Complainant Smt.Bawi has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to honour her claim and to make the payment of Rs.30,000/-  qua her claim in terms of the insurance policy in question alongwith interest @ 18% P.A. from the date of actual realization.  Opposite parties be further directed to pay Rs.50,000/- as compensation on account of mental agony, physical harassment and deficiency in service alongwith Rs.10,000/- as litigation expenses, in the interest of justice.

2.        The case of the complainant in brief is that she obtained Insurance Policy from the opposite parties bearing No.4018821305 valid upto 31.08.2017. All of sudden she fell ill and remained under treatment from City Hospital Gurdaspur and spent Rs.30,000/- on her treatment. Thereafter, she submitted her claim for reimbursement of the amount to the opposite parties but till today no response has been given by the opposite party nor the amount spent by her on her treatment has been reimbursed without any reasonable cause or excuse. A legal notice dated 25.05.2018 was served through her counsel to opposite party but all in vain. The act of the opposite parties of not making full payment of amount spent by her is illegal, null, void and arbitrarily against the terms and conditions of the policy. Thus there is deficiency in service on the part of the opposite parties. Hence this complaint.

 3.         Notice of the complaint was issued to the opposite parties.  Opposite party no.2 appeared through its counsel and filed its written reply by  taking the preliminary objections that   Mr.Jodh Singh had taken a Group Mdiclaim Policy No.120300/34/16/00000005 for the period 1.9.2016 to 31.8.2017 for sum assured Rs.1,50,000/-. Mrs. Bawi wife of Jodh Singh allegedly remained admitted in City Hospital, Dinanagar, Distt.Gurdaspur from 07.06.2017 for drug induced gastritis and discharged on 10.06.2017 and the complainant lodged her claim vide claim no.94933749 for the claim amount of Rs.13,559/- with the claim settling authority 'M/S MEDI ASSIST INDIA PVT.LT., (TPA) through the opposite party no.1 i.e. the Life Insurance Corporation of India for settling the claim as per the terms and conditions of the policy and as per the required record/documents. "M/S.MEDI ASSIST INDIA PVT.LLTD.", is the claim settling authority, who settles the Claim under the terms and conditions of policy. On scrutinizing all the documents including medical treatment record, M/s. MEDI ASSIST INDIA PVT.LTD.' asked the complainant to provide the following documents vide letter dated 26.10.2017 and reminder dated 06.11.2017.

            i) Original reports of Rs.1300/- dt. 07.06.2017 and Rs.600/-                  dt.09.06.2017.

          ii) Letter from treating consultant stating the presenting complaints         of the patient and indications for hospitalization.

But the complainant failed to supply the above mentioned required documents to the TPA Medi Assist India Pvt.Ltd., which are very much essential documents from settling the claim of the complainant. Hence, the TPA Medi Assist India Pvt.Ltd. closed the file of the complainant for want of the above mentioned documents. The present complaint of the complainant is not maintainable and liable to be dismissed on this score only; the present complaint is bad for mis-joinder and non-joinder of necessary parties. And the complainant has no cause of action against the opposite party. On merits, the same contentions have been repeated while denying and rebutting the other allegations made in the complaint and prayed for dismissal of the complaint.    

4.         Notice issued to opposite party no.1 had not been received back. Period of 30 days had already been elapsed. Presumption could be drawn that opposite party no.1 had been served but it was intentionally evading the service of the notice. Case called several times, but none had appeared on behalf of opposite party no.1. Hence, opposite party no.1 was ordered to be proceeded against exparte vide order 05.3.2019.

5.        Alongwith the complaint, complainant has filed his own affidavit Ex.W-1/A alongwith copies of documents Ex.C-1 to Ex.C-14.

6.        Alongwith the written statement, opposite party has filed affidavit of Sh.Kuldeep Raj, Senior Divisional Manager, N.I.A. Co.Ltd. Ex.OP-2/A alongwith other documents Ex.OP-2/1 to Ex.OP-2/6.

7.      Rejoinder filed by the complainant.

8.      Written arguments filed on behalf of opposite party no.2.

9.    We have carefully gone through the pleadings of counsel for the parties; oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the parties for the purposes of adjudication of the present complaint.

10.       Complainant Bawi wife of Jodh Singh was insured by opposite parties in the present case through Group Insurance Policy No.4018821305 valid upo 31.9.2017. Complainant had sought treatment from City Hospital, Gurdaspur for the period from 07.06.2017 to 10.06.2017 for gastritis. Complainant had submitted bills for her treatment to opposite party which were not honoured by opposite party on frivolous excuse.

11.    After going through the facts of the case, we are of the considered opinion that opposite party is liable for payment for the treatment cost borne by the complainant for the period 07.06.2017 to 10.06.2017 at City Hospital, Gurdaspur while being covered by the policy under Group Insurance Scheme.

12.       Complaint is partly allowed and opposite parties are directed to pay to the complainant an amount to the tune of bills submitted by the complainant as admitted by opposite party to be Rs.13,885/- alongwith interest @ 7% p.A. payable from the date of submission of the bills by the complainant in the first instance till its realization. Opposite party is further directed to pay Rs.10,000/- on account of harassment and  litigation expenses. Compliance of the order be made within 30 days from the date of receipt of copy of order.

13.     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.

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

            (Naveen Puri)

                                                                            President   

Announced:                                                   (R.S.Sukhija)

January 05, 2023                                                 Member

*MK*