DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Consumer Complaint No : 631/2015.
Date of Institution : 18.09.2015.
Date of Decision : 16.03.2016.
In the matter of:
Sunita aged about 38 years wife of Sandeep Kumar, resident of # B-XI/434, Street No. 10, K.C. Road, Barnala, Tehsil and District Barnala.
...Complainant
Versus
1. Medi Assist India, (TPA) Pvt. Limited, Head Office 47/1, Sri Krishna Arcade, Ist Main, 9th Cross, Sarakki Industrial Layout, JP Nagar, 3rd Phase, Banalore-560078 through its Manager.
2. The Oriental Insurance Company Limited, registered Head Office A-25/27, Asaf Ali Road, New Delhi-110002, through its Manager.
3. Punjab National Bank, Main Branch, Bhagat Singh Road, Barnala, through its Branch Manager. ...Opposite Parties
Complaint Under Section 12 of Consumer Protection Act, 1986.
Present: Sh. Rajiv Goyal counsel for complainant.
Sh. Jatinder Kumar counsel for opposite parties No. 1 & 2.
Sh. Vinod Kumar Goyal counsel for opposite party No. 3.
Quorum.-
1. Shri S.K. Goel : President.
2. Sh. Karnail Singh : Member
3. Ms. Vandna Sidhu : Member
ORDER
(SHRI S.K. GOEL PRESIDENT):
The complainant namely Sunita has filed the present complaint under Consumer Protection Act, 1986 (hereinafter called as Act) against Medi Assist India (TPA) Pvt. Limited and others (hereinafter called as the opposite parties).
2. The facts emerging from the present complaint are that the complainant obtained a PNB Oriental Royal Mediclaim Policy bearing No. 233200/48/2015/2153 through her husband Sandeep Kumar from the opposite party No. 2 through opposite party No. 3 valid from 26.10.2014 to 25.10.2015 having card No. MA-ID-5006048212 serviced by opposite party No. 1. It is averred that the complainant got insured herself through the above said policy.
3. It is alleged that on 13.4.2015 the complainant suddenly fell ill and was brought in the hospital of Dr. Ajit Singh Khurana at Ludhiana by her husband, where the complainant was treated and operated for modified SMR by Dr. Ajit Singh Khurana and the complainant was discharged on 15.4.2015. It is further averred that the complainant spent Rs. 26,662/- on operation fee, theater expenses, Anesthesia fee, medicines including accommodation and other misc. expenses. After the discharge from the hospital, the complainant alongwith her husband approached to opposite parties for the reimbursement of amount of Rs. 26,662/-. However, the opposite parties instead of paying the claim linger on the matter on one pretext or the other and lastly on 11.9.2015 they refused to pay the claim amount. Hence, the present complaint is filed seeking the following reliefs.
To pay the amount of Rs. 26,662/- alongwith interest @ 18% per annum from the operation till realization.
To pay Rs. 25,000/- as compensation and Rs. 11,000/- as litigation expenses.
4. Upon notice of this complaint, the opposite parties No. 1 & 2 appeared and filed written version taking legal objections on the grounds interalia no cause of action or locus-standi, complaint is premature, estoppel, not come to the Forum with clean hands etc. On merits, the opposite parties No. 1 & 2 denied that the complainant suddenly fell ill on 13.4.2015 and was brought by her husband to the hospital of Dr. Ajit Singh Khurana at Ludhiana. It is further submitted that the complainant failed to intimate about her admission within 24 hours from hospitalization or date of admission as per the instructions issued by the opposite party No. 1 at the time of issuance of the said policy. It is further averred that the complainant lodged her claim with the opposite party No. 1 for reimbursement of the amount spent on her treatment. She was asked by opposite party No. 1 vide its letter dated 22.6.2015 to provide certain documents, but the complainant failed to provide the same. It is further averred that the complainant wrote a letter dated 9.7.2015 to opposite party No. 2 and the opposite party No. 2 vide its letter No. CSD/3/466/2015 dated 24.7.2015 intimated the complainant that the needful was being done by its concerned office. However, they have denied that the matter was lingered on the matter and they refused to pay the claim. They have also denied that the complainant is suffering from any harassment and mental agony and there is any deficiency in service on their part. Rather, the complainant failed to provide documents as asked by opposite party No. 1. Hence, the present complaint is liable to be dismissed.
5. Opposite party No. 3 has filed a separate written version taking legal objections on the grounds of maintainability and the complainant is not consumer. On merits, it is averred that the complainant got Oriental Royal Insurance Policy from the opposite party No. 2 and the amount for policy was transferred to opposite party No. 2 from the account of complainant or her husband as per her request and the complainant is not the consumer as the alleged policy was issued by opposite party No. 2. However, they have denied that there is any deficiency in service on their part and prayed for the dismissal of complaint.
6. In order to prove her case, the complainant tendered in evidence her own affidavit Ex.C-1, copy of policy schedule Ex.C-2, copy of policy card Ex.C-3, copy of medi claim card Ex.C-4, copy of letter dated 24.7.2015 Ex.C-5, copy of bill Ex.C-6, copy of discharge slip Ex.C-7, copy of prescription slip Ex.C-8, copy of bills Ex.C-9 to Ex.C-10, copy of bill No. 154 dated 15.4.2015 Ex.C-11 and closed the evidence.
7. In order to rebut the case of complainant, the opposite party No. 1 & 2 tendered in evidence affidavit of Amarjit Singh Dingra Ex.O.P-1.2/1 and closed the evidence. No evidence is lead by the opposite party No. 3.
8. We have heard the Ld. Counsels for the parties and have gone through the records.
9. In order to prove her case, the complainant has placed on record her detailed affidavit Ex.C-1, wherein she reiterated her stand as taken in the complaint. She specifically stated in the affidavit Ex.C-1 that on 13.4.2015 she suddenly fell ill and was brought to the hospital of Dr. Ajit Singh Khurana and she was discharged on 15.4.2015 and she spent Rs. 26,662/- on operation fee, theater expenses, Anesthesia fee, medicines including accommodation and other misc. expenses.
10. Ex.C-2 is the Mediclaim Policy for herself and other family members for a sum of Rs. 3,00,000/- for the period from 26.10.2014 to 25.10.2015. Ex.C-6 is the bill of the hospital showing the expenses to the tune of Rs. 25,000/-. Ex.C-7 is the discharge slip showing the date of admission 13.4.2015 and date of discharge as 15.4.2015. Ex.C-8 is the certificate of Dr. Ajit Singh Khurana, which shows diagnosis of the complainant. Ex.C-9 is the bill of medicines to the tune of Rs. 996/-. Ex.C-10 is the another bill of Rs. 666/- and Ex.C-11 is the receipt of the Dr. Ajit Singh Khurana dated 15.4.2015 of receiving Rs. 25,000/-.
11. On the basis of the above said evidence, Ld. Counsel for the complainant has contended that the complainant is entitled to Rs. 26,662/- alongwith interest. To rebut the case of the complainant, the opposite parties have placed on record affidavit of Amarjit Singh Dingra Divisional Manager Ex.O.P1.2/1. Except the said affidavit there is no other document or evidence produced by the opposite parties to rebut the case of the complainant. In view of the evidence regarding diagnosis of the complainant as well as the expenses paid by the complainant through receipts and bills, it is proved that the complainant has been diagnosed and she has incurred the said expenses.
12. Facing the situation, Ld. Counsel for the opposite parties contended that the complainant has not produced certain documents before the authority and the case is premature and the claim was not rejected. This contention of the Ld. Counsel for opposite parties is untenable.
13. Perusal of the affidavit placed on record by the complainant clearly shows that she was discharged on 15.4.2015 and after that she approached the opposite parties many times for her claim. It is also submitted that since the matter is kept pending by the opposite parties on one pretext or the other and lastly on 11.9.2015 the opposite parties refused to pay the claim. Thus, it is clear from 15.4.2015 till 11.9.2015 the opposite parties failed to decide her claim. Therefore, by stretch of any imagination it cannot be held that this case is premature till date.
14. As a result of the above discussion, there is a merit in the complaint and the same is accepted against the opposite parties No. 1 & 2 and the opposite parties No. 1 & 2 are directed to pay Rs. 26,662/- alongwith interest @ 9% per annum from the date of filing the present complaint. The opposite parties No. 1 & 2 are further directed to pay Rs. 2,000/- to the complainant as compensation and Rs. 1,100/- as litigation expenses. This order of ours shall be complied within 30 days from the date of the receipt of the copy of this order. Copy of this order be supplied to the parties free of cost. The file after its due completion, be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
16th Day of March, 2016.
(S.K. Goel)
President.
(Karnail Singh)
Member.
(Vandana Sidhu)
Member.
