DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.

Complaint Case No : CC/35/2019

Date of Institution : 05.04.2019

Date of Decision : 01.10.2019

Ashok Kumar Jindal s/o Sh. Banarsi Dass resident of H. No. B-X-154, Ahata Narain Singh Wala, Barnala, District Barnala.                    …Complainant

Versus

1. M/s Oriental Insurance Company Limited, KC Road, Near Easyday, Barnala through its Branch Manager.

2. M/s Oriental Insurance Company Limited, Divisional Office, 4501, 1st Floor, Bank Bazaar, Bathinda-151001 through its Divisional Manager.

3. M/s Raksha Health Insurance TPA Private Limited, SCO-39, 1st Floor, Sector-26, Madhya Marg, Above Barbeque Nation, Chandigarh-160019 through its Managing Director. 

…Opposite Parties

Complaint Under Consumer Protection Act.

Present: Sh. RK Singla counsel for complainant.

Sh. Varinder Kumar Goyal counsel for opposite parties No. 1 and 2.

Opposite party No. 3 exparte.

 

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

(ORDER BY KULJIT SINGH, PRESIDENT):

    The complainant namely Ashok Kumar Jindal has filed the present complaint under Consumer Protection Act (in short the Act) against Oriental Insurance Company Limited, Barnala and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that complainant is having his Account No. 0044000104246940 with PNB Main, Shaheed Bhagat Singh Road, Barnala and he purchased PNB-Oriental Royal Medical Claim Policy from the opposite party No. 1 through the said bank and paid the premium from his bank account for the period from 28.7.2018 to 27.7.2019 bearing policy No. 233200/48/2019/1225. At the time of said policy the doctors of the opposite parties checked the complainant and found him fit for insurance.  

3. It is further alleged that on 15.10.2018 the complainant suffered from fever/uneasiness/vomiting problem and he went to Dr. Naresh Hospital and Heart Centre, Barnala for treatment. The complainant was admitted in the said hospital on 15.10.2018 and informed the opposite parties about the same and was discharged on 19.10.2018. The complainant incurred the expenses of Rs. 10,445/- for the said treatment and doctor advised the complainant to go some multi specialty hospital for further treatment. The complainant asked the opposite parties to pay the said charges to the doctor as the policy is cashless but they told the complainant to pay the charges and opposite parties will reimburse the same within some day and on believing the words of opposite parties the complainant paid the said amount. After that on 19.10.2018 the complainant went to Dayanand Medical College and Hospital, Ludhiana where Dr. NP Jain checked the complainant and advised him to get admitted in the hospital and he admitted on 19.10.2018 and discharged on 24.10.2018 and spent Rs. 65,185/- on his treatment in the Dayanand Medical College and Hospital. The complainant again asked the opposite party to pay the hospital charges but they again told the complainant to pay the charges and opposite parties will reimburse the same within some days so complainant paid the same. Thereafter, the complainant lodged the claim with the opposite parties of the expenditure of both the hospitals but opposite parties gave different claim reference for both hospitals. After that the complainant approached the opposite parties many times to settle the claim but they avoided the complainant and vide letter dated 15.2.2019 the opposite party No. 2 denied the claim of the complainant on the instance of opposite party No. 3 despite the fact that opposite parties are bound to settle the claim within 60 days, which is deficiency in service and unfair trade practice on the part of the opposite parties.  Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay a sum of Rs. 75,630/- paid to Dr. Naresh and DMC Ludhiana on account of treatment of complainant with interest at the rate of 18% per annum from the dates of payments till realization.    

2) To pay Rs. 1,00,000/- on account of mental tension, agony and  harassment.           

3) To pay Rs. 11,000/- as litigation expenses.  

4) Any other relief this Forum deems fit. 

4. Upon notice of this complaint, the opposite parties No. 1 and 2 filed written version taking legal objections interalia on the grounds that as per Clause 5.2 of the terms and conditions of the policy that the alleged claim have not filed within stipulated period of 7 days with the opposite parties so the claim is liable to be dismissed. Further, complainant has not come to the Forum with clean hands and he is guilty of breach of terms of contract of Health Insurance. Further, they have raised objections on the grounds of no cause of action or locus standi, jurisdiction, unwanted litigation and present complaint is abuse of process of law.    

5. On merits, the opposite parties denied the purchase of insurance policy and it is also denied that doctor checked the complainant before issuance of policy. However, it is submitted that complainant applied for PNB Oriental Royal Medical Claim Policy from PNB, Barnala and submitted all the documents and signed the documents for issuance of policy. Rest of the averments of the complaint are denied by the opposite parties. However, it is submitted that opposite parties issued a letter dated 14.12.2018 for claim No. 55651819322797 and demanded some information with a request to submit the original documents within 15 days from the receipt of this letter to enable the processing of claim by Raksha TPA Pvt. Ltd. But no reply has been received by Raksha TPA and again letter dated 29.12.2018 was issued for supply of same information but no reply has been received. Then a final reminder letter dated 11.1.2019 was issued for supply of same information but even then no reply has been received by the opposite party No. 3. Then opposite party No. 3 issued a letter dated 18.1.2019 to the answering opposite parties for non payment of claim and on the basis of this letter the answering opposite parties vide letter dated 15.2.2019 denied the claim of the complainant for the reason that as per Clause 5.2 Claim Documents: Final claim alongwith originals of Hospital bills/cash memos reports, claim form and list of documents as listed below should be submitted to the company/TPA within 7 days of discharge from the hospital. So, there is no deficiency in service and unfair trade practice on the part of the answering opposite parties. Rest of the averments of the complaint are denied by the answering opposite parties with a request to dismiss the present complaint with costs. 

6. The opposite party No. 3 not appeared before this Forum despite service so the opposite party No. 3 was proceeded against exparte vide order dated 26.8.2019. 

7. In support of his complaint, the complainant tendered into evidence his own affidavit Ex.C-1, copy of passbook Ex.C-2, copy of policy Ex.C-3, copy of treatment chart Ex.C-4, copy of discharge summary Ex.C-5, copy of detail of bill Ex.C-6, copy of certificate Ex.C-7, copy of claim form Ex.C-8, courier receipt Ex.C-9, copy of letter dated 22.1.2019 Ex.C-10, courier receipt Ex.C-11, copy of letter dated 15.2.2019 Ex.C-12, copy of letter dated 15.2.2019 Ex.C-13, copies of bills Ex.C-14 to Ex.C-32 and closed the evidence. 

8. To rebut the case of the complainant, the opposite parties No. 1 and 2 tendered into evidence affidavit of Ashwani Kumar Ex.OP-1.2/1, copy of policy Ex.OP-1.2/2, copy of proposal form Ex.OP-1.2/3, copy of terms and conditions Ex.OP-1.2/4, copy of letter of repudiation of claim dated 28.1.2019 Ex.OP-1.2/5 and closed the evidence.   

9. We have heard the learned counsel for the parties and have gone through the record. Written arguments filed by the parties have also been gone through. 

10. It is proved on the file by the complainant vide policy Ex.C-3/Ex.OP-1.2/2 that he has purchased the Health Insurance Policy from the opposite parties No. 1 and 2 by paying premium of Rs. 19,587/- for the period from 28.7.2018 to 27.7.2019 for sum assured of Rs. 5,00,000/- for himself and his wife. It is also proved by the complainant vide treatment chart Ex.C-4, copy of discharge summary Ex.C-5 and copy of detail of bill Ex.C-6 that he has taken the treatment from the concerned hospitals during the validity of the health insurance policy. It is also proved on the file by the complainant that he has lodged insurance claim with the opposite parties vide claim form Ex.C-8 for a sum of Rs. 75,630/- on 7.12.2018. It is admitted by the opposite parties No. 1 and 2 that they have repudiated the claim of the complainant vide letter dated 15.2.2019 on the basis of letter dated 18.1.2019 issued by opposite party No. 3 to them on the ground that as per Clause 5.2 claim documents i.e. Final claim  alongwith originals of hospital bills/cash memos reports, claim form and list of documents should be submitted to the company/TPA within 7 days from the discharge from the hospital but complainant failed to do so. However, complainant duly proved on the file that he vide letter dated 22.1.2019 submitted all the necessary documents as demanded by the opposite parties to them. But it is proved on the file vide discharge summary Ex.C-5 that complainant submitted the documents after about three months from the date of discharge from the Dayanand Medical College and Hospital, Ludhiana vide letter dated 22.1.2019 Ex.C-10 but it is also proved on the file that he lodged the claim on 7.12.2018 and these documents have been submitted in reference to the letter of the opposite parties dated 13.12.2018, so in our view the delay is only about 40 days from the date of issuance of letter by the opposite parties. 

11. Further, the opposite parties failed to rebut the case of the complainant by way of any cogent and convincing evidence. Even they failed to tender any letter dated 14.12.2018, 29.12.2018 and 11.1.2019 vide which they made queries from the complainant as alleged by the opposite parties in their written version. Without tendering these letters in their evidence we cannot believe on the submissions of the opposite parties and it is a basic law that parties must prove their submissions by way of tendering the documents on which they have relied upon. Further, even the opposite parties failed to tender the repudiation letter dated 15.2.2019 which is also a major lapse on the part of the opposite parties and it is only the complainant who filed this most important document on  the file. In this way, the opposite parties have not taken any care to rebut the allegations or evidence of the complainant in the present complaint.  

12. The Hon'ble National Commission, New Delhi in case titled Shriram General Insurance Co. Ltd. Versus Kuldeep reported in IV (2018) CPJ-579 (NC) held as under.-

“Consumer Protection Act, 1986- Sections 2(1)(g), 21(b)- Insurance-Theft- Delay in intimation alleged-Claim repudiated- Deficiency in service- District Forum partly allowed complaint- State Commission dismissed appeal- Hence revision- Theft happened during the risk period covered by insurance policy- Complaint is not barred by limitation- Mere delay of 35 days alone cannot be the sole ground for repudiation- Repudiation not justified- Interest @ 9% p.a. awarded.”

In para No. 10 of this citation it is mentioned that in the written version filed before the District Forum there is absolutely no whisper of the cover note having been issued after the date of theft. In fact in the Written Version both in their preliminary objections and in their reply based on merits, the insurance company has only raised the ground of delay in intimation and it was barred by limitation. It is also pertinent to mention that in the repudiation letter, had the theft not been covered by the policy, that would have been the first and main ground for repudiation. Secondly it is also strange that the Investigation report dated 13.5.2011 clearly specifies the Policy period from 22.10.2010 to 21.10.2011. If the cover note was issued after the date of theft not only would that be the main ground for repudiation but also the investigator would not have been appointed and further the same would have also been mentioned in his report. On the contrary, the investigator mentions the claim No. as “10000/31/11/C/031424” and the policy period as 22.10.2010 to 21.10.2011 in his report dated 13.5.2011. Even in their subsequent letters written by the Insurance Company to the Complainant or in their grounds of Appeal before the State Commission this issue was never raised. For all the afore-noted reasons, we are of the considered view that the theft happened during the risk period covered by the insurance policy, that the Complaint is not barred by limitation and we are also of the considered view that both the Fora below have rightly held that there was deficiency of service on behalf of the Insurance Company in repudiating the claim. It is observed that only a reasonable rate of interest @ 9% p.a. has been awarded from the date of theft which date is modified to the date of repudiation i.e. 7.1.2011. In the result this Revision Petition is partly allowed modifying the order of the State Commission only to the extent of period of payment of interest i.e. 9% p.a. interest is to be paid on Rs. 11,20,000/- from the date of repudiation instead of date of theft. The rest of the order of the State Commission stands affirmed. 

This citation of the Hon'ble National Commission, New Delhi is fully applicable to the present matter as in the present matter also the only objection of the opposite parties is that the complainant submitted the documents delayed from the period as mentioned in the terms and conditions of the insurance policy. But this complaint is within the period of limitation and the complainant has also taken treatment during the validity period of the insurance policy so the insurance company cannot repudiate the claim of the complainant only on the technical ground of late submission of documents by the complainant with the opposite parties. 

13. Further, Hon'ble Rajasthan State Commission, Jaipur in case titled Vikas Kumar Sharma Versus New India Assurance Co. Ltd. And others reported in III (2018) CPJ-125 (Raj.) held in paras No. 4, 5, 6, 7 and 10 that there is no dispute about the fact that the policy was renewed with the respondent hence, the fact that NCB was claimed was within the knowledge of the Insurance Company and appellant has rightly relied upon the judgment passed by the National Commission in Revision Petition No. 2920/2015, United India Insurance Co. Ltd. Versus M/s Jindal Poly Buttons Ltd., where after deduction of 20% of the claim was allowed as declaration regarding no claim bonus was found false. The other contention of the respondent is that the matter was reported with delay to the Insurance Company. It is not in dispute that the claim was submitted to the Insurance Company with delay of ten days but the contention of the appellant is that he immediately reported the matter to the Insurance Company on telephone. The further contention of the appellant is that when repudiation has not been made on the ground of delay, this plea cannot be allowed to the insurer now and reliance has rightly been placed on II (2017) CPJ-345 (NC) United India Insurance Co. Versus Bhundu Ram. Hence in view of the above that delay was not the ground of repudiation the insurer cannot allow to plead this ground. Further, in view of the law laid down by the Apex Court in Civil Appeal No. 15611/2017, Om Parkash Versus Reliance General Insurance Co. VII (2017) SLT-654, IV (2017) CPJ-10 (SC), the genuine claim should not be rejected on technical ground of delay only. Hence in view of the above the claim have been allowed. Further, in para No. 10 of this citation it is mentioned that in view of the above, the appeal is allowed and the order of the Forum below dated 2.11.2016 is set aside. The complainant is entitled for the insured value after deducting 20% amount from Rs. 41,094/- i.e. Rs. 32,875/-. The complainant is also entitled for 9% interest on the said amount from the date of presentation of the complaint i.e. 11.4.2011 and Rs. 10,000/- as cost of proceedings. The order be complied within one month. 

This citation is fully applicable to the facts of the present complaint as in the present matter also the claim is repudiated by the insurance company i.e. Opposite parties No. 1 and 2 only on the technical ground of delay in submission of documents, whereas as per the view of the Hon'ble Apex Court of India in Civil Appeal No. 15611/2017, Om Parkash Versus Reliance General Insurance Co. VII (2017) SLT-654, IV (2017) CPJ-10 (SC), the genuine claim should not be rejected on technical ground of delay only, the opposite parties cannot repudiate the claim of the complainant only on the ground of delay of submission of documents. 

14. In view of above mentioned facts, circumstances and citations of the Higher Courts/Commissions as the opposite parties No. 1 and 2 repudiated the claim of the complainant only on the ground of delay and not processed the claim of the complainant on merits, so it is clear cut deficiency in service and unfair trade practice on the part of the opposite parties No. 1 and 2. 

15. As a result of our above discussion and numerous citations of the Hon'ble Higher Courts/Commissions in our view there is merit in the present complaint and same is partly allowed against the opposite parties No. 1 and 2. Accordingly, the opposite parties No. 1 and 2 are directed to pay Rs. 60,675/- to the  complainant on account of insurance claim as per medical bills and receipts tendered by the complainant on the file on account of amount spent by him on his treatment alongwith interest at the rate of 6% per annum from the date of filing the present complaint till actual realization. The opposite parties No. 1 and 2 are also directed to pay Rs. 3,000/- to the complainant as consolidated amount of compensation on account of mental tension, harassment and litigation expenses. The opposite parties No. 1 and 2  are also directed to deposit Rs. 5,000/- as costs in the Consumer Legal Aid Account maintained by this Forum. The opposite parties No. 1 and 2  jointly and severally liable to comply with this order. Compliance of the order be made within the period of 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 costs. The file be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN FORUM:

    1st Day of October 2019

 

 

            (Kuljit Singh)

            President

              

(Tejinder Singh Bhangu)

Member