BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.30 of 2017
Date of Instt. 03.02.2017
Date of Decision: 25.11.2019
Rakesh Kumar S/o Mathura Parshad, 113, Tobri Mohalla, Satya Narayan Mandir, Jalandhar, Punjab, 144001.
..........Complainant
Versus
1. M/s Religare Health Insurance Company Limited, Registered Office at D-3, P3B, District Center, Saket, New Delhi-110017 Through its Managing Director.
2. M/s Religare Health Insurance Company Limited, Bracnh Office at 2nd Floor, SCO-4, PUDA complex, Jalandhar City. Through it’s Area/Branch Manager Sh. Navdeep Sharma.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. S. K. Chopra, Adv. Counsel for the Complainant.
Sh. R. K. Sharma, Adv Counsel for the OPs.
Order
Karnail Singh (President)
1. The instant complaint has been filed by the complainant, wherein alleged that he purchased health insurance policy No.1052329790230157 from respondent’s company at Jalandhar Office, the said policy is valid upto 27.01.2017. The said insurance policy critical illness of the complainant is covered as insured for a sum of Rs.10,00,000/-. During the subsistence of above said health insurance policy, the complainant suffered heart problem and he was treated at Shri Ram Cardiac Centre, Joshi Hospital, Kapurthala Chowk, Jalandhar. The complainant was diagnosed for Coronary Artery Disease (CAD), Acute Anterior Wall MI, Angina. As per medical terms, the said disease leads to Heart Attack and the treatment for heart attack was given. As per terms and conditions of the policy, in case of acute illness the complainant is entitled to lump-sum amount of Rs.10,00,000/- from OPs as health and insurance. The illness of the complainant for Heart Attack is fully covered under the definition of critical illness as defined under the Health Insurance Policies, therefore, the complainant is entitled to recover an amount of Rs.10,00,000/- from OPs, but the claim of the complainant has been repudiated by the OP, illegally, on flimsy grounds, vide email dated 24.10.2016 and accordingly, a legal notice was served to the OPs dated 02.11.2016, but all in vain and accordingly, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to make a payment of Rs.10,00,000/- being the health insurance claim along with Rs.50,000/- as mental agony due to their illegal acts and the respondents may also be directed to make the payment of Rs.11,000/- as legal fee of the counsel alongwith other charges.
2. Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the instant complaint is not maintainable against the answering OPs. The complainant is guilty of concealment of material facts from this Forum as the complainant has filed another complaint CC No.421 of 2016, titled as “Rakesh Kumar Vs. HDFC ERGO General Insurance Co. Ltd.” claiming on account of same alleged critical illness. It is pertinent to mention here that the complainant cannot avail double benefits/remedies for one and the same claim as such the complaint is liable to be dismissed at the very outset and further admitted that the claim of the complainant has been repudiated, vide letter dated11.11.2016 by invoking Clause 2.1 of the insurance policy. On merits, it is admitted that the complainant got insurance policy and submitted a claim, but the same was repudiated. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Replication not filed.
4. In order to prove the case of the complainant, the complainant himself tendered into evidence his own affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-19 and then closed the evidence.
5. Similarly, counsel for the OPs tendered into evidence affidavit of Sh. Parshant Singh as Ex.OA alongwith some documents Ex.O-1 to Ex.O-11 and closed the evidence.
6. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also gone through the written arguments submitted by both the counsel for the parties as well as case file very minutely.
7. Before imparting with the main issue, firstly we take a preliminary objection taken by the OPs that the instant complaint of the complainant is not maintainable, being reason the complainant has concealed the material facts from the Forum because the complainant has already filed another complaint qua the same treatment of insurance claim and alleged that the instant complaint may be dismissed.
8. We have taken into consideration the above point raised by the OPs and find that admittedly the complainant has filed a complaint bearing No.421 of 2016, titled as “Rakesh Kumar Vs. HDFC ERGO General Insurance Co. Ltd.”, which is also decided alongwith this complaint today. From the scrutiny of both the complaints, it reveals that the complainant has claiming the same treatment amount in both the complaints, though the insurance companies are different in both the complaint cases, but the complainant can avail benefits from one insurance company, he is not entitled to claim the amount of treatment from both the insurance companies rather one treatment can be claimed from either of the insurance policy, but not from both the insurance companies. So, accordingly, the other complaint of the complainant as stated above i.e. Complaint No.421 of 2016 has been decided today in favour of the complainant. Thus, the instant complaint is not maintainable, therefore, the same is dismissed with no order of cost. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.
9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
25.11.2019 Member President
