ch, which shows the details of the hospital such as bed, OT and round the clock staff present details and ICU etc.  But, we failed to understand why the OPs did not settle the claim of the complainant and what the Ops were requiring more from the complainant.  As such, we feel that the complainant is entitled to get the claim from the Ops on account of the amount spent by him on his treatment. 

 

6.             Now, coming to the point of compensation payable to the complainant.  The complainant has claimed an amount of Rs.29,978/- in the relief part of the complaint, but at the same time, the complainant has produced on record his own sworn affidavit wherein it has been clearly stated that the he spent a total amount of Rs.14,989/- on his treatment.  We may further mention that in the affidavit in al the paras the complainant has stated that he had spent an amount of Rs.14,989/- on the treatment. The complainant has also produced on record the bills for treatment only to the tune of Rs.14,989/-.  As such, we are of the considered opinion that ends of justice would be met if the Ops are directed to pay to the complainant an amount of Rs.14,989/- only.

 

 

7.             So, from the above discussion, we find that the OPs are not only deficient in service, but also had indulged in unfair trade practice in not settling the rightful claim of the complainant. As such, we allow the complaint and direct the OPs to pay to the complainant an amount of Rs.14,989/-  along with interest @ 9% per annum from the date of filing of the present complaint i.e. 01.11.2016 till realisation. We further order the OPs to pay to the complainant a sum of Rs.5,000/- being the amount of compensation for mental tension and agony and a sum of Rs.2500/- being the litigation expenses.

 

8.             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.

                March 3, 2017.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                             

                                                                (Sarita Garg)

                                                                    Member

 

 

                                                         (Vinod Kumar Gulati)

                                                                    Member