Complainant Hardial Singh had filed the present complaint U/s 12 of the Consumer Protection Act against the opposite parties and praying that the opposite parties be directed to pay Rs.18,396/- alongwith interest @ 12% from the date of admission till its realization and opposite parties may be burdened with Rs.50,000/- as harassment, mental agony and Rs.10,000/- as litigation expenses by allowing the complaint.

2.       The case of the complainant in brief is that he is working in the Branch Office at Batala-I Distt. Gurdaspur of opposite party No.3 i.e. Life Insurance Corporation of India as ZM-Club Member having Registration Agent Code 02441-136 and is having Medi Claim Policy under opposite parties No.1 and 2 as he is a member of Group Medi Claim Insurance Policy with the opposite parties No.1 and 2 since 2011/2012 (01.09.2011) bearing policy No.120300/34/13/05/00000001, claim No.92787274 and premium of which has been regularly deducted by the opposite parties from the salary of the complainant and the said policy was availed by him through opposite party No.4 i.e. New India Assurance Co. Ltd. Branch Batala. It was pleaded that on 28.07.2014, the complainant fell ill and got hospitalized/admitted on 28.07.2017 at Bajwa Hospital, 314-315, Akash Avenue Fatehgarh Churrian Road, Amritsar having in patient No.239 where he had undergone treatment of Chest Pain (Infection) A/C Sweating, Nausea and vomiting by the doctors and discharged against medical advise on 05.08.2014 and complainant incurred the amount of Rs.57,396/- on his treatment as well as on the medicines. It was stated that complainant gave intimation to the opposite parties regarding his admission in the hospital in time and lodged claim vide Claim No.92787274 with the opposite parties and fulfilled all the formalities as and when demanded and asked by the opposite parties but they did not pay the medi claim amount inspite of various letters/representations of the complainant. It was further pleaded that a legal notice dated 21.09.2016 was also issued to the opposite parties by the complainant through his counsel to settle the medi claim within stipulated period who gave reply and assured to settle the claim. It was also pleaded that opposite parties paid only Rs.39,000/- against the total claimed amount of Rs.57,396/- and withheld an amount of Rs.18,396/- on basis of false excuses which is illegal and deficiency in services on the part of the opposite parties and due to this illegal act and conduct of the opposite parties complainant suffered mental and physical harassment, hence this complaint.

3.       Upon notice opposite parties No.1 and 4 appeared through their counsel and filed written reply by taking preliminary objection that the complainant has not disclosed any deficiency in service of opposite parties as such complaint is not maintainable. On merits, it was stated that on 28.07.2014 complainant was hospitalized at Bajwa Hospital for treatment of chest pain and discharged on 05.08.2014. It was further stated that the claim was partly settled with an amount of Rs.41,349/- against the total claim amount of Rs.57,396/- and disallowed to the tune of Rs.16047/- and a letter dated 05.03.2016 was sent to the complainant by The TPA-Medi Assist for original investigation reports confirming diagnosis which was not provided to opposite party No.4. As per policy condition the insured was insured to the tune of Rs.75,000/- + Rs.14,700/- for room rent + nursing charges. Out of which room rent and nursing charges covered the opposite parties already paid Rs.7500/- and rest of Rs.7200/- were deducted with regard to excess of room rent and nursing charges and further Rs.8500/- were deducted as the insured did not submit the original bills and original investigation reports confirming diagnosis. It was also stated that on 29.02.2016, the claim was received and after receiving the same the claim got processed and since the same belongs to the years 2013-14 and there was no room rent restriction and as such file of the complainant was reopened and Rs.7200/- further approved on 24.10.2017 which has already been received by the complainant. It was next stated that for the balance amount of Rs.8847/-, the complainant is required to furnish original investigation reports and bills of Rs.8500/- for which complainant may be directed and then opposite parties will proceed further. All other averments made in the complaint have been denied and lastly prayed for dismissal of complaint.

4.       Earlier, upon notice Sh.Pranav Sharma Advocate appeared on behalf of opposite parties No.1 to 3 and filed written reply but later on he made a separate statement on 17.01.2018 that "Inadvertently he had mentioned written statement on behalf of opposite parties No.1 to 3 but he represent only opposite parties no.2 and 3 and he has no objection if opposite party No.1 is represent through New India Assurance Company as opposite party No.1 is agent and TPA of the New India Assurance Company". After that Sh.Rajesh Kapoor Advocate had appeared on behalf of opposite party no.1 and filed his vakalatnama and joint written reply on behalf of opposite parties no.1 and 4 which has already been discussed above.

5.       In written reply preliminary objections were taken by opposite parties no.2 and 3 that complaint is not maintainable in the present form as the LIC had nothing to do with the claim in question as the claim under Mediclaim policy issued by the New India Assurance Co. Ltd. vide Policy Group Insurance. The complainant is simply agent of the LIC and is a member of Club- member agents and is getting commission earned on procurement of insurance business deducted from his commission once in the year i.e. month of September and coverage of policy is Ist Sept. to 31 August for year and as such it is clear that complainant is not the employee of the LIC of India and not pay rolls and he is only agent of LIC; that claim is actually against opposite party No.1 who is the TPA of the New India Assurance Co. Ltd. as in Medi claim the claims under Mediclaim Policies which are referred to their advisors and on their advise and instructions the claims are settled and paid by New India Assurance Co. Ltd. As such present claim is not maintainable and same may be dismissed being uncalled and legally not sustainable. On merits, it is admitted that complainant is the agent of LIC and not the employee as he only gets commission being agent for producing LIC business. It was stated that LIC is not liable for any claim as have nothing to do with it. It was further stated that duty of LIC is only to facilitate process of claim settlement and it is the TPA of New India Assurance Co. Ltd. who settle the claim. All other averments made in the complaint have been denied and lastly prayed for dismissal of complaint being false, bogus, baseless and legally not maintainable.

6.       Counsel for the complaint had tendered into evidence affidavit of complainant alongwith copies of documents Ex.C1 to Ex.C27 and closed the evidence on behalf of complainant.

7.       Counsel for the opposite parties No.1 and 4 had tendered into evidence affidavit of Sukhwinder Kumar Branch Manager alongwith copies of documents Ex.OP-1/4/1 to Ex.OP-1/4/6 and closed the evidence on behalf of opposite parties no.1 and 4.

8.       Sh.Mohinder Pal Kalotra Admn. Officer of opposite parties no.2 and 3 had appeared in person and had tendered into evidence his affidavit Ex.OP-2,3/1 and copy of letter dated 04.10.2016 Ex.OP-2,3/2 and closed the evidence on behalf of opposite parties no.2     and 3. 

9.       Written arguments filed by complainant and opposite parties no.1 and 4 but not filed by opposite parties No.2 and 3.

10.     We have carefully examined all the documents/evidence produced on record for its contained statutory merit and have also judiciously considered and perused the arguments duly put forth by the learned counsels for the parties as well as written arguments filed by counsel for opposite parties no.1 and 4.

11.     Learned Counsel for the complainant has argued that complainant is employed in Life Insurance Corporation and the                        member of Group Medical Claim Insurance Police with opposite party No.4 and upto date premium has been paid from the salary of the complainant. The medical claim policy was availed by the complainant through opposite party no. 4. It is further argued by the counsel for the complainant that on 28.07.2014, complainant fell ill and was hospitialized at Bajwa Hospital, Amritsar, where he had undergone treatment and was admitted in the hospital on 28.07.2017 and discharged against medical advised on 05.08.2014 and amount of Rs. 57,396/- was spent on the treatment of the complainant. It is further argued by the counsel for the complainant that intimation was given to the opposite parties regarding admission of the complainant in the hospital and claim was lodged and all the formalities were fulfilled, but the opposite parties did not pay the medical claim amount. Complainant got issued legal notice on 21.09.2016 to the opposite parties through his counsel and thereafter, only amount of Rs. 39,000/- was paid against total due amount of Rs. 57,396/- withholding of amount of Rs. 18,396/- amount to deficiency in service.

12.     On the other hand, counsel for the opposite parties No.2 and 3 has argued that LIC has nothing to do with the claim in question and the claim was payable by opposite party No. 4. Counsel for opposite parties no.1 and 4 has argued that complainant was hospitialized at Bajwa Hospital for treatment of chest pain on 28.07.2014 and was discharged on 05.08.2014. The claim was partly settled with the amount of Rs. 41,349/- against total claim amount of Rs. 57396/- and amount of Rs. 16,047/- was declined. The amount was declined on the basis of letter dated 05.03.2016 issued by TPA mediassist for want of original investigation report confirming diagonsis which was not provided to the opposite party no.4. As per the policy condition, the insured was insured to the tune of Rs. 75000/- + Rs. 14700/- for room rent + nursing charges. Out of which, room rent and his nursing charges coverage the answering opposite parties have already paid Rs. 7500/- and Rs. 4200/- was deducted with regard to room rent and nursing charges. The amount of Rs. 8500/- was deducted as complainant did not submit the original investigation reports confirming diagnosis and has further argued that there is no deficiency in service on the part of opposite party no. 4.

13.     We have heard the counsel for the parties and gone through the record. It is admitted fact that the complainant had obtained Group Medical Insurance from opposite party No. 4. It is further admitted fact that complainant remained admitted at Bajwa Hospital, Amritsar. It is further admitted fact that amount of Rs. 57,396/- was spent by the complainant on his treatment. Only dispute is regarding non-payment of amount of Rs. 8500/- which has been withheld by the opposite party no. 4 for want of production of diagnosis report. We have gone through the documents placed on record, perusal of which shows that complainant undertook treatment from Bajwa Hospital Amritsar and the treatment record and medical bills have been placed on file as Ex.C8 to Ex.C19. Besides above, there are receipts of Bajwa Diagnosis Centre Ex.C21 and Ex.C26. The only plea of opposite party no.1 and 4 is that the diagnosis reports are not available, however, this Commission is of the view that since the complainant was under treatment and was only under obligation to pay charges for the investigation got conducted which is proved from the receipts Ex.C21 to Ex.C26 and the complainant is not supposed to be in possession of such reports, as the said reports must be lying with the hospital authorities and the opposite parties can very well avail the said documents from the concerned hospital through their investigators. Moreover, this Commission is of the view that no treatment can be carried out by any Doctor without report of Diagnotic Centre, as such, this Commission is of the view that withholding of amount of Rs. 8500/- by opposite parties no.1 and 4 amounts to deficiency in service. Accordingly, the present complaint is party allowed and opposite party no.1 and 4 are directed to pay Rs.8500/- to the complainant along with interest @ of 9% per annum from the filing of the present complaint till its realization. Opposite party No.1 and 4 are further directed to pay Rs.2000/- to the complainant on account of mental tension and harassment and costs of litigation.

14.      The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

15.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record room. 

                               (Lalit Mohan  Dogra)

                                                                        President

Announced:                                          (B.S.Matharu)

July 26, 2023                                                Member

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