BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.276 of 2014

Date of Instt. 13.8.2014

Date of Decision :1.12.2014

Bimla Rani wife of Lt.Kasturi Lal, R/o 367, Greater Kailash, Near C.T.Public School, Near Maqsudan, Jalandhar-144008, presently resident of C-62, Pilot Courts, Essel Towers, MG Road, Sector -28, Near IFFCO Chowk, Gurgaun(Haryana).

..........Complainant

Versus

1. M/s United India Insurance Co.Ltd, through its managing director/chairman, Regd. & Head Office:24, Whites Road, Chennai-600014, Branch Office No.2, Syal House, Lajpat Nagar Market, Jalandhar.

2. M/s Rakesh TPA Pvt.Ltd, through its managing director/chairman, 15/5 Mathura Road, Faridabad-121003, Branch Offfice: SCO 181, 2nd Floor, Sector &-C, Chandigarh-160019(UT).

.........Opposite parties

Complaint Under the Consumer Protection Act 1986.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Present: Sh.Rajesh Sharma Adv., counsel for complainant.

Sh.RS Arora Adv., counsel for opposite parties.

Order

J.S. Bhatia (President)

1. The complainant has filed the present complaint under the Consumer Protection Act 1986 against the opposite parties on the averments that the complainant is in the habit of purchasing mediclaim insurance policy from the opposite party No.1 through agent of the opposite party No.1. The complainant on 20.12.2012 before the expiry of earlier individual health insurance policy-2010 paid the premium of Rs.13,545/- to the opposite party No.1 through cheque No.625609 dated 20.12.2012 for the continuation of the earlier individual health insurance policy -2010 and the opposite party issued an insurance policy bearing policy No.201300/48/12/97/00000 884 for the period 24.12.2012 to 23.12.2013 and the premium with service tax etc shown paid only Rs.12,348/-. The opposite party No.1 has refunded the excess received amount of Rs.1197/- vide cheque dated 11.2.2013 to the complainant after about two months. Complainant only received the two pages of the policy issued by opposite party No.1 and there are no terms and conditions mentioned in the said policy bearing policy No.201300/48/12/97/00000884 for the period 24.12.2012 to 23.12.2013. The complainant never received any terms and conditions of the above mentioned policy at any time till now. Unfortunately complainant on 28.1.2013 fell ill and admitted in the Medanta-The Medicity, Sector-38, Gurgaon, Haryana-122001 of Global Health Pvt,Ltd,Regd.Office: E-18, Defence Colony, New Delhi-110024 and discharged on 5.2.2013 after treatment and the complainant has paid the total amount of Rs.1,44,150/- to the said hospital for the treatment. Complainant when again fell ill and again on 2.4.2013 admitted in the Medanta-The Medicity, Sector-38, Gurgaon, Haryana-122001 of Global Health Pvt,Ltd,Regd.Office: E-18, Defence Colony, New Delhi-110024 and discharged on 6.4.2013 after treatment and the complainant has paid the total amount of Rs.65,630/- to the said hospital for the treatment. The complainant on the receipt of a letter dated 18.3.2013 from the opposite party No.2 provided the said certificate of Dr.Himanshu Garg of the concerned Medanta, the Medicity Hospital to the opposite parties. The opposite party No.2 wrote a letter dated 4.4.2013 to the said Medanta-The Medicity, Sector-38, Gurgaon, Haryana-122001 of Global Health Pvt,Ltd,Regd.Office: E-18, Defence Colony, New Delhi-110024 and requested for the submission of the claim after the discharge and denied the facility of cashless hospitalization. Complainant when again fell ill and again on 19.4.2013 admitted in the Medanta-The Medicity, Sector-38, Gurgaon, Haryana-122001 of Global Health Pvt,Ltd,Regd.Office: E-18, Defence Colony, New Delhi-110024 and discharged on 23.4.2013 after treatment and the complainant has paid the total amount of Rs.55,745/- to the said hospital for the treatment. The complainant through her relative Sh.Hari Sarup Ahuja S/o Lt.Sh.Dawarka Dass, R/o 412, Guru Gobind Singh Avenue, Opposite IOC, Bye Pass, Jalandhar, lodged the claims with the opposite party No.1 at Jalandhar and all the original documents were received by Mr.Yogesh Khurana, Development Officer of the opposite party No.1 at Jalandhar. The complainant through her relative, Sh.Hari Sarup Ahuja S/o Lt.Sh.Dawarka Dass, R/o 412, Guru Gobind Singh Avenue, Opposite IOC, Bye Pass, Jalandhar, at all times provided the required original documents to the opposite party No.1 and the original documents were received by Mr.Yogesh Khurana, Development Officer of the opposite party No.1 at Jalandhar. The opposite party No.2 wrote a letter dated 21.5.2013 to the complainant and closed the file of the complainant claim with regards to the claim reference No.545512132 00033 illegally and arbitrarily. The opposite party No.2 wrote a letter dated 17.7..2013 to the complainant and closed the file of the complainant claim with regards to the claim reference No.545513140 24466 illegally and arbitrarily. The complainant has not received the alleged letter dated 16.3.2013, 10.4.2013, 30.4.2013, 10.5.2013, 30.5.2013, 21.6.2013 and 21.5.2013. The complainant has received the letter dated 21.5.2013 of the opposite party No.2 alongwith a reply dated 17.4.2013 to a legal notice dated NIL sent by Sh.RS Arora, Advocate, 19, Green Model Town, Jalandhar. At last the complainant through her counsel Sh.Rajesh Sharma, Advocate, Jalandhar got served a legal notice sent on 7.4.2014 through registered AD to the opposite parties and demanded the payment of claim under the said policy. Despite the service of the above mentioned legal notice sent on 7.4.2014 the opposite parties failed to pay the amount of Rs.2,65,525/- on false, illegal, arbitrary, against actual facts grounds. On such like averments, the complainant has prayed for directing the opposite parties to pay her Rs.4,99,000/- as compensation.

2. Upon notice, opposite parties appeared and filed a written reply raising preliminary objections regarding limitation, not approach the forum with clean hands etc. They further pleaded that there is no deficiency on part of the opposite parties because the complainant did not furnish the requisite information in reply to the queries, which information was repeatedly sought from the complainant, therefore, the complaint is liable to the dismissed. The complainant is wrongly denying the receipt of letters dated 21.5.2013 to 17.7.2013. It is submitted that if the complainant had completed the formalities and also had rightfully furnished the information to the queries made, there was no reason for the opposite party in writing again and again the same thing and send various reminders, but had to do so in view of the guarded silence maintained by the complainant. They denied other material averments of the complaint.

3. In support of her complaint, learned counsel for complainant has tendered affidavits Ex.CA and Ex.CB alongwith copies of documents Ex.C1 to C13 and closed evidence.

4. On the other hand, learned counsel for opposite parties has tendered affidavit Ex.OA alongwith copies of documents Ex.OC-1 and closed evidence.

5. We have carefully gone through the record and also heard learned counsel for the parties.

6. Ex.C-9 (also Ex.O-7) is letter dated 21.5.2013 vide which the file was closed in respect of claim No.54551213200033 on the ground that complainant did not send the documents mentioned in it. Similarly Ex.O10 is letter dated 11.6.2013 vide which the file of the complainant in respect of claim No.545221314002182 was closed on the same ground i.e not sending the documents mentioned in it. Ex.C-11(also Ex.O-12) is letter dated 17.7.2013 regarding closing the file of the claim of the complainant in respect of claim No.54551314024466 on the same ground. So all the claims of the complainant were not decided by the opposite parties on merits but the claim files were closed for want of submission of certain documents by the complainant. Counsel for the opposite parties contended that the present complaint is time barred as per clause 5.13 of the policy Ex.C-1. We have carefully considered the above contentions advanced by learned counsel for the opposite parties. As per clause 5.13 if the insurance company disclaim its liability to the insured and the insured does not within 12 months from the date of receipt of such disclaimer, notify the TPA/company in writing that he does not accept such disclaimer and intends to recover the claim from the TPA/company then the claim shall be deemed to have been abandoned. In the present case, we feel that the insurance company did not specifically repudiate or disown its liability to pay all the claims in questions but TPA/company simply closed the claim files for want of submission of certain documents. Closing of the claim file and disowning liability to pay claim are two distinct things. So in our opinion, the above said clause is not attracted in this case. Since the TPA/insurance company has not decided the claims of the complainant on merits, as such we feel that an opportunity should be given to the opposite parties to decide the same on merits.

7. In view of above discussion, the present complaint is disposed off with the directions to the complainant to submit any further document or information to the opposite parties within 15 days from the date of receipt of copy of this order and thereafter opposite parties shall positively decide the all claims of the complainant on merits on the basis of documents already submitted by her and further on the documents produced by her during the trial of the present complaint and documents, if any, which the complainant may further submit to the opposite parties within two months positively failing which it shall be presumed that the opposite parties have accepted all the claims of the complainant in toto. In the circumstances of the case, there shall be no order as to cost. Copies of the order be sent to the parties free of costs under the rules. File be consigned to the record room.

Dated Jyotsna Thatai Jaspal Singh Bhatia

1.12.2014 Member President