Punjab

Faridkot

CC/19/117

Veerpal Kaur - Complainant(s)

Versus

M.D India Health Insurace - Opp.Party(s)

L.S. Chauhan

03 Feb 2020

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :        117 of 2019

Date of Institution:     01.05.2019

Date of Decision:       03.02.2020

 

Veerpal Kaur aged about 40 years w/o Mander Singh s/o Chinder Singh r/o Village Shimre Wala, Tehsil and District Faridkot.

...Complainant

Versus

1.     MD India Health Insurance TPA Pvt Ltd. Max Pro Info Park, D-38, Phase – I, Industrial Area, Mohali, Punjab 160055.

2.     M D United India Insurance Co.  Ltd, SCO-72, Phase -9, Mohali (Punjab)-160062.

3.     Managing Director, P H S C and Secretariat Health (Chairman) State Level Disputes Redressal Committee, Bhagat Puran Singh Health Insurance Scheme, S A S Nagar, Mohali Punjab -160056.

4.     Deputy Medical Commissioner, Faridkot District Level Disputes Redressal Committee, Bhagat Puran Singh Health Insurance Scheme, Tehsil and District Faridkot.

.....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt Param Pal Kaur, Member.

 

Present: Sh Lalwinder Singh Chauhan, Ld Counsel for complainant,

              Sh Atul Gupta, Ld Counsel for OP-1 and 2,

              Sh Aseem Dhir, Ld Counsel for OP-3 & 4,

 

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ORDER

(Ajit Aggarwal, President)

                                        Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of Rs.5 lacs on account of death of her husband against  insurance policy and for further directing OPs to pay Rs.50,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.5,000/-.

2                                     Briefly stated, the case of the complainant is that husband of complainant was insured under Bhagat Puran Singh Health Insurance Scheme and was having card no.9304 5000 0790 3554 2 valid for the period from 1.11.2016 to 31.05.2019 and as per insurance policy in the event of death of head of family, family is entitled for sum of Rs. 5 lacs. It is further submitted that during the subsistence of policy in question husband of complainant died in an accident on 4.03.2017 in respect of which, General Diary No. 10 dated 4.03.2017 was got registered in Sadar Police Station, Faridkot and proceedings under Section 174 were conducted. Thereafter, complainant contacted OPs on their toll free number regarding death of her husband and also furnished all documents required for processing the death claim to the investigator to OPs, but they did not pay even a single penny on account of insurance claim for the death of her husband. Legal notice issued by complainant to Ops also served no purpose. All this amounts to deficiency in service.

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They have caused unnecessary harassment to her by not paying the genuine  claim on account of death of her husband and this act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to complainant for which she has prayed for directions to OP to pay Rs.50,000/-as compensation alongwith Rs.5,000/-as cost of litigation besides the main relief. Hence, the present complaint.

3                                   The counsel for complainant was heard with regard to admission of the complaint and vide order dated 6.05.2019, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                             On receipt of the notice, OP-1 and 2 filed written statement taking preliminary objections that complainant is not their consumer and therefore, present complaint is liable to be dismissed. It is averred that complaint involves complex questions of law and facts, which require voluminous evidence and it can not be decided by this Forum having limited jurisdiction and limited time span and therefore, it is liable to be referred to competent Civil Court. It is further averred that alleged accident did not occur during the subsistence of policy in question and moreover, as per Post Mortem Report, cause of death of Mander Singh is not certain. No cause of action arises against answering Ops and present complaint is vague and is based on wrong facts and complainant has no locus standi to file the same. It is further averred that complainant was not insured with them at the relevant time and neither complainant nor other respondents provided them proper insurance particulars and

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therefore, they are not liable to make payment of any insurance claim. There are several regional offices, divisional offices and branch and micro offices and it is not possible to locate the insurance particulars without supply of the same by complainant or by other OPs. It is further averred that despite issuance of letters dated 11.04.2018, 9.05.2018, 11.04.2019,  27.05.2019 and 20.08.2019 by OP-2 to complainant, she did not furnish death certificate, chemical examination report and final report of doctor on Post Mortem and therefore, complaint filed by complainant is premature. It is sternly denied that deceased was insured with OPs and even complainant has no locus standi to file the present complaint. However, on merits OP-1 and 2 have denied all the allegations of complainant being wrong and incorrect and it is reiterated that there is no deficiency in service on the part of answering OPs and they have denied all the allegations of complainant being wrong and incorrect and prayed for dismissal of complaint with costs.

5                                       Ld Counsel for OP-3 and OP-4 also filed written statement taking preliminary objections that Bhagat Puran Singh Sehat Bima Yojna has already been closed by Punjab Government with effect from 31.05.2019 and therefore, present complaint is not liable before this Forum. It is averred that they have not taken any consideration from answering OPs and therefore, complainant is not their consumer. However, on merits OP-3 and OP-4 admitted before the Forum that Mander Singh son of Shinder Singh resident of Shimrewala deceased

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husband of complainant was insured with OP-1 and OP-2 under Bhagat Puran Singh Sehat Bima Yojna and matter about relief sought is between complainant and OP-2 and there is no liability on the part of OP-3 and OP-4 to make payment of insurance claim or compensation sought by complainant. There is no deficiency in service on their part. All the other allegations and the allegation with regard to relief sought too are denied being incorrect and ld counsel for OP-3 and 4 prayed for dismissal of complaint with costs.

6                                              Parties were given proper opportunities to   

prove their respective case. Ld Counsel for complainant tendered in evidence affidavit of complainant as Ex.C-1 and documents Ex C-2 to Ex C-16 and then, closed the evidence.

7                                              In order to rebut the evidence of the complainant, ld counsel for OP-1 and 2 tendered in evidence, affidavit of Hemlata Panwar as Ex OP-1,2/1 and documents Ex OP-1,2/2 to Ex OP-1,2/5 and then, closed the same on the part of OP-1 and OP-2. Ld Counsel for OP-3 and 4  tendered in evidence affidavit of Dr. Chander Shekhar as Ex OP-3, 4/1 and thereafter, did not tender any evidence despite availing several opportunities and therefore, evidence of OP-3 and 4 was closed by this Forum vide order dated 22.01.2020.

8                                              We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents placed on the file.

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9                                              Ld Counsel for complainant has vehementally argued that being a member of Bhagat Puran Singh Sehat Bima Yojna having card no. 9304 5000 0790 3554 2 against policy in question, husband of complainant was insured under this scheme. It was valid from 1.11.2016 to 31.05.2019 and during the subsistence of policy in question, husband of  complainant died in a vehicular accident on 4.03.2017 regarding which DDR No.10 dated 4.03.2017 has been registered in Police Station City, Faridkot and due intimation regarding death of her husband was given by complainant to OPs. Complainant also furnished all documents required for processing the claim and also completed all required formalities, but till now, OPs have not cleared the genuine claim of complainant, which amounts to deficiency in service and trade mal practice on the part of OPs. She has prayed for accepting the present complaint alongwith compensation and litigation expenses besides main relief. She has stressed on documents Ex C-1 to 16.

10                                              To controvert the allegations of complainant, ld counsel for OP-1 and 2 argued that complainant is not their consumer and therefore, present complaint is liable to be dismissed. It is averred that complainant has no locus standi to file the present complaint and have denied all the allegations of complainant being wrong and incorrect and asserted that there is no deficiency in service on their part. It is further argued that despite issuance of letters dated 11.04.2018, 9.05.2018, 11.04.2019,  27.05.2019 and 20.08.2019, complainant, did

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not furnish death certificate, chemical examination report and final report of doctor on Post Mortem and therefore, complaint filed by complainant is premature and is liable to be dismissed. it is reiterated that deceased was not covered in the insurance under Bhagat Puran Singh Sehat Bima Yojna Insurance Policy and prayed for dismissal of complaint.

11                                       Ld Counsel for OP-3 and OP-4 argued before the Forum that complainant has sought relief regarding insurance claim on account of death of her husband from OP-2 and there is nothing to be done on their part in clearing the said insurance claim. It is admitted that deceased was insured under Bhagat Puran Singh Sehat Bima Scheme and there is also no denial to the fact that husband of complainant died on 4.03.2017 in an accident, but they have denied the liability for making payment of insurance claim as deceased was insured under said scheme with OP-1 and OP-2. There is no deficiency in service on the part of OP-3 and OP-4 and prayed for dismissal of complaint with costs.

12                                         After careful perusal of the record available on file and going through the evidence led by parties, it is observed that case of the complainant is that her husband was insured under Bhagat Puran Singh Health Insurance Scheme and was duly allotted card for availing the policy. During the subsistence of policy in question, her husband died in an accident and after his death, complainant duly intimated OPs and completed all requisite formalities and requested Ops to pay insurance claim on account of death of her husband. Grievance of

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complainant is that despite repeated requests OPs did not make payment of insurance claim under the policy in question. On the other hand plea  taken by OPs is that complainant is not their consumer and even husband of complainant was not insured with them as card of deceased was not valid at the time of accident in which husband of complainant died. Therefore, in order to prove her pleadings, complainant has stressed on document Ex C-2 copy of card issued under Bhagat Puran Singh Health Insurance Scheme that clearly depicts that policy in question was issued in the name of deceased Mander Singh. Ex C-15 is copy of pamphlet that contains information about Bhagat Puran Singh Health Insurance Scheme. Bare perusal of it clears the point that in case of death of head of family member of insured, family is entitled for Rs.5 lacs as insurance claim. Moreover, card of deceased issued under Bhagat Puran Singh Sehat Bima Yojna is valid for the period from 1.11.2016 to 31.05.2019. Ex C-4 to Ex C-11 are copies of legal notices alongwith postal receipts that further prove the pleadings of complainant that despite repeated requests, OPs have not made a single penny to clear the claim on account of death of her husband. Ex C-3 is copy of adahar card of complainant to prove that she was the wife of deceased Mander Singh. Ex C-11 is copy of Post Mortem Examination Report that reveals the fact that Mander Singh died on 4.03.2017 in accident and Ex C-12 copy of DDR No.10 dated 4.03.2017 also proves the pleadings of complainant. Ex C-14 is copy of brochure showing salient features of Bhagat Puran Singh Health Insurance Scheme

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wherein it is clearly pronounced that in the event of accidental death or disability of two parts, sum of Rs.5 lacs would be  given to the family of deceased or to the beneficiaries and validity of policy is also mentioned over here as commencing from 1.11.2016 to 31.05.2019. There is no doubt that complainant was aggrieved by the act of OPs in not making payment of insurance claim to her. Card issued to deceased under Bhagat Puran Singh Sehat Bima Yojna is beyond any doubt. It is observed that demand raised by Ops for chemical examination report of deceased Mander Singh is irrelevant as from the perusal of ExC-12 /General Diary Details dated 4.03.2017, there remains no doubt that death of Mander Singh is caused due to accident. Further Post Mortem reveals the fact that death occurred due to injuries sustained during accident. Complainant has placed on record sufficient and cogent evidence to prove her pleadings. There is no reason to doubt that complainant has suffered huge harassment and mental agony by action of OPs in not making payment of insurance claim to complainant on account of death of her husband.

13                                    From the above discussion and in the light of evidence produced by the respective parties, we are of considered opinion that complainant has succeeded in proving her case and therefore, present complaint is hereby accepted against OP-1 and OP-2. OP-1 and OP-2 are directed to pay Rs.5 lacs to complainant on account of insurance claim for death of husband who was insured with OPs alongwith interest at the rate of 9 % per anum from the date of filing the present complaint till final

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realization. OP- 1 and 2 are further directed to pay Rs.5,000/-to complainant as compensation for harassment and mental agony suffered by him as well as litigation expenses. Compliance of this order be made  within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Complaint against OP-3 and OP-4 stands hereby dismissed. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 03.02.2020       

(Param Pal Kaur)            (Ajit Aggarwal)  

 Member                         President