Punjab

StateCommission

FA/1241/2013

Royal Sundaram Alliance Insurance Co. Ltd. - Complainant(s)

Versus

Kuldeep Jindal - Opp.Party(s)

Raj Kumar Bashamboo

24 Feb 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, DAKSHIN MARG, SECTOR-37A, CHANDIGARH

 

FIRST APPEAL No.1241 of 2013

 

                                                 Date of Institution: 13.11.2013

 Date of Decision  :  24.02.2015

 

Royal Sundaram Alliance Insurance Company Limited, Chennai represented through Shri G.Vinay Parkash, Legal Manager of Royal Sundaram Alliance Insurance Company Limited, Subramanian Building, IInd Floor, Club House Road, Annasalai, Chennai-600014 duly constituted attorney.

 

…..Appellant/Opposite Party

 

VERSUS

Kuldeep Jindal son of Sh. Dev Raj Jindal resident of House No.136, Mohan Nagar, Ward No.12, Gidderbaha, Tehsil Gidderbaha, District Sri Muktsar Sahib.

 

…..Respondent/Complainant

 

First Appeal against the order dated 16.09.2013 passed by the District Consumer Disputes Redressal Forum, Sri Muktsar Sahib.

 

Quorum:

 

Hon’ble Mr.Justice Gurdev Singh, President

          Sh. Baldev Singh Sekhon, Member

                   Smt. Surinder Pal Kaur, Member

Present:

 

          For the appellant       :        Sh. R.K.Bashamboo, Advocate

          For the respondent   :        Sh. J.S.Jassi, Advocate

 

BALDEV SINGH SEKHON, MEMBER

          This appeal has been filed by the appellant/opposite party (in short 'OP')  against the order dated 16.09.2013 passed by the District Consumer Disputes Redressal Forum, Sri Muktsar Sahib (in short “District Forum”), vide which the complaint filed by the respondent/complainant was allowed  by the majority decision and OP was directed to pay Rs.61,879/- to the complainant within 45 days from the receipt of copy of that order failing which the complainant was held entitled to get interest @ 9% per annum from the date of order till its actual realization. However, the President of the District Forum, vide a separate order of even date, dismissed the complaint for want of territorial jurisdiction.

2.      Briefly stated, the facts of the case are, that the complainant purchased a Health Shield Insurance Policy of the Opposite Party,  bearing No.HL00038310000100, having sum assured of Rs.1,00,000/-and that was valid for the period 25.08.2011 to 24.08.2012. On 02.01.2012, the complainant suddenly fell ill and was admitted in Dr. R.P. Singh Hospital & Laparoscopic Surgery Centre, Malout, with history of abdominal pain in right hypochondrium, which was radiating to whole of the abdomen. It was accompanied by vomiting and high fever since 5 days with shivering. The wife of the complainant informed the OP about his admission in the said hospital, vide registered letter dated 4.1.2012. Upon investigation, the TLC of the complainant was found to be on the higher side and the ultrasound of abdomen showed features of Acute Viral Hepatitis with Acalulus Cholecysticis.  He got treatment in the said hospital and was discharged on 10.01.2012, during which he spent Rs.61,879/- on his treatment:- Rs.24,900/-, as hospital charges; Rs.32,179/-, on medicines; Rs.4,300/- on lab tests; and Rs.500/- on ultrasound. He submitted his insurance claim, alongwith documents, Including the bills of the hospital record duly attested by the treating doctor, as per the advice of OP. He repeatedly requested OP to pay his claim but it intimated him, vide its letter dated 13.3.2012 that his claim would be processed on receipt of additional documents; which were also submitted by him but still the claim was not settled. Ultimately, he received a letter dated 21.3.2012 from the OP wherein it was alleged that the medical records submitted by him were fabricated for making fraudulent claim and it expressed its inability to entertain his claim. Alleging that the decision of the OP was illegal, arbitrary, null and void, the complainant filed complaint before District Forum seeking directions to OP to pay him a sum of Rs.61,879/-, alongwith interest @ 18% per annum from 2.1.2012 till realization, besides Rs.20,000/- on account of mental tension, harassment and Rs.10,000/- as litigation expenses.

3.      Upon notice, OP filed written reply pleading therein that the complaint was not maintainable before the District Forum as it lacked  territorial jurisdiction.  Complainant took policy from its Chennai office. The insurance claim was filed by complainant at Chennai office and the same was also denied by the same office. No cause of action had accrued in the territorial jurisdiction of the District Forum, Sri Muktsar Sahib. As such,  the complaint was liable to be dismissed; being not maintainable for want of territorial jurisdiction.  It was admitted that the complainant took "Health Shield Standard Policy" bearing No.HL00038310000100 valid from 25.8.2011 to 24.8.2012 and that he submitted the claim for his treatment obtained from Dr. R.P.Singh Hospital. It was pleaded that complainant was reportedly  treated for Acute Viral Hepatitis with acute Acalulus Cholecystitis. The matter was got investigated from M/s Mack Insurance Auxiliary Services Ltd. and the investigation revealed a number of discrepancies in his claim. He was, in fact, trying to make a fabricated and fraudulent claim. Though he was reportedly treated for Acute Viral Hepatitis, yet the type of Hepatitis was not detected and the treatment could not have been given without detecting the same. The ICU of the hospital was in shabby condition and there was no ventilator or oxygen supply in the Lab. Even ultra sound report and bill book of hospital were not shown to investigator.  Therefore, the claim of the complainant was declined having been filed with the ulterior motive for making wrongful gains, by relying upon the exclusion clause that provides as under :

          "If any claim is in any respect fraudulent, or if any      fraudulent means or devices are used by the    Insured/Insured Person or anyone acting on their behalf to   obtain any benefit under this Policy, all benefit under this          Policy shall be forfeited the Company may choose to void   the Policy and reclaim all benefits paid to the   Insured/Insured Person."

 

          Accordingly, the claim filed by the complainant was rightly declared not payable. Dismissal of the complaint with costs was prayed.

4.      Parties led their evidence, by way of affidavits and documents, before the District Forum. The complaint was allowed by the two Members of the District Forum, in aforesaid terms while the President of District Forum dismissed the complaint for want of territorial jurisdiction.

5.      Aggrieved by this order the OP has come up in appeal on the ground that learned District Forum (majority view) has fell in error while holding that it had the territorial jurisdiction to entertain the complaint as no cause of action had accrued in its jurisdiction. The policy was purchased by complainant from its Chennai Office. The claim was received there and same was delivered from same office. It was further submitted that learned District Forum wrongly held that it is not a case of fraud. Infact, there was a violation of the terms and conditions of the policy as the complainant could not prove the sickness itself and the claim was found fraudulent. On receipt of the claim, an independent investigator was appointed to investigate the claim who opined that though the patient Kuldeep Jindal alleged that he was admitted in ICU in said hospital but same  was in shabby condition. No ventilator, no oxygen supply and no emergency facilities were available in the said ICU. Even  hospital record was not shown to the investigator. There was definite conclusion by the investigator that claim was not genuine and accordingly, the same was rightly repudiated by the OP. Acceptance of the appeal and setting aside of the impugned order was prayed.

6.      Learned Counsel for the complainant submitted that the District Forum (majority view) has rightly concluded that the amount was payable as the OP has failed to establish that the treatment was not taken by the complainant in the said hospital or that the documents/medical record proved on record were fabricated.

7.      We have thoroughly gone through the pleadings of the parties, have carefully perused the evidence on record and heard the learned counsel of the parties.

8.      The first and foremost question to be answered by this Commission is, whether the District Forum had the territorial jurisdiction to entertain and decide the complaint of the complainant?  It is contended by the OP that the policy was issued from its Chennai Office, the claim was also received at their Chennai office and same was declined by the said office. No cause of action has accrued to the complainant within the territorial jurisdiction of the District Forum. On the other hand, the complainant has contended that OP advertised about their Health Shield Policy through electronic and print media and complainant was allured by that advertisement and the policy was purchased by him online at Gidderbaha and payment of the premium was also made on line at Gidderbaha.

9.      OP has not specifically denied the averments made by complainant about the mode or purchase of policy. It has merely pleaded that policy was purchased from its Chennai Office without  specifying how the same was done from Chennai. It cannot be believed that complainant went all the way from Gidderhaha in Punjab to Chennai in Tamil Nadu for the purchase of a health policy when offices of a number of general insurance companies are located in Punjab even in the vicinity of Gidderbaha.

10.    According to Section 11(2)(c) of the Consumer Protection Act, 1986,  the complaint can be instituted in the District Forum within the local limits of whose jurisdiction the cause of action arises wholly or in part.  Cause of action means a bundle of facts, which the complainant is required to prove in order to establish the right claimed in the complaint. The place where the premium amount was paid by the insured and where the policy was received by him forms part of the cause of action, as in order to succeed in the complaint the complainant was required to prove those facts also. No doubt, the Certificate of Insurance, Ex.C-58/OP-2 purports to have been issued by the office of opposite party No.1 at Chennai on 27.8.2011 but it was specifically deposed by the complainant in his affidavit Ex.CA that complainant purchased the policy online at Gidderbaha and paid Rs.1,861/-, as premium. At the time of arguments, it was also submitted by the learned counsel for the complainant that the Certificate of Insurance, Ex.C-58, was received by the insured at his said residential address, which appears to be correct as the said address is noted in the Certificate of Insurance. 

11.    To rebut the evidence produced by the complainant, OPs  proved on record the affidavit of  its Manager Legal, G.Vinay Prakash as Ex.OP-1.  In that affidavit, he did not rebut the deposition made by the complainant that complainant purchased the policy online at Gidderbaha and mode the payment of premium has remained unrebutted.  Thus, a part of cause of action accrued within the local limits of the jurisdiction of District Forum at Sri Muktsar Sahib.

12.    OP has declined to accept the claim of the complainant, vide letter dated 21.3.2012 (Ex.OP-7) on the ground that as per the investigation report (Ex.OP-4, OP-5) of M/s Mack Insurance and Auxiliary Services Pvt. Ltd., the complainant fabricated the record of his medical treatment and that R.P.Singh Hospital and Laparoscopic Surgery Centre, Malout from where he reportedly obtained treatment, was not having adequate facilities for the same. But this investigation report is not supported by any affidavit of the person, who conducted the investigation. Morever, Dr. R.P.Singh of Dr. R.P.Singh Hospital and Laproscopic Centre, Malout was duly examined by District Forum, who confirmed on oath that treatment was taken by complainant in his hospital and that the medical record proved by complainant before District Forum was genuine. He even explained in detail the treatment taken by complainant and the procedure undertaken by him. Dr. R.P.Singh was never cross examined by OP to establish the averments made in its written reply. Under these circumstances, it is to be held that complainant had actually obtained the treatment from the said hospital and that the repudiation of his claim by OP, vide letter dated 21.3.2012 (Ex.C-59) on the ground that medical record of the complainant was fabricated, was baseless.

13.    Accordingly, the appeal of the OP is dismissed and the order of the District Forum (majority view) is affirmed and upheld. No order as to costs.

14.    The appellant had deposited a sum of Rs.25,000/- at the time of filing of the appeal. This amount along with interest which has accrued thereon, if any, shall be remitted by the registry to respondent/complainant by way of a crossed cheque/demand draft after the expiry of 45 days of the sending of certified copy of the order to them.

15.    The arguments in the case were heard on 06.02.2015 and the order was reserved.  Now, the order be communicated to the parties.

16.    The appeal could not be decided within the statutory period because of the heavy pendency of the court cases.

 

 

 

 (JUSTICE GURDEV SINGH)

PRESIDENT

 

(BALDEV SINGH SEKHON)

MEMBER

 

 

(SURINDER PAL KAUR)

MEMBER

February 24, 2015