Delhi

New Delhi

CC/975/2013

S.S. Jain - Complainant(s)

Versus

M/S. The New India Assurance Company Ltd. - Opp.Party(s)

23 May 2016

ORDER

 

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

 NEW DELHI-110001

 

Case No.C.C./975/2013                         Dated:

In the matter of:

SH. S.S. JAIN,

S/o Late Sh. N.C. Jain,

R/o C-3A/84-B,

Janak Puri,

New Delhi-110 058.

        ……..COMPLAINANT

 

VERSUS

1.     The Divisional Manager,

        The New India Assurance Co. Ltd.,

        Divisional Office-310100,

        Deendayal Upadhaya Bhawan,

        Ist Floor,

        7-E, Jhandewalan Extn.,

        New Delhi-110055

 

2.     The Manager (OS),

        Divisional Office-I,

        Jeevan Parkash Building,

        5^th Floor,

        25-K.G. Marg,

        New Delhi-110 001

 

       

               .... OPPOSITE PARTY

 

 

PRESIDENT: S.K. SARVARIA

 

ORDER

 

The repudiation of the medical claim of the complainant, a retired typist from LIC, by the opposite parties has led the complainant file the present complaint against the opposite parties by invoking provisions under section 12, 17 and 21 of The Consumer Protection Act, 1986. The case of complainant, in brief, is that he retired from LIC in October 1999 and is covered under the Medi-Claim Scheme applicable to the complainant under the Rules. He submitted to bills in connection with admission of his wife Smt. Maya Devi Jain in the hospital during the prescribed period of time. The supplementary bills were also submitted in time relating to aforesaid  medical claim, but despite repeated requests and letters dated 15/2/2013, 4/4/2013, 4/5/2013 and 4/6/2013 for the settlement of a supplementary Medi-Claim bills forwarded through Senior Divisional Manager, LIC of India, Divisional Office-I, New Delhi in the month of August, 2012 and January 2013, the complainant has received a letter No. P. O1/05/pomc dated 19/6/2013 from OP 2, that the claim has been repudiated and the doctor report has been enclosed along with the said letter dated 14/6/2013. The said supplementary bills for Rs. 10,786/- and Rs. 9579/- respectively, were repudiated while the main bill in relation to this was passed on being fully satisfied with regard to the compliance of all the relevant conditions in this connection. The amount of Rs. 9284, has been credited in the account of the complainant on 19/4/2013 without disclosing against which of the two supplementary bills, the said amount has been credited in his account, i.e., either against the bill of August, 2012 or January, 2013 for which the opposite parties were required to specify the same. The complainant was compelled to issue a legal notice dated 24/8/2013 through his advocate to the opposite parties but in vain. The complainant has prayed for the following reliefs:

1. That this Hon’ble Forum may please be directed to pay the supplementary bill amount remained unpaid within upto date interest till date to the complainant alongwith with interest @24% p.a. from filing the present complaint till its realization, in the interest of justice.
2. Damage to the tune of Rs.1,00,000/- be passed in favour of the complainant towards the mental torture, harassment, pain and agony caused by the respondent to the complainant.
3.     Cost of the present complaint may also be awarded in favour of the complainant and against the respondent.

Notices of the complaint were issued to the opposite parties and OP 2 by contesting the complaint has filed reply alleging in brief that in order to protect the interest of the emplyees and their dependents from any disease or illness, the OP 2 Corporation has taken a Group Medi claim Insurance Policy from the OP 1 insurance company. This Medi claim Policy is basically an agreement between the OP 2 and OP 1, wherein OP 2 is insured and the OP 1 is the insurer to avail the services of this Policy. The OP 2 annually pays premium to OP 1. If any disease or injury is caused to the employees of OP 2, or the dependents, then the claim filed by the employees is forwarded by OP 2 to OP 1 insurance company. Thereafter, the claim is processed by OP 1 and if it is found genuine and payable as per terms and condition of the policy, the amount is paid by OP 1. The Medi claim of the complainant was forwarded by OP 2 to OP 1 insurance company and a letter dated 14/6/2013 was also issued to OP 1 requesting them to expeditiously settle the claim of the complainant. But the OP 1 has repudiated the claim of the complainant, stating that the claim is not supplementary to the claim, 2012/R-167, and therefore is not payable to the complainant. With these please and denying other facts stated in the complaint, the OP 2 has prayed for dismissal of the complaint with costs.

OP 1 was proceeded with ex parte on 3/4/2014 and no reply is filed by OP 1, the complainant filed rejoinder to the reply of OP 2. In support of his case, the complaint has filed his affidavit in evidence. The defence of OP 2 was closed by order dated 19/11/2014 as OP 2 failed to file affidavit in evidence despite opportunities.

We have heard the complainant in person and have gone through the record of the case and relevant provisions of law.

The complainant in the affidavit in evidence has proved the facts stated in the complaint. In the absence of any pleading and evidence, on behalf of OP 1, who had chosen to abondon the proceedings to become ex-parte instead of contesting the complaint, whatever is stated by complainant in the affidavit in evidence and documents produced by complainant should be believed, as there is no reason to disbelieve the same. From the case of complainant, it is clear and it is conceded during the course of argument by the complainant that the main medical reimbursement bill, which was a bit more than Rs. 47,000/– had been passed by OP 1 insurance company. One of the two supplementary bills in the sum of Rs. 10,786/– and Rs. 9579/– is also passed by crediting the amount of Rs. 9284/– in the account of the claimant on 19/4/2013. Therefore, it appears that the said credit of the amount in the sum of Rs. 9284/– is in respect of the supplementary bill in the sum of Rs. 9579/–. The claim of the complainant, in our view, remains for the supplementary bill in the sum of Rs. 10,786/– In this case, besides, the affidavit and the arguments relied upon by complainant remained unchallenged on account of OP 1 being ex-parte, the complainant has issued a legal notice dated 24/8/13 to OP 1 and its non-reply also strengthens the case of the complainant as it may be deemed that the OP 1 admitted the facts stated in the notice of the complainant. Further, on behalf of OP 1, a sum of Rs. 9000/– was offered to the complainant on 20/4/2015 in full and final settlement, but the complainant refused to receive the same. Therefore, the complaint deserves to be allowed. Though the compensation amount claimed by the complainant in our view is quite on higher side and we feel that it should be granted to complainant on lower side than claimed.

In view of the above discussion, we allow the complaint and direct the OP 1 insurance company to pay to the complainant, the amount of Rs. 10,786/– pertaining to the supplementary Medi claim bill of the wife of complainant. We also direct OP 1 insurance company to pay the compensation in the sum of Rs. 10,000/- to the complainant, inclusive of the litigation cost of the present complaint. In case the said total amount of Rs. 20,786/– is not paid by the OP 1 insurance company within a period of one month from the date of receipt of this order, the same shall be recoverable by the complainant from OP 1 insurance company along with simple interest at the rate of 10% per annum from the date of this order till realization of the said amount. OP 2 is perform  party, so no relief is granted to the complainant against OP 2. A copy of the order be sent to each of the parties free of cost by registered post.  This order be sent to server (www.confonet.nic.in ).

File be consigned to record room.    

Pronounced in open Forum on 23/05/2016.

 

 

(S K SARVARIA)

PRESIDENT

 

 

                                            (H M VYAS)

MEMBER