Punjab

Faridkot

CC/20/198

Kamaljeet Kaur - Complainant(s)

Versus

MD India Health Insurance TPA Pvt Ltd - Opp.Party(s)

Sheetal Kumar Garg

30 Jan 2023

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  FARIDKOT

 

Complaint No. :        198 of 2020

Date of Institution:     15.12.2020

Date of Decision:        30.01.2023

 

Kamaljeet Kaur aged about 31 years w/o Satpal Singh now deceased r/o House No. 60, Part No. 1, Village Dod, Tehsil Jaitu & District Faridkot.

...Complainant

Versus

1. MD India Healthcare Services (TPA) Pvt Ltd., Plot No. 18/13, Ground Floor, WEA, Ganga Plaza, Pusa Lane, Karol Bagh, New Delhi-110005.
2. United India Insurance Company Ltd., SCO 72, Phase IX, Mohali, Division Office, Mohali through its Authorized Signatory.
3. The Director, Bhagat Puran Singh Sehat Sewa Bima Yojna, Backside Civil Hospital, Phase – VI, Mohali.

.....Opposite Parties

Complaint under Section 35 of the

Consumer Protection Act, 2019.

 

Quorum: Sh Kanwar Sandeep Singh, President,

                Smt Param Pal Kaur, Member,

                Sh Vishav Kant Garg, Member.

 

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Present: Sh Sheetal Garg, Ld Counsel for complainant,

              Sh Ashok Monga, Ld Counsel for OP-2,

              Sh Manpreet Singh, Ld Counsel for OP-3,

              OP-1 Ex-parte.

ORDER

(Kanwar Sandeeep Singh, President)

 

                                    Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 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 compensation for harassment, inconvenience, mental agony besides litigation expenses.

2                                    Briefly stated, the case of the complainant is that Satpal Singh husband of complainant was insured under Bhagat Puran Singh Sehat Sewa Scheme. He was issued card no.0304 5000 7410 3563 3 and as per Bhagat Puran Singh Sehat Sewa Bima Yojna 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 a vehicle accident on

cc no. - 198 of 2020

05.06.2020. On 05.06.2020, deceased was coming home after work on his motorcycle and at about 8.15 p.m., when he reached near wine shop adjoining Bajakhana Chowk flyover, his vehicle struck with stray dog and it became over controlled. Her husband fell on ground and got serious injuries. He was admitted to Civil Hospital, Bajakhana, but due to serious injuries, he was referred to Guru Gobind Singh Medical College and Hospital, Faridkot where he died during treatment there and DDR to this effect was also got registered. 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 of OPs, but they did not pay even a single penny on account of insurance claim for the death of her husband. Complainant made several requests to OPs to make payment of genuine insurance claim, but all in vain, which amounts to deficiency in service. 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

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she has prayed for directions to OP to pay compensation alongwith 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 21.12.2020, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                          Notice issued to OP-1 through registered cover did not receive back undelivered. Acknowledgment might have been lost in transit. Summons were deemed to be served, but despite repeated calls, no body appeared on behalf of OP-1 either in person or through counsel on date fixed. Statutory period expired and therefore, vide order dated 02.11.2021, OP-1 was proceeded against exparte.

5                           On receipt of the notice, OP-2 filed written statement taking preliminary objections that complainant is not their consumer and there is no relationship of consumer or service provider between complainant and answering OP. It is averred that policy of insurance in respect of blue card holders had already expired on

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31.03.2019 because no premium regarding insurance of common blue card holders was paid to answering OP company after 30.03.2019 and contract of insurance expired on 31.03.2019 where as death of husband of complainant occurred on 05.06.2020. As per documents furnished by complainant, policy in question was not in force as it had already expired on 31.03.2019 for Blue Card Holders and thus, no risk or liability can be assumed by answering OP. No cause of action arises against answering OP. It is averred that complaint involves complex questions of law and facts, which require voluminous evidence and it can not be decided by this Commission having limited jurisdiction and limited time span and therefore, it is liable to be referred to competent Civil Court.  No proper particulars of insurance have been produced on record either by complainant or by other OPs. It is averred that answering OP has numerous regional offices, divisional and branch officers and it is not possible for them to locate the insurance particulars without supplying the said documents and therefore, insurance of alleged deceased is denied. Even as per law andprovisions of scheme, complaint filed by complainant is not maintainable. Even

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deceased never paid any Rs.30/-to answering OP and complainant is not entitled for any medical reimbursement of Rs. 5 lakhs on account of death of holder of said smart card. Moreover, Smart Card of deceased pertains to Blue Card Category and insurance for Blue Card Holders had come to an end and was valid till 31.03.2019, whereas accident and death of her husband occurred on 05.06.2020 and thus, there is no liability on the part of OP-2.It is further averred that complainant has even concealed the date and time of death of deceased and this fact is clear from the copy of GDR and copy of post mortem report and thus, complaint is liable to be dismissed. It is reiterated that there is no deficiency in service on their part and made prayer for dismissal of complaint with costs.

6                            Ld Counsel for OP-3 filed reply taking preliminary objections that Bhagat Puran Singh Sehat Bima Yozna has been closed by the Punjab Government with effect from 31.05.2019 and therefore, present complaint is liable to be dismissed. It is averred that complainant is not their consumer and there is no relationship of consumer or service provider between them. However, on merits, OP-3

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admitted before the Forum that said scheme was launched by Punjab Government and answering Ops were running the same, but it is denied that premium amount of Rs.30/-was paid by deceased and he was issued a Smart Card by them. It is further averred that policy under which benefit is sought by complainant, has expired on 31.05.2019 whereas occurrence of death of husband of complainant is 05.06.2020 and thus, benefits under said scheme are not admissible to complainant. Answering OP has no role to play in making payment of insurance claim. It is asserted that neither complainant informed them about death of her husband nor she is entitled to claim any compensation for death of her husband. Moreover, claim is not payable Opposite Party no.3. All the other allegations are denied being wrong and incorrect and it is further averred that there is no deficiency in service on the part of answering OPs. Prayer for dismissal of complaint with costs is made.

7                        Parties were given proper opportunities to prove their respective case. Ld Counsel for complainant tendered in evidence

 

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affidavit of complainant as Ex.C-1 and documents Ex C-2 to Ex C-8 and then, closed the evidence.

8                        In order to rebut the evidence of the complainant, Ld Counsel for OP-2 tendered in evidence affidavit of R N Bansal Ex OP-2/1, document Ex OP-2/2 and then, closed the same on behalf of OP-2. Ld Counsel for OP-3 tendered in evidence affidavit of Dr. Rohini Goyal Ex OP-3/1 and then, closed the same on behalf of OP-3.

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

10                       Ld Counsel for complainant has vehementally argued that being a member of Bhagat Puran Singh Sehat Bima Yojna against policy in question, Satpal Singh husband of complainant was insured under this scheme and during the subsistence of policy in question, husband of  complainant died in a road accident on 05.06.2020 regarding which GDR No.021 dated 06.06.2020 has been registered in Police Station Bajakhana due intimation regarding death of her

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husband was given by complainant to OPs. Complainant also furnished all documents required for processing the claim to Investigator appointed by Ops 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 document Ex C-1 to 8.

11                     To controvert the allegations of complainant, ld counsel for OP-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 no information regarding death of insured was given to them thereby preventing them to gather first hand information, which is a violation of terms and conditions of the policy. Moreover, neither complainant nor other OPs have produced on record particulars

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in respect of insurance of deceased. It is averred that OP-1 has numerous regional, divisional and branch officers and it is not possible for them to locate the insurance particulars of deceased husband of complainant without supplying the same and therefore insurance of alleged deceased is denied.  Moreover, complainant has concealed about date and time of death of said Satpal Singh, which is clear from GDR and Post Mortem report. It is further argued that all the allegations of complainant are incorrect and wrong and made prayer for dismissal of complaint with costs.

12                   Ld Counsel for OP-3 argued that Bhagat Puran Singh Sehat Bima Yozna has been closed by the Punjab Government with effect from 31.05.2019 and even complainant is not their consumer and there is no relationship of consumer or service provider between them. As per their counsel, said scheme was launched by Punjab Government and they were running the same. Death of husband of complainant occurred on 05.06.2020, but alleged policy stands expired on 31.05.2019 and therefore, benefits of said scheme are not admissible to

 

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complainant. There is no deficiency in service on their part and prayer for dismissal of complaint with costs is made.

13                              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 gave due intimation regarding death of her husband to OPs and completed all requisite formalities and requested Ops to pay insurance claim on account of death of her husband. Grievance of 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 OP-2 is that complainant is not their consumer and even husband of complainant was not insured with them as no intimation regarding death of Satpal Singh and documents in respect of his insurance were ever provided by complainant or other OPs. As per OP-2 they have several regional, divisional, branch and micro offices set by them and it

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is difficult for them to locate detail regarding insurance of  husband of complainant. It is also denied that any accident dated 05.06.2020 was ever occurred and deceased sustained injuries in said accident. it is averred that GDR No.021 dt 06.06.2020 has nothing to do with present complaint and said Satpal Singh did not die at the spot and moreover, no intimation regarding accident, treatment or death was ever supplied to them. Moreover, Satpal Singh deceased husband of complainant never paid Rs.30/-to them and he was not insured with them and even no smart card was issued to her husband by them for the period when he died. It is reiterated that said Smart Card pertains to Blue Card Category and insurance for Blue Card Holders had come to an end and it was valid till 31.03.2019, but death of her husband occurred on 05.06.2020 and therefore, answering OP is not liable to indemnify the loss. They have denied the payment of insurance claim. There is no deficiency in service on the part of OP-2.

14                         From the above discussion and in the light of evidence produced by the respective parties, we are of considered opinion that complainant is not entitled for relief sought by her as

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complainant has failed to bring on file insurance policy in question. Further perusal of the file reveals that Bhagat Puran Singh Sehat Sewa Beema Yojna was valid only uptil 31.05.2019. This policy was extended by Government only upto 31.05.2019. Death of husband of complainant occurred on 05.06.2020, but policy expired on 31.05.2019 and therefore, she is not entitled to obtain insurance claim in respect of death of her husband from OPs. Moreover, she has failed to place on record any documentary evidence to prove that death of her husband occurred  during subsistence of policy in question. Therefore, complaint against OPs stands hereby dismissed.

15             The complaint could not be decided within the statutory period due to heavy pendency of cases.

16                  Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Commission

Dated : 30.01.2023

 

 

     (Vishav Kant Garg)  (Param Pal Kaur)    (Kanwar Sandeep Singh)

      Member                   Member                 President