Chandigarh

DF-II

CC/436/2014

Sh. Parbodh Chander Vashisht - Complainant(s)

Versus

Indian Overseas Bank - Opp.Party(s)

Pradeep Sharma, H.Kansal, B.L.Sharma, Chetan Gupta, Adv.

13 Mar 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	436/2014
Date of Institution	:	25.08.2014
Date of Decision	:	13/03/2015

 

                  

                                                         

 

Sh.Parbodh Chander Vashist r/o H.No.642-B, Sector 65, Mohali.

                                      ...  Complainant.

Versus

 

1. Indian Overseas Bank, 762, Anna Salai, Chennai, through its Chairman & Managing Director.
2. Indian Overseas Bank, Regional Office SCF No.XI, Madhya Marg, Chandigarh -160019 through its Deputy G.M.
3. E-Meditek (TPA) Services Ltd., Plot No.577, Udyog Vihar, Phase-V, Gurgaon (Haryana) -120016.
4. Universal Sompo General Insurance Co. Ltd., Unit 401, 4^th Floor, Sangam Complex, 127, Andheri Kurla Road, Andheri (East) Mumbai-400005.

…. Opposite Parties.

 

BEFORE:  SHRI RAJAN DEWAN, PRESIDENT

SHRI JASWINDER SINGH SIDHU, MEMBER

 

Argued by:  Sh.Pradeep Sharma, Counsel for the complainant

                        None for OPs No.1 and 2.

                        OP No.3 exparte.

                        Sh.Sahil Abhi, Counsel for OP No.4.

 

PER RAJAN DEWAN, PRESIDENT

1.           In brief, the case of the complainant is that he served Indian Overseas Bank, OP No.2 which is the regional office of OP No.1 for many years and was covered under New Group Health Insurance Scheme induced by OPs No.1 and 2 (Welfare Section) named as Retired Employees Medical Assistance Scheme (REMAS) as per which the limit of coverage per family was to be Rs.1,50,000/- covering self and spouse, implementable w.e.f. 01.07.2012.  A copy of the Retired Employees Medical Assistance Scheme and confirmation letter dated 21.01.2008 issued by OP No.1 are Annexures C-1 and C-2.  According to the complainant, his wife )Mrs.Kanti Vashist who was suffering from pain in both knees, admitted in the PGI, Chandigarh on 01.10.2012 for replacement of knees and she was discharged on 21.10.2012. Thereafter, the complainant applied the insurance claim by submitting the requisite documents as per the aforesaid Insurance Scheme on 05.12.2012.  A copy of the claim form and bills is Annexure C-3 and Annexure C-4 (Colly.) respectively.   However, the said claim was repudiated vide letter dated 24.01.2013, Annexure C-5 on the ground that the waiting period for the ailments of joint replacement due to degenerative conditions and the age related osteoarthritis, was 3 years under the policy.   It was stated that the claim was wrongly repudiated and as such he wrote letter dated 18.07.2013, Annexure C-6, which was followed by another letter dated 26.03.2014, Annexure C-7  to reconsider the claim.  Subsequently, the complainant received a SMS on 11.07.2014 mentioning that an amount of Rs.79,525/- were credited to his account on account of the medical reimbursement without any calculation. According to the complainant, he incurred Rs.2,84,689/- and as per the scheme, he was  entitled to Rs.1.50 lacs whereas he was paid only Rs.79,525/- and as such he is entitled to the remaining amount of Rs.70,475/-.  According to the complainant when nothing was done by the Opposite Parties, he got served a legal notice dated 19.07.2014, Annexure C-14 but all in vain. Alleging that the aforesaid acts amounted to deficiency in service and unfair trade practice on the part of the opposite parties, the complainant filed the instant complaint.
2.           OPs No.1 and 2 in this written statement admitted the factual matrix of the case. It was stated that an amount of Rs.79,525/- was credited to the account of the complainant on 11.07.2014 through cheque dated 25.06.2014 for hospitalization of Smt.Kanta Vashishth.  It was further stated that the complainant had suppressed the material fact from the Forum that an amount of Rs.70,475/- vide cheque dated 30.09.2013 on account of hospitalization of his wife had already been reimbursed to him.  According to OPs No.1 and 2, there was no deficiency in service on their part and the complaint deserves to be dismissed.
3.           In its separate written statement, the Opposite Party No.4 admitted the factual matrix of the case. However it was stated the policy in question was issued on family floater basis subject to the terms and conditions of the Insurance Policy.  It was further stated that first claim for the period from 01.10.2012 to 21.10.2012 was repudiated on the grounds that the same did not fall within the purview of the Insurance Policy and fell under the exclusion clause of the policy as for joint replacement surgery related to Osteoarthritis three years waiting period was required whereas the policy in question commenced from 01.07.2012 and the period of three years was not completed. Later on, on representation of the complainant for review of the claim, the same was settled and paid to the complainant. It was further stated that the complainant lodged two claims for reimbursement of medical expenses for the treatment of his wife Mrs.Kanti Vashisht and the entire sum insured of Rs.1.50 lacs in full and final satisfaction of both the claims was paid to him as detailed below:-

1. First claim with hospitalization from 01.10.2012 to 21.10.2012 was settled for Rs.79,525/- and paid on 25.06.2014 vide letter dated 24.07.2014, Annexure R-3.
2. Second claim with hospitalization from 17.04.2013 to 30.04.2013 was settled for Rs.70,475/- and paid on 30.09.2013 vide letter dated 24.07.2014, Annexure R-4.

                   The same were accepted by the complainant in full and final satisfaction of his claims without any protest, unconditionally and without reserving any right to recover any further amount. It was further stated that after the receipt of the above said claims, the complainant ceased to be a consumer since the relationship of the consumer and service providers comes to an end as per the law.  It was further stated that the filing of the instant complaint is simply a misuse of process of law by concealing the material fact from this Forum that the maximum sum insured was Rs.1.50 lacs which was paid to him.  The remaining averments were denied, being false. Pleading that there was no deficiency in service on its part, the prayer for dismissal of the complaint was made.

4.           Notice was sent for the service of Opposite Party No.3 through registered post on 29.08.2014.  However, neither the same was received back served/unserved till date.  As the period of more than 30 days had passed, therefore, it was presumed that it had been duly served.  None appeared on behalf of the Opposite Party No.3 on the date fixed, hence it was proceeded against exparte vide order dated 13.10.2014.
5.           The complainant filed rejoinder to the written reply of Opposite Parties No.1, 2 and 4 controverting their stand and reiterating his own. It was stated upon receipt of the written statement of the OPs, the complainant came to know and accordingly verified his bank account that such balance amount of Rs.70,475/- was credited to his account by the Opposite Parties on 30.09.2013. It was further stated that since he was out of country at that moment, therefore, he never received its intimation.
6.           We have heard the Counsel for the complainant, Opposite Party No.4 and have gone through the entire evidence on record.
7.           After going through the submissions of the Counsel for the parties and evidence on record, we are of the considered view that the complaint is liable to the dismissed for the reasons recorded hereinafter. In the instant complaint, the complainant sought the refund of balance amount of Rs.70,475/- alongwith interest. Undisputedly, the amount of Rs.70,475/-  was  credited to the account of the complainant on 30.09.2013 i.e. much prior to the filing of the instant complaint and serving of the legal notice dated 19.07.2014.  The complainant did not disclose this fact in the complaint, which was filed on 25.08.2014 i.e. much after the receipt of the amount of Rs.70,475/-.   The complainant did not whisper any word even regarding the second claim in respect of his wife in the entire complaint.  Moreover, the complainant admitted receipt of Rs.70,475/-, after the filing of the written statement by the Opposite Parties, in his rejoinder only and it itself speaks volumes about the act and conduct of the complainant.  Had the Opposite Parties not credited the amount aforesaid prior to the filing of the complaint or receipt of the legal notice then the matter certainly would have been different. The complainant has, thus, failed to make any case of deficiency in service on the part of the Opposite Parties. 
8.           For the reasons stated above, finding the complaint to be devoid of any substance and merit, the same is hereby dismissed leaving the parties to bear their own costs.
9.           Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

13/03/2015

Sd/-

(RAJAN DEWAN)

PRESIDENT

 

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER

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