BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Sumedh Pathak, Flat No.5180/2, Modern Housing Complex, Manimajra, Chandigarh.

….…Complainant

                           V E R S U S

M/s Genins India Ltd., B-127, Sector 2, Noida 201301.

                                  ..…Opposite Party

CORAM:  SH.JAGROOP SINGH MAHAL        PRESIDENT

              DR.(MRS) MADHU BEHL       MEMBER

              SH.RAJINDER SINGH GILL   MEMBER

Argued by: None for complainant.

OP exparte.

PER DR.(MRS) MADHU BEHL,  MEMBER

             Succinctly put, the complainant being retired employee of M/s National Fertilizers Ltd. (NFL) opted the medi-claim scheme evolved by them under which 80% of the premium was to be borne by NFL and 20% by the employee.  In October 2008 he underwent surgery for fistula in Govt. Multi Specialty Hospital, Sector 16, Chandigarh and remained there from 18.10.2008 to 23.10.2008 and the requisite bills verified by the concerned surgeon were sent to the OP by speed post on 31.12.2008. However the OP did not settle the claim till 5.2.2009 upon which  he sent a reminder vide email.  In response thereto, he was asked to submit some documents which were sent by him vide email dated 25.2.2009 and also informed about the change of address.  However, he received a cheque for Rs.3,999/- only and the amount of MRI bill was deducted.  The cheque was sent to his Chandigarh address and not the changed address and even his name was wrongly mentioned as ‘Sumesh’ on the cheque.  He pointed out the lapse on the part of the company vide letter dated 27.7.2009 and returned the wrong cheque but no response was received.  Thereafter he contacted the OP through telephone as well as email and only thereafter he received an email dated 26.8.2009 from the OP stating that his claim for Rs.2750/- for MRI was admissible but a letter from NFL was needed and when he contacted NFL on telephone regarding the same, they informed that the necessary correction was sent to the OP which has been denied by the OP.   It has been alleged by the complainant that he has been made a rolling stone by the OP and the NFL which caused tremendous mental and physical harassment to him. Hence this complaint alleging that the aforesaid acts of the OPs amount to deficiency in service and unfair trade practice.

2.             Initially Sh. Vikas Kumar, authorized representative of the OP appeared on its behalf and the case was fixed for filing reply and evidence but subsequently none appeared and, therefore, it was proceeded against exparte.

3.             Complainant led evidence in support of his contention.

4.             We have perused the record. 

5.             Annexure A is the document which shows that the complainant had taken the medi-claim policy from OP in the name of Sumedh Pathak and not of Sumesh Pathak and also shows that the complainant had renewed the membership of medi-claim policy for ex-employees of NFL for the year 2008-2009. Annexure B is the record that he was the indoor patient in the Govt. Multi specialty Hospital, Sector 16, Chandigarh from 18.10.2008 to 23.10.2008 where he had under gone treatment and was operated for Fistula.  Accordingly the complainant sent a claim for reimbursement duly attested by the concerned surgeon of the hospital on 31.12.2008 through speed post vide RLA 6203.

6.             It is the grouse of the complainant that till date his claim of Rs.6,849/- has not been settled by the OP.  Annexure E is the document which shows that on 30.03.2009, OP had sent one cheque number 572954 of Rs.3,999/- against the claim of Rs.6,849/- and on which the OP had wrongly mentioned the name of the claimant as Sumesh Pathak instead of Sumedh Pathak.  It is the contention of the complainant that he had submitted all the documents which were required for reimbursement of claim to the OP in support of which OP deducted Rs.2750/- on the ground that the complainant had not submitted two documents one is the Doctors advise for MRI and other is the receipt of HIV, whereas these receipts had already been attached with  the claim form.

7.      In our opinion there is deficiency in service on the part of the OP as they are negligent in sending the part payment to the complaint by mentioning his wrong name, hence delaying the payment for no fault of the complainant which also is an unfair trade practice because the member ship card also shows the name of the complainant as Sumedh Pathak and not Sumesh Pathak.

8.      It is a sorry state-of-affairs that we are having cases after cases in which the claims of the insured persons are being delayed deliberately and intentionally under the garb of not producing of the relevant documents and complainants have to suffer without any fault of their own. In the present case also the OP has deducted the payment of MRI Bill and delayed the legitimate payment of Rs.2750/- for MRI which was admissible but a letter from NFL was needed for the name rectification.

9.              In view of the aforesaid reason we accept the complaint and the same is accordingly allowed.  For such delay in settling the claim, the OP must pay adequate compensation to the insured. Therefore the OP is directed to pay the admissible claim of the complainant i.e. Rs.6,849/- alongwith Rs.3,000/- as compensation for causing him mental and physical harassment by delaying his genuine claim and compelling him to make rounds of their offices. The complainant would also be entitled to Rs.2,200/- as costs of litigation. The aforesaid amount of Rs.12,049/- shall be paid within 30 days from the date of receipt of the copy of this order failing which the OP would be liable to pay the entire amount alongwith penal interest @12% p.a. since the filing of the present complaint i.e. 02.12.2009 till the payment is actually made to the complainant.

       Certified copies of this order be sent to the parties free of charge.  The file be consigned.