BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 94 of 2013

Date of Institution: 01-02-2013

Date of Decision: 08-07-2015

1. Sh.Gurmeet Singh son of Joginder Singh, 19, Court Road, Opposite HDFC Bank, Amritsar.
2. Smt.Manmeet Kaur wife of Sh.Gurmeet Singh son of Joginder Singh, 19, Court Road, Opposite HDFC Bank, Amritsar. 

Complainants

Versus

1. Indian Overseas Bank, 10/B, Shopping Centre Market, Green Avenue, Amritsar through its Manager/ Person over all Incharge.
2. M/s.Universal Sompo General Insurance Company Limited, Registered Office at A Wing, 201-208, Crystal Plaza, 2^nd Floor, Opposite Infinity Mall, Link Road, Andheri (W), Mumbai through its General Manager/ Person Over all Incharge.
3. M/s.Universal Sompo General Insurance Company Limited, SCO 4, 2^nd Floor, PUDA Complex, Ladowali Road, Jalandhar through its Branch Manager/ Person Over all Incharge.
4. M/s.Universal Sompo General Insurance Company Limited, SCO 4, 2^nd Floor, PUDA Complex, Ladowali Road, Jalandhar through its Regional Manager.
5. M/s.TTK Healthcare TPA Pvt. Limited having its office at 88, 2^nd Floor, Anmol Palani, G.N.Chetty Road, T.Nagar, Chennai. 

Opposite Parties

Complaint under section 11 and 12 of the Consumer Protection Act, 1986.

Present: For the Complainants: Sh.G.S.Nagra, Advocate.

              For the Opposite Party No.1: Sh.R.K.Sharma, Advocate

              For the Opposite Parties No.2 to 5: Sh.P.N.Khanna, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by the complainants under the provisions of the Consumer Protection Act alleging therein that the complainant No.1 is having a Joint Saving Bank Account No. 11116 with Opposite Party No.1 and in the year 2010, the complainant obtained the facility of Housing Loan from Opposite Party No.1 and at the same time, as per the policy of the Opposite Parties, the complainants and their other family members were got insured under the IOB Health Care Plus Policy and this fact was later on came into the knowledge of the complainants and as such they were not aware about the impugned policy at that time and moreover, at the time of sanctioning the housing loan the complainant was made to sign on certain blank agreements, stamp papers and printed as well as on blank papers by Opposite Party No.1 on the pretext that said papers and stamp papers were required during the processing of the loan case.  The contents of the aforesaid blank loan agreement and other documents of the impugned policy were neither read over nor explained to the complainants and as per the policy of the Opposite Parties No.1 and 2, the complainants alongwith their other family members were duly insured under the IOB Health Care Plus Policy and at the time of obtaining the facility of Housing Loan the complainants and their family members were also insured under the policy namely IOB Health Care Plus Policy vide Policy No.2817/50285032/01/B00 and in respect thereof, the premium was deducted time to time from the Joint Bank Account of the complainants directly by Opposite Parties No.2 & 3 and this policy was further renewed by the Opposite Parties No.2 & 3. However, relating to the impugned insurance, no policy schedule alongwith terms and conditions were at all supplied to the complainants at any time. Complainants allege that during the period of the insurance policy, in the month of July, 2011 the complainant No. 2 i.e. wife of the complainant No.1 underwent some treatment and on the advice of their doctor, the complainant No.2 was got admitted in the hospital for surgery of her uterus and during the course of said treatment, the complainants spent an amount of Rs.60,000/- towards hospitalization charges and medical expenses, etc. on the belief that they would be reimbursed by the Opposite Parties No.2 & 3 positively. The complainant No.1 submitted a claim of Rs.60,000/- to the Opposite Party No.1 alognwith all requisite documents for settlement and payment under the said insurance policy and also requested the insurance company i.e. Opposite Parties No.2 & 3 to settle the claim and in respect thereof false assurances were given by Opposite Parties No.2 & 3 to settle the claim within a short period and very soon, but all in vain. The complainant also served a legal notice dated 29.3.2012 through his counsel to Opposite Parties No. 1 to 3 to make the payment of the impugned claim, but to no affect. Alleging the same to be deficiency in service, complaint was filed seeking directions to the Opposite Parties to pay a sum of Rs.60,000/- to the complainants alongwith interest @ 18% per annum. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party No.1 appeared and filed written version in which it was submitted that  admittedly, complainant No.1 is having a joint saving bank account No. 11116 with Opposite Party No.1. It is also admitted that the complainant obtained the facility of housing loan from Opposite Party No.1. It is also admitted that the complainants and their other family members were got insured under the IOB Health Care Plus Policy, but that policy was taken by the complainant voluntarily at his own accord from Opposite Parties No.2 & 3. It is denied that at the time of sanctioning of the housing loan, the complainant was made to sign on certain blank agreements, stamp papers and printed as well as blank papers. Moreover, the Opposite Party No.1 forwarded the claim of the complainant  to Opposite Parties No.2 & 3 and now it is only the Opposite Parties No.2 & 3 who have to pay the claim to the complainant. It is admitted that Opposite Party No.1 also recommended the Opposite Parties No.2 & 3 to settle the claim of the complainant and also even wrote letters to Opposite Parties No.2 & 3 requesting to settle the claim of the complainant.  While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite Parties No. 2 to 5 appeared and filed written version in which it was submitted that the present complaint is not legally maintainable. In fact the claim should have been made under H.C.Plus Policy i.e. being Cashless Policy and requisition was to be made by the concerned hospital authorities with the Opposite Parties No. 2 to 4. Moreover, as per the allegations made in the complaint, the complainant No.2 suffered some ailment in July, 2011 whereas the letter was received from Opposite Party No.1 in the month of December, 2011, which should be given immediately and thereafter documents required by the insurance company for processing the claim on merits should also be supplied within reasonable time. As both these conditions have been violated in the present case, the present complaint is not legally maintainable. However, TPA M/s. TTK Healthcare TPA Private Limited after scrutinizing the documents produced by the complainant, observed that the following documents are still required.

i)       Treating Doctor’s clarification about exact during of illness and first consultation report.

ii)      Treating Doctor’s clarification about previous treatment detail (all doctor’s prescription and lab reports)

iii)     Treating Doctor’s clarification about whether the patient had any similar previous episodes and treatment details of those episodes.          

Accordingly, the said TPA demanded the aforesaid documents from the complainant by writing letters and various reminders, but the said documents were not supplied and a such, finally vide letter dated 15.8.2012 the complainant was informed that as the concerned queries were not cleared, therefore, the claim file stands closed.  While denying and controverting other allegations, dismissal of complaint was prayed.

4. Complainants tendered into evidence the affidavit of Gurmeet Singh, one of the complainants Ex.C1 alongwith documents Ex.C2 to Ex.C27 and closed the evidence on behalf of the complainant.
5. Opposite Party No.1 tendered into evidence affidavit of Sh.Heera Singh, Manager Ex.OP1/1 alongwith copy of letter Ex.OP1/2  and closed the evidence on behalf of the Opposite Party No.1
6. Opposite Parties  No.2 to 5 tendered into evidence the affidavit of Sh.Piyush Shanker, Manager Ex.OP2-5/1, affidavit of Anmol Palani, Chief Operating Officer Ex.OP2-5/2 alongwith documents Ex.OP2-5/3 to Ex.OP2-5/7 and closed the evidence on behalf of Opposite Parties  No.2 to 5. 
7. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
8. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that complainant No.1 is having a Joint Saving Bank Account No. 11116 with Opposite Party No.1. In the year 2010, the complainant obtained the facility of Housing Loan from Opposite Party No.1 and as per the policy of the Opposite Parties, the complainants and their other family members were insured under the IOB Health Care Plus Policy which fact came into the knowledge of the complainants and as such they were not aware about the impugned policy. However, the complainants were informed by Opposite Party No.1 that the complainant and their family members were duly insured    under the IOB Health Care Plus Policy and at the time of obtaining the facility of Housing Loan the complainants and their family members were also insured under the policy namely IOB Health Care Plus Policy vide Policy No.2817/50285032/01/B00 and in respect thereof, the premium was deducted time to time from the Joint Bank Account of the complainants directly by Opposite Parties No.2 & 3 and this policy was further renewed by the Opposite Parties No.2 & 3. Complainants allege that in the month of July, 2011 the complainant No. 2 i.e. wife of the complainant No.1 undergone some treatment and admitted in Altec Laser & Super Specialty Centre, Majitha Road, Amritsar on 16.6.2011 and was discharged on 19.6.2011  as per discharge summary Ex.C6. The complainant No.1 spent a sum of Rs.60,000/- on the medical treatment of the complainant No.2 towards hospitalization charges and medical expenses, etc. (as per medical bills Ex.C7 to Ex.C14). The complainants submitted the claim to Opposite Party No.1 alognwith requisite documents and the Opposite Party No.1 sent the claim alongwith relevant documents to Opposite Parties No.2 & 3 for settlement of the claim. Not only this, Opposite Party No.1 in writing recommending and requesting the Opposite Parties No.2 & 3 to settle the claim of the complainant vide letter dated 20.12.2011 Ex.C5, but Opposite Parties No.2 & 3 did not pay any heed to the request of the complainant as well as Opposite Party No.1 and closed the case of the complainant vide letter dated 15.8.2012 Ex.OP2-5/6.   Ld.counsel for the   complainants  submitted that all this amounts to deficiency of service on the part of the Opposite Parties.
9. Whereas the case of the Opposite Party No.1 is that the complainant No.1 has joint Saving Bank Account with Opposite Party No.1. He obtained the facility of housing loan from Opposite Party No.1. Opposite Party No.1 also admitted that the complainants and their other family members were got insured by Opposite Party No.1 from Opposite Parties No.2 & 3 under IOB Health Care Plus Policy,   but that policy was taken by the complainant voluntarily at his own accord from Opposite Parties No.2 & 3. Opposite Party No.1 also admitted that premium was deducted from time to time from the aforesaid joint account of the complainant No.1. Opposite Party No.1 also admitted that the complainant lodged claim with Opposite Party No.1 by submitting claim form and relevant documents and Opposite Party No.1 forwarded the claim of the complainant to Opposite Parties No.2 & 3. Not only this, even through letter Ex.C5, Opposite Party No.1 requested and recommended Opposite Parties No.2 & 3 to settle the claim of the complainants. So, it is the Opposite Parties No.2 & 3 who have to settle and pay the claim of the complainant. Ld.counsel for the Opposite Party No.1 submitted that there is no deficiency of service on the part of the Opposite Party No.1.
10. Whereas the case of Opposite Parties No.2 to 5 is that that  the complainant has  Cashless Policy issued by Opposite Parties No.2 & 3 through Opposite Party No.1. Complainant No.2 was also insured with the said insurance policy. As per the averments of the complainant No.1, the complainant No.2 i.e wife of the complainant No.1 suffered some ailment in July, 2011. However, the claim alongwith relevant documents were received by Opposite Parties No.2 & 3 from Opposite Party No.1 in December, 2011. Whereas as per the terms and conditions of the policy, the intimation should have been given to the insurance company immediately and the claim should have been lodged within a reasonable time. Therefore, the complainants have violated the terms and conditions of the policy in question. Further, the information supplied by the complainants was not complete. Opposite Party No.5 asked the complainant to submit further documents such as Treating Doctor’s clarification about exact during of illness and first consultation report,  previous treatment detail (all doctor’s prescription and lab reports) and that whether patient had any similar previous episodes and treatment details of those episodes. In this regard, Opposite Party No.5 wrote letter dated 3.8.2012 to the complainants, but the complainants did not supply the aforesaid documents. As such, the claim of the complainant was closed and intimation was given to the complainant vide letter dated 15.08.2012 of Opposite Party No.5 Ex.OP2-5/6.  Ld.counsel for the Opposite Party No.1 submitted that there is no deficiency of service on the part of the Opposite Party No.1.
11. From the entire above discussion, we have come to the conclusion that  the complainant No.1 having joint saving bank account bearing No. 11116 with Opposite Party No.1-Bank and in the year 2010, the complainant obtained facility of housing loan from Opposite Party No.1 Bank and as per the policy of Opposite Party No.1, the complainant and their family members were also insured  alongwith loan facility by Opposite Party No.1 from Opposite Parties No.2 & 3 under IOB Health Care Plus Policy Ex.OP2-5/7. It is also admitted case of the Opposite Parties  that said policy was being renewed by Opposite Parties No.2 & 3 and premium thereof was being deducted time to time from the joint saving bank account of the complainant No.1 directly by Opposite Parties No.2 & 3. Complainant No. 2 i.e. wife of the complainant No.1 duly insured with Opposite Parties NO.2 and 3 under the policy in question Ex.OP2-5/7, had undergone medical  treatment and she was admitted in Altec Laser & Super Speciality Centre, Majitha Road, Amritsar on 16.6.2011 and was discharged on 19.6.2011  where she was operated for surgery of her uterus as per discharge summary Ex.C6 and treatment record Ex.C18 to Ex.C20 and the complainants spent  a sum of Rs.60,000/- on her medical treatment as per bills/ receipts Ex.C7 to Ex.C14 and Ex.C21 to Ex.C23. The complainant submitted the claim on regular claim form Ex.C15 alognwith relevant documents to  Opposite Party No.1 who further forwarded the same to Opposite Parties No.2 & 3 and gave intimation to the complainant vide letter dated 27.12.2012 Ex.OP1/2. Opposite Parties No.2 & 3 sent the claim for scrutiny to Opposite Party No.5 i.e. TPA. Opposite Party No.5 also admitted that they have received the claim form alongwith relevant documents i.e. discharge summary, bills/ receipts and treatment record of the complainant No.2. However, they required some more documents from the complainant i.e. Treating Doctor’s clarification about exact duration of illness and first consultation report,  previous treatment detail (all doctor’s prescription and lab reports) and that whether patient had any similar previous episodes and treatment details of those episodes. These documents may be collected by Opposite Party No.5 from the hospital authorities, but Opposite Parties No.2 to 5 were not justified in closing the case of the complainant for non supplying of Treating Doctor’s clarification about exact duration of illness and first consultation report, etc., if any, of complainant No.2 because it is the duty of the Opposite Parties No. 2 to 5 to collect evidence, if the patient/ insured had any previous history of such disease or not and the complainant was not bound to supply the Treating Doctor’s clarification about exact duration of illness and first consultation report, etc., if any, of  the insured as complainant No.2 has categorically stated that she did not undergo any such treatment previously. So, Opposite Parties No.2 to 5  were not justified in treating the claim case of the complainant as closed.
12.  Ld.counsel for Opposite Parties No. 2 to 5 further submitted that the complainant No.2 underwent medical treatment in July, 2012, but the claim case of complainant No.2 was received by Opposite Parties No.2 & 3 from Opposite Party No.1 in December, 2012 which should have been lodged immediately after the discharge from the hospital, as such the complainant has violated the terms and conditions of the policy in question. But the Opposite Parties No.2 to 5 could not produce on record such terms and conditions of the policy. Not only this, this Forum vide order dated 29.4.2014 had directed the counsel for Opposite Parties No. 2 to 5 to produce the policy and its terms and conditions before this Forum. Not only this, again vide order dated 29.10.2014, 10.11.2014, 26.11.2014, 16.12.2014, 14.1.2015, 29.1.2015 the ld.counsel for Opposite Parties No. 2 to 5 was directed to produce the policy and its terms and conditions, but the Opposite Parties No. 2 to 5 have failed to produce the terms and conditions of the policy. All this fully proves that the terms and conditions of the policy were not supplied by Opposite Parties No. 2 to 5 to the complainant as stated by the complainant, that is why Opposite Parties No. 2 to 5 have also failed to produce on record of this Forum said terms and conditions of the policy.  As such, we hold that the complainant has not violated any terms and conditions of the policy. However, the complainants lodged the claim with Opposite Party No.1-Bank who got the insurance policy for the complainants and their family members from Opposite Parties No.2 & 3 and the name of the policy is also IOB Health Care Plus Policy and the Opposite Party No.1 sent  the claim form alongwith relevant documents to Opposite Parties No.2 & 3 and not only this, Opposite Party No.1 through their letter dated 20.12.2011 Ex.C5 recommended and requested Opposite Parties No.2 & 3 for settlement of the case of the complainants as special case. Even then, Opposite Parties No.2 & 3 did not settle the claim case of the complainant despite issuance of letter Ex.C2, legal notice dated 29.3.2012 Ex.C3 by the complainant No.1 upon the Opposite Parties through registered post.
13. In view of the entire above circumstances and facts of the case, we hold that Opposite Parties No. 2 to 5 were not justified in treating the claim case of the complainants as closed. All this amounts to deficiency of service on the part of the Opposite Parties No. 2 to 5.
14. Consequently, we allow the complaint of the complainants with cost and the Opposite Parties No.2 & 3 are directed to reimburse the amount of Rs.60,000/- to the complainants within one month from the date of receipt of copy of this order, failing which the Opposite Parties No.2 & 3 shall be liable to pay  interest @ 9% per annum on this amount of Rs.60,000/- from the date of filing of the complaint till the payment is made to the complainants. Opposite Parties No.2 & 3 are also directed to pay the litigation expenses to the tune of Rs.2,000/-  to the complainants. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 08-07-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member