BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 121 of 2017
Date of Institution : 31.5.2017
Date of Decision : 12.3.2018.
Jitin Goyal (aged about 35 years) son of Sh. Kailash Goyal, House No.12, HUDA, Sector 20, Sirsa- 125055.
……Complainant.
Versus.
- Divisional Manager, The New India Assurance Company Near Bus Stand, Hisar Road, Sirsa.
- The General Manager, RAKSHA TPA Pvt. Ltd. SCO 359-360, 1st Floor, Sec. 44-D, Chandigarh- 160047.
..…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. MOHINDER PAUL RATHEE …… MEMBER.
Present: Sh. Ravinder Monga, Advocate for the complainant.
Sh. R.K. Mehta, Advocate for opposite parties.
ORDER
The case of the complainant in brief is that agent of opposite parties approached to the complainant and explained about the medi claim policy. The agent of op no.1 brought brochure and explained the features, terms and conditions of the policy. The complainant after fully understanding the same agreed to purchase the said policy alongwith his family members i.e. his wife and daughter. The complainant had also paid a premium of Rs.5735/- in favour of insurance company. The complainant and his family members were got examined by the medical board of the insurance company under the supervision and guidance of authorized agent/ official of the company. That thereafter a previty of contract between complainant and op no.1 was enforced on 24.11.2016 after fulfillment of all the required formalities in favour of the insurance company as per the guidelines. Thereafter, a policy no.3537003416 2800000033 commencing from 24.11.2016 to 23.11.2017 covering the risk of one year in this regard has also been issued by op no.1. It is further averred that complainant had to attend a close marriage party in Mumbai on 16.2.2017. The complainant was staying alongwith his family in Hotel Blue Diamond, Navi Mumbai and suddenly fell down from the stairs in the said hotel. One of the person appeared to be having medical knowledge advised to apply ointment, pain killer etc. upon absorbing the swelling on the knee. The said person told to the complainant that he belongs to medical line and as per his experience there is minor ligament injury inside and nothing else. The complainant believing upon the advise of said person applied ointment, crabe bandage on the injury area. Though there was regular pain on the knee area, some how with the regular pain the complainant attended the function and came back to Sirsa through flight. Then he immediately went to the hospital of Dr. Parveen Chawla, Hisar on 19.2.2017. Dr. Chawla after investigation advised for “Orthoscopy” and he was admitted in the hospital on 20.2.2017 and Dr. Chawla operated upon the knee of complainant to fill the injury by applying the latest treatment. The complainant informed to the agent/ official of the company on 20.2.2017 through telephone and he asked to take complete treatment. None of the official, agent ever visited to the hospital at the stay time of complainant. Finally, after coming to Sirsa he sent a written intimation letter on 27.2.2017 by attaching the discharge summary, hospital bills, claim form etc. alongwith other detail as advised by the agent. That the complainant received a letter from op no.1 demanding few documents and complainant sent the required documents as demanded through letter claim reference no.9051617546778. That the complainant could not hear anything from the insurance company, then again a written letter was sent. Surprisingly the said company again demanded few documents through letter dated 21.3.2017 though the complainant had already informed that all the original documents submitted before the company but despite this he had further sent another required documents through written letter dated 14.3.2017. Now the complainant is not having a single document with regards to his claim. The complainant requested and advised to fulfill the requirement, if any, by their own sources from Dr. Chawla at Hisar. The complainant had already visited thrice for collecting the duplicate documents as required by op no.1 and had also spent a sum of Rs.5000/- in three rounds. That the complainant is feeling helpless against the company, TPA and their regular requirement which had been already fulfilled. In this way, the complainant is fully humiliated, harassed and the ops have caused deficiency in service. The complainant lastly received a letter dated 5.4.2017 thereafter on 19.4.2017 which is an example for the ops who are habitual for sending sterio type letters with the pre-determined mind to decide the claim against the complainant. Hence, this complaint.
2. On notice, opposite parties appeared through counsel. Op no.1 filed written statement taking certain preliminary objections. It is submitted that complainant failed to submit the documents required from him vide letter and reminder dated 8.3.2017, 21.3.2017, 5.4.2017 and 19.4.2017, despite contractual obligation for providing assistance, cooperation and submission of all documents, upon which claim is based. The detail of documents which were required by op no.2- Raksha TPA (TPA is the agency appointed as per policy of Govt. of India for deciding the medi claim lodged by various consumer, for impartial decision, as there might have been an apprehension in the mind of consumers that insurance company did not intend to make payment of claim) is as under:-
(i) Treating doctors certificate mentioning history of Buckle Handle Tear clearly specifying duration
(ii) Treating doctors certificate mentioning probable etiology of the present ailment.
(iii) Prescription and investigation report of patient/ complainant supporting treatment taken for ailment Buckle Handle Tear prior to admission, if any.
It is further submitted that present complaint is pre mature without any cause of action as instead of providing the desired documents, information to the opos by the complainant, he has filed the present complaint without waiting the decision by op no.2, hence present complaint is not maintainable before this Forum. It is further submitted that there is violation of terms and conditions of the policy by the complainant as complainant lodged the claim with op no.1 on 27.2.2017 for the treatment allegedly taken by him on 19.2.2017. As per term and conditions of the policy, which is binding upon complainant, complainant should intimate/ lodge the claim immediately/forthwith with the company but he failed to lodge the claim immediately/forthwith even after discharge from the hospital on 20.2.2017. Remaining contents of the complaint are also denied.
3. However, opposite party no.2 did not file written statement despite appearance.
4. The complainant produced his affidavit Ex.CW1/A, and copies of documents Ex.C1 to Ex.C24. On the other hand, op no.1 produced affidavit of Sh. Karan Singh Chaudhary, Senior Divisional Manager as Ex.RW1/A and copy of letter dated 27.2.2017 Ex.R1.
5. We have heard learned counsel for the parties and have perused the case file carefully.
6. Learned counsel for complainant has strongly contended that it is proved case of complainant that complainant got health policy from opposite party no.1 for the period 24.11.2016 to 23.11.2017 and during subsistence of the policy, complainant fell down from the stairs of the hotel where he was staying in Mumbai on 16.2.2017 and thereafter he came back to Sirsa and got the treatment of knee injury from Dr. Parveen Chawla of Chawla Hospital at Hisar who advised for orthoscopy and thereafter advised surgery which was got conducted by complainant from Dr. Parveen Chawla. Complainant lodged claim with op no.1 alongwith all the documents but however op no.1 did not settle and pay the claim of complainant on the ground that certain documents have not been supplied to Raksha TPA Pvt. Ltd. despite the fact that complainant submitted all the documents to the insurance company which further passed on the same to op no.2. There was insurance contract between complainant and op no.1 and there was no insurance contract between complainant and op no.2 but however, op no.1 had given a free hand to op no.2 to settle the claim of complainant. The complainant wrote five letters to op no.1 for settlement of the claim but however, all the time the op no.1 tried to avoid payment of the claim on one pretext or the other.
7. On the other hand, learned counsel for op no.1 has contended that alleged injury was suffered by complainant on 16.2.2017 at Mumbai and complainant got injury examined on 19.2.2017 at Hisar and also got conducted surgery on 20.2.2017. Intimation was given to op no.1 on 27.2.2017. The complainant has not explained the delay why he did not get treatment there at Mumbai and at Sirsa during intervening period of 16.2.2017 to 19.2.2017. Complainant has not submitted all the required documents as per requirement of op no.2 despite four letters written by op no.2. As such claim of complainant was closed.
8. We have considered the rival contentions of the parties and have gone through the record carefully.
9. It is undisputed fact between the parties that complainant had purchased a mediclaim policy from opposite party no.1 on payment of premium of Rs.5735/- for the period 24.11.2016 to 23.11.2017. As per allegations of the complainant, complainant had gone to Mumbai and was staying in Hotel Blue Diamond where he fell down and suffered injury on his knee, but however, he only get first aid there and thereafter came back to Sirsa by air which is evident from copy of booking ticket Ex.C6. It is evident from the evidence of complainant that complainant had approached Dr. Parveen Chawla of Chawla Nursing Home at Hisar who examined knee of complainant and thereafter advised for orthoscopy and after the report of orthoscopy, he advised the surgery on the knee which was got conducted by complainant from aforesaid Dr. Parveen Chawla of Chawla Nursing Home, Hisar on 20.2.2017 and thereafter he was discharged from hospital on 21.2.2017 which is evident from the copy of discharge card Ex.C4. It is further evident from the record that complainant wrote five letters to the ops for settlement and payment of claim amount but however, the claim was not settled and paid by ops due to reason best known to them.
10. Though during the course of arguments, learned counsel for ops has relied upon letters written by op no.2 by which they called upon the complainant to supply the documents qua the reports of the treating Doctor but however, op no.1 has not denied in its written statement and affidavit of the concerned officer namely Sh. Karan Singh Chaudhary, Senior Divisional Manager that complainant had not submitted the requisite documents regarding his treatment as well as the surgery which he got conducted on his knee from Dr. Parveen Chawla rather discharge card of Chawla Nursing Home Ex.C4 is self explanatory in itself which was supplied by complainant to the ops and further more perusal of evidence of op no.1 reveals that op no.1 has placed on record only affidavit of Mr. Karan Singh, Senior Divisional Manager of New India Assurance Company Ltd. who simply deposed in terms of written statement and on the tune of report of Raksha TPA and referred letters dated 8.3.2017, 21.3.2017, 5.4.2017 and 19.4.2017 written by Raksha TPA Pvt. Ltd., calling upon the complainant to submit documents detailed in para no.3 of the affidavit Ex.RW1/A. But the ops have not placed on record all these letters nor they have placed on record any report of the Raksha TPA Pvt. Ltd., on the basis of which the op no.1 has declined claim of complainant nor the op no.1 has furnished affidavit of any doctor of Raksha TPA who examined the reports qua treatment of the complainant, nor op no.1 has placed on record any document which was submitted by Raksha TPA to the insurance company by which they recommended for the repudiation of the claim of complainant. Rather it appears from the record that originally Sh. Rajesh Kumar Mehta put his appearance on behalf of opposite party no.1 insurance company by filing his memo on 31.3.2017 and thereafter Sh. V.P. Arora, Advocate had filed memo of appearance on behalf of ops no.1 and 2, but however, power of attorney was only filed on behalf of op no.1 by Sh. Rajesh Kumar Mehta, Advocate and no power of attorney was filed on behalf of op no.2 i.e. General Manager, Raksha TPA Pvt. Ltd. The record further reveals that no written statement on behalf of op no.2 was filed by op no.2 meaning thereby the op no.2 could not stand on their own legs in order to defend and contest the complaint of complainant though op no.1 has put the claim of complainant on the shoulder of op no.2. So, it appears that ops have declined the claim of complainant only in casual, mechanical and flimsy manner without considering the merits of the claim of complainant which clearly amounts to deficiency in service on the part of ops.
11. In view of the above, we allow the present complaint and direct the opposite parties to pay claim amount of Rs.28,622/- to the complainant within a period of 30 days from the date of receipt of copy of this order, failing which the complainant will be entitled to receive the above said amount alongwith interest @9% per annum from the date of order till actual payment. We also direct the ops to further pay a sum of Rs.5000/- as composite compensation and litigation expenses to the complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:12.03.2018. Member District Consumer Disputes
Redressal Forum, Sirsa.
