Punjab

Faridkot

CC/19/92

Geeta Devi - Complainant(s)

Versus

MD India Health Insurance - Opp.Party(s)

Lalwinder Singh Chauhan

02 Dec 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :        92 of 2019

Date of Institution:    29.03.2019

Date of Decision:      02.12.2019

 

Geeta Devi aged about 40 years w/o Ram Bilas Ram s/o Musafir Ram r/o Street No.10, Sanjay Nagar, Faridkot, 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 Sandeep Sharma, Ld Counsel for OP-2,

              Sh Kashmir Lal, Ld Counsel for OP-3 & 4,

   OP-1 Ex-parte.

 

Complaint No. - 92 of 2019

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.10,000/- 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.0304 5003 9118 00219 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 11.01.2019 in respect of which, FIR No.07 dated 12.01.2019 was got registered in Police Station City, Faridkot under Section 304 of IPC. 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

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purpose. All this 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 she has prayed for directions to OP to pay Rs.10,000/-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 3.04.2019, 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 and was presumed to be served. Despite repeated calls, no body appeared on behalf of OP-1 either in person or through counsel on date fixed to contest the allegations levelled by complainant. Statutory period expired and therefore, vide order dated 14.05.2019, 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 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

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limited jurisdiction and limited time span and therefore, it is liable to be referred to competent Civil Court. It is further averred that at the time of said accident, card number of deceased was not valid and effective for the purpose of insurance from OP-1 and OP-2. There is no deficiency in service on the part of answering OP because as and when they received information regarding death of Ram Bilas, they immediately appointed Investigator Ravi Mani who after investigation gave his report dated 12.03.2019 wherein mentioned that death claim case should be decided as per terms and conditions of the policy and as per terms and conditions of the policy, smart card of the deceased was not covered in the insurance under Bhagat Puran Singh Sehat Bima Yojna Insurance Policy. Record regarding insured card holders is maintained with OP-1 in computer software and same is provided by them at the time of claim. E-mail dated 18.04.2019 and 19.06.2019 were duly served to OP-1 to confirm about the card of deceased and in response to that Op-1 vide reply dated 20.06.2019 confirmed that no detail regarding card number of deceased is available with them and as per confirmation given by TPA OP-1 settled the claim of claimant as No Claim as per claim note dated 26.06.2019 and repudiation letter dated 27.06.2019 to this effect was also duly served to claimant and therefore, 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-2 has denied all the allegations of complainant being wrong and incorrect and asserted that there is no

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deficiency in service on their part. It is further averred that detail pertaining to card of deceased does not exist in the record of answering OP. It is reiterated that there is no deficiency in service on the part of answering OP and OP-2 has denied all the allegations of complainant being wrong and incorrect and prayed for dismissal of complaint with costs.

6                                       Ld Counsel for OP-3 and OP-4 also filed written statement taking preliminary objections that complainant has not approached Grievance Redressal Committees constituted at District Level and State Level for providing relief under such cases. 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 deceased 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-1 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.

7                                              Parties were given proper opportunities to   

prove their respective case. Ld Counsel for complainant tendered in

 

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evidence affidavit of complainant as Ex.CW-1/A and documents Ex C-1 to Ex C-14 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 Hemlata Panwar as Ex OP-2/1 and documents Ex OP-2/2 to Ex OP-2/11 and then, closed the same on the part of OP-2.  Ld Counsel for OP-3 and 4  tendered in evidence affidavit of Dr. Chander Shekhar as Ex OP-3, 4/1 and closed the same on behalf of OP-3 and 4.

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 having card no.0304 5003 9118 00219 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 11.01.2019 regarding which FIR No.07 dated 12.01.2019 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 to Investigator appointed by Ops and also completed all require formalities, but till now,

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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 14.

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 on receipt of information regarding death of Ram Bilas, they immediately appointed Investigator Ravi Mani who after investigation gave his report dated 12.03.2019 wherein mentioned that death claim case should be decided as per terms and conditions of the policy and at the time of said accident, smart card of the deceased was not covered in the insurance under Bhagat Puran Singh Sehat Bima Yojna Insurance Policy. Record regarding insured card holders is maintained with OP-1 in computer software and same is provided by them at the time of claim. In response to E-mail dated 18.04.2019 and 19.06.2019 issued by OP-2, OP-1 vide reply dated 20.06.2019 confirmed that no detail regarding card number of deceased is available with them and as per confirmation given by TPA, OP-1 settled the claim of claimant as No

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Claim on 26.06.2019 and vide repudiation letter dated 27.06.2019 complainant was duly informed about this. As per OP-2, deceased was not insured with OPs. They have denied all the allegations being wrong and incorrect and prayed for dismissal of complaint with costs.

12                                       Ld Counsel for OP-3 and OP-4 argued before the Forum that complainant has not approached Grievance Redressal Committees constituted at District Level and State Level for obtaining relief under her claim. It is argued that complainant has sought relief regarding insurance claim on account of death of her husband from OP-3 and OP-4 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 12.01.2019 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.

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 duly

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intimated 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 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 Ram Bilas. Ex C-13 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-7 to Ex C-10 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-2 is copy of adahar card of complainant to prove that she was the wife of deceased Ram Bilas. Ex C-11 is copy of Post Mortem Examination Report that reveals the fact that Ram Bilas died on 12.01.2019 in accident and Ex C-12 copy of FIR No.0007 dated

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12.01.2019 also proves the pleadings of complainant. Ex C-14 is copy of brochure showing salient features of Bhagat Puran Singh Health Insurance Scheme 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. 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 on account of death of her husband.

14                                    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 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

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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 : 02.12.2019       

(Param Pal Kaur)            (Ajit Aggarwal)  

 Member                         President