Delhi

New Delhi

CC/828/2011

Raja Ram Yadav - Complainant(s)

Versus

M/S. General Manager MNTL - Opp.Party(s)

28 Oct 2022

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

(NEW DELHI), ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

                                       Case No.CC.828/2011        

IN THE MATTER OF:

 

Raja Ram Yadav,

Retired Phone Mechanic

R/o RZ-8L (917), Gali No. 5,

Main Sagarpur, New Delhi.                                                                                 ...COMPLAINANT

 

VERSUS

 

1. General Manager

          MTNL

        Head Quarter, Khursheed Lal Bhawan

         New Delhi.

1. The Regional Manager

         M.D. India Health Care Services

           (T.P.A) Pvt. Ltd Regional Office

           Plot No. 18/13, WEA,

          Ground Floor Ganga Plaza,

          Pusa Lane, Karol Bagh,

          New Delhi-110005.

2. United India Insurance Co. Ltd.

          Core-1 Second Floor, Scope Minar,

          Laxmi Nagar, Delhi-110092                                                                              ...OPPOSITE PARTIES

 

Quorum:

 

Ms.Poonam Chaudhry, President

Shri Bariq Ahmad, Member

Ms.  Adarsh Nain, Member

                                                                                                                                 Date of Institution:-09.08.2011                                                                                                                                                                           Date of Order   : -     28.10.2022

 

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

1. The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986 (in brief referred as CP Act). Briefly stated the facts of the case are that the complainant is a retired MTNL employee. It is further alleged that OP No.-1 for the treatment of its employee either in service or retired, had launched a scheme for medical claim and for the said purpose OP-2 had been authorized by OP-1. It is also alleged that as per collaboration of OP-1 and OP-2 Medical facility claim had been provided according to which if a person takes treatment from hospital, he could file claim before the company and the company after examining the claim on the basis of essentiality certificate issued by the concerned hospital, which had to pay the medical claim. It is also alleged that the complainant had opted for the said scheme and became a member of the Health Policy granted by OP-1 through OP-2. It is further alleged that the complainant had suffered a head injury for which he was admitted in Ganga Ram Hospital on 08.03.2009 and was treated as an Indoor patient till 26.03.2009. The complainant had spent about Rs. 2,90,804/- (Rupees Two Lakh Ninety Thousand Eight Hundred Four) and 98,730/- (Rupees Ninety Eight Thousand Seven Hundred Thirty) respectively w.e.f. the period 11.06.2009 till 14.06.2009. After getting the treatment the complainant applied for reimbursement of Medical claim. However, he received reply from OP-2 asking for certain documents. The said documents were provided, however despite that the amount was not released. It is also alleged that action of OP is illegal and arbitrary. The complaint is covered under the Health Scheme of OP no.-1. It is also alleged that vide letter dated 02.07.2010 OP No.-2 asked the complainant to submit receipts. The complainant had in response to the said letter submitted documents with representation but the insurance company failed to make payment. The present consumer complaint has been filed seeking reliefs directed to OP to pay the claim amount of Rs. 2,90,804/- (Rupees Two Lakh Ninety Thousand Eight Hundred Four) with interest @ 18% p.a. and compensation as well as litigation expenses.

 

2. Notice of the complaint was issued to Op`s  pursuant to which none of the OP`s entered appearance, proceeded ex-party and ex-party order/award  dated 01.10.2013 was passed. The OP No.1 preferred an appeal No.566/2014 and vide order dated 10.02.2016 Hon`ble State Commission New Delhi directed to this commission to hear the case on merits. The OP.1 contest the case on merits and filed written statement stating inter alia that it was not under any contractual obligation to pay the amount claimed. It was stated there was an agreement between OP No.-1 and OP No.-3 whereby OP No.-3 was appointed as insurer who was under obligation to reimburse the medical claim. It was also stated that OP No.-1 was not a necessary or proper party and the complaint was bad for misjoinder of parties. It was also stated that there was no deficiency of service on part of OP No.-1 and prayed that the complaint be dismissed.

 

 

3. OP-3 filed written statement stating that there was no deficiency of services on its part. It was also stated that complainant failed to submit the information sought by OP No.-2, hence,  OP No.-2 had rejected the claim vide letter dated 30.12.2010.  The OP No.-3 has not disputed the insurance policy which was issued vide policy bearing no. 222800/48/08/41/0001514 for the period of 01.10.2008 to 30.09.2009. It was stated that OP NO.-2 is a company is acting as TPA/service provider for settlement of claims on behalf of OP-3. It was denied that the OP-3 is entitled to pass the claim. It was prayed that the complaint be dismissed.

 

4. Both the parties filed their evidences by affidavit. Op-1 filed their evidence of its AGm (MR) Sh. Esh Kumar Prabhu Dayal Malik and OP-3 filed their evidence of its manager Sh. B.B. Goel reiterating the averments made in the written statement and evidences.

 

5. We have heard the Ld. counsels for parties and perused the record.

 

6. The complainant is a retired MTNL employee and availed an insurance policy (Retired Employees Contributory Medical Scheme-2008) from OP No.3 through primary Agreement dated 24^th September, 2008 for a period of one year effective from 01.10.2008 till the last day of the currency of the policy. OP No.-2 T.P.A./agent M.D. Health Care service was hired by OP No.-1 MTNL to provide facilities to his retired employee. The complainant sustained a head injury and was admitted on 08.03.2019 at Ganga Ram Hospital and was treated as indoor patient till 26.03.2009 and incurred the expenses a sum of Rs. 2,90,804/- (Rupees Two Lakh Ninety Thousand Eight Hundred Four) and Rs. 98,730/- (Rupees Ninety Eight Hundred Seven Hundred Thirty) and he claim lodged for reimbursement of bills. OP.3 admitted that the complainant had adopted this  scheme as per Exbt. PW1/1.  Further he has also not disputed on hospitalization & expenses incurred on medical treatment at Ganga Ram Hospital as per Exbt. PW1/2. Further as per grievance of Op.2, certain documents were supplied as per Exbits. Pw1/3 & Pw1/4 already placed. Thereafter complainant sent his representation as per Exbts.PW1/5, PW1/6 and PW1/7 but OP-3 neither repudiate the claim nor processed the claim.  The complainant was informed after lapse of one year on 02.07.2010 by OP-2 to submit receipts of bills. Despite of all formalities being completed by complainant, OP did not reimburse its claim. The complainant thus filed the complaint.

 

7. The complainant stated in his evidence that OP-2 was authorized on behalf of OP-1 to provide medical facilities to retired employee of MTNL. It also not disputed complainant opted for the scheme launched by OP. The complainant was hospitalized and incurred expenses on medical treatment at Ganga Ram Hospital. Complainant stated that pursuant to OP No.-2 demanding documents, the same were supplied. Complainant had sent his representation to OP No.-1 but OP No.-1 to 3 neither repudiated the claim nor processed the claim. OP-1 also remained silent because this scheme was introduced by OP-1 in collision of OP-2.

 

8. In recent judgment passed by Hon`ble Supreme court in Gurnel Singh vs Branch Manger, National Insurance Co, Civil Appeal No.4071 of 2022 dated 20 May 2022, it is held that “it is found that the insurance   companies   are   refusing   the   claim   on   flimsy grounds   and/or   technical   grounds.   While   settling   the claims, the insurance company should not be too technicaland ask for the documents, which the insured is not in a position   to   produce   due   to   circumstances   beyond   his control”.

 

9. In the above facts and circumstances, we hold insurance claim of the complainant by OP No.3 isunsustainable.The insurance company has becometoo   technical   while   settling   the   claim   and   has   acted arbitrarily. This further leads us to conclude that there was negligence and deficiency  in service on the part of insurance company by not settling the complainant claim. Repudiation of the complainant claim by OP-3 is bound to be set aside. The complainant had submitted all the requisite documents to the OP as and when demanded however the claim was not paid arbitrarily. The OP No.3 is the insurer and is under obligation to make the payment as per primary agreement. OP.1 also remained silent on this part because the Scheme was introduced by OP.1 by collaboration with OP.2 to provide medical facilities to retained employees on certain contribution given by them.

 

10. We hold, OP NO.-3 is liable to pay Rs.2,90,804/- (Rupees Two Lakh Ninety Thousand Eight Hundred Four) and Rs.98,713/- (Rupees Ninety Eight Thousand Seven Hundred Thirteen) total Rs.3,89,517/- (Rupees Three Lakhs Eighty Nine Thousand Five Hundred seventeen Only) towards insurance claim along with interest @ 9% p.a. from the date of rejection of claim till realization to the complainant  and  we also award Rs.35,000/- (Rupees Thirty Five Thousand Only) as compensation for harassment along with a sum of Rs.10,000/- (Rupees Ten Thousand) for litigation cost which is to be paid jointly & severally by the OP No.1 and OP No.3 within 30 days of the receipt of the order failing which OP-1 & 3 will be liable to pay interest @ 12% p.a. on the awarded amount.

 

 

A copy of the order be provided to all parties free of cost.

The order be uploaded on the website of the Commission.

File be consigned to record room with a copy of the order.

Announced on  28^th Day of October, 2022.

 

(POONAM CHAUDHRY)

President

   (BARIQ AHMAD)                                                                      (ADARSH NAIN)     

Member                                                                                    Member