Punjab

Ludhiana

CC/16/374

Gurvinder Pal - Complainant(s)

Versus

National Ins.Co.ltd - Opp.Party(s)

sukhdev Singh Adv.

25 Jan 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

                                                           

Consumer Complaint No.374 of 13.05.2016

Date of Decision          :   25.01.2017

 

Gurinder Pal Singh son of S. Rajinder Singh, resident of B-XXXIV-2838/1, New Tagore Nagar, Haibowal Kalan, Ludhiana.

….. Complainant

Versus 

1. National Insurance Company Ltd., Regd. Office 3, Middleton Street, Kolkata-700071.
2. National Insurance Company Ltd., Regional Office S.C.O. 332-334, Sector 34-A, Chandigarh 160022
3.  National Insurance Company Ltd., Branch Office at Dhandari Kalan, G.T. Road, Ludhiana.
4. Chander Prabha, Agent Code No.502/5, National Insurance Company Ltd., Branch Office at Dhandari Kalan, G.T. Road, Ludhiana.

..…Opposite parties

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.PARAM JIT SINGH BEWLI, MEMBER

 

COUNSEL FOR THE PARTIES:

For Complainant              :         Sh. Gurinder Pal Singh in person.      

For OP1 to OP3               :         Sh. D.R. Rampal, Advocate.

For OP4                           :         Complaint against OP4 not admitted.

ORDER

PER G.K. Dhir, PRESIDENT

1.                 Complaint under Section 12 of the Consumer Protection Act (hereinafter referred as Act) filed by complainant by pleading that he availed medi claim policy of Rs.2,00,000/- in 2014 after representation of OP4 that the policy is good one. After issue of this policy, complainant was legally entitled to get himself treated from any reputed hospital on cashless basis up to limit of Rs.2,00,000/-. In 2014, complainant did not avail any facility from OP, but thereafter in 2015 the policy was got renewed by paying requisite premium. OP2 and OP3 assured complainant that after issue of the policy, he will be legally entitled for payment on cashless basis up to limit of Rs.2,00,000/-. In December 2015, complainant had to got himself operated from Dayanand Medical College, Ludhiana. As per assurance of OP at the time of admission on 18.12.2016, complainant requested hospital authority to provide him treatment on cashless basis up to limit of Rs.2,00,000/- as per terms and conditions of medi claim policy purchased from OP1. At that time representative of OP1 was present in the hospital and on his asking, complainant complied with certain conditions including verification from concerned doctor, filling of forms and presenting medical tests and reports. However, OP1 intentionally and willfully refused to provide treatment on cash less basis and the same alleged to be an act of deficiency in service. Compensation for mental harassment of Rs.50,000/- and litigation expenses also claimed along with directions to Ops to pay sum of Rs.20,000/- incurred as expenses on treatment. These amounts sought with interest @18% per annum.

2.                 In joint written statement filed by OP1 to OP3, it is claimed that complaint in present form is not maintainable; complaint bad for nonjoinder and misjoinder of necessary parties; complainant has not approached the Forum with clean hands because he has suppressed the material facts. Besides it is claimed that in view of the involvement of complicated questions of law and facts, matter can be got decided from Civil Court of competent jurisdiction. OP2 is regional office of OP1. It is claimed that complainant has not lodged any claim, due to which he is estopped by act and conduct from filing the complaint. However, it is claimed that intimation dated 17.12.2015 was given to M/s. Park Mediclaim (TPA) before hospitalisation of complaint on 18.12.2015. As per terms and conditions of the policy, complainant bound to lodge the claim regarding hospitalization within 7 days, but same was not lodged thereafter and even until the date of filing of the complaint. It is claimed that complainant has leveled vague and baseless allegations. Each and every other averment of the complaint denied by claiming that complaint is false and frivolous. However, it is admitted that such type of cases are dealt with by Park Mediclaim TPA Pvt. Ltd. on behalf of National Insurance Co. Ltd.

3.                 Complaint against OP4 was not admitted at the admission stage itself because she was an agent having role of filling forms, getting premium from complainant and then forwarding the same to insurance company. It is the insurance company who is to allow or disallow the insurance claim qua medical treatment and as such, complaint against OP4 was found not maintainable.

4.                 Complainant to prove his case tendered in evidence his affidavit Ex. CA along with documents Ex.C1 to Ex. C6 and thereafter, his counsel closed evidence.

5.                 On the other hand, counsel for OP1 to OP3 tendered in evidence affidavit Ex. RA of Sh. Surinder Kumar, Officer of National Insurance Company branch Dhandari Kalan, Ludhiana along with documents Ex. R1 to Ex. R4 and thereafter, closed evidence.

6.                 Written arguments not submitted by any of the parties. Oral arguments addressed by complainant in person as well as by counsel for Ops.

7.                 Complainant sent notice Ex. CW5 dated 18.12.2015 to Park Medi Claim TPA Pvt. Ltd.  of OP1 for informing that all the records have already been sent by him to TPA. So this Ex. CW5 enough to establish that the records of treatment were forwarded by complainant to TPA, the processing agency on 18.12.2015.  Ex. CW1 and Ex. CW2 are the insurance cover notes, whereas Ex. CW6 is the copy of the discharge summary of treatment got by complainant from Dayanand Medical College, Ludhiana  during period from 18.12.2015 to 18.12.2015 itself.  Ex. CW4 is the copy of the bills of treatment expenses, whereas Ex. CW3 is the TPA card issued by Park Medi claim on behalf of insurance company in favour of complainant. There is no dispute regarding the fact that complainant got treatment from Dayanand Medical College, Ludhiana  during subsistence of the medi claim policy in question by spending money from his pocket.

8.                 Ex. R1 and Ex. R2 is the letter relied upon by counsel for Ops for arguing that notice of claim under policy must have been sent within 7 days from the date of hospitalization, but that was not sent and that is why the claim was held not entertain able. Ex. R3 is the same thing as is Ex. CW1 whereas Ex. R4 is the same thing as Ex. CW2. Repudiation of the claim on account of non lodging of claim in this case is improper, particularly when the complainant through Ex. CW5 dated 18.12.2015 informed the TPA that he has sent records of treatment for processing the claim with respect to the cash less treatment. Even if the claim form not submitted by complainant, despite that he intimated TPA by sending record and as such, it was the duty of Ops or the TPA to call upon the complainant to submit the duly filled claim form along with other records (if needed), but that was not done by OP1 to OP3 or its officials or by TPA and as such, fault lays with Ops in not responding to the request Ex. CW5 submitted by complainant to TPA.

9.                 As per law laid down in Sunil Sharma Vs National Insurance Co. Ltd. II (2015) Consumer Protection Judgments 46 (Delhi State Consumer Disputes Redressal Commission) an otherwise genuine claim of insurance should not be rejected on flimsy and technical grounds. In case it is so, then the confidence of the people in insurance companies would be deeply eroded. So Consumer Courts are not expected to go in the technicalities of the civil or criminal jurisprudence. Rather Consumer Forms to decide disputes on yardstick of reasonableness, probability and principles of natural justice. When these yardsticks applied to the facts of the present case, then in view of the deficiency in service on the part of TPA in not calling complainant to submit the claim in writing, the repudiation of the claim is not justified. Therefore ends of justice warrants that on submission of claim within 15 days from the date of receipt of copy of this order by complainant along with available documents, OP1 to OP3 will get the claim processed through TPA concerned within 45 days of receipt of claim form along with available documents. In case after such processing any amount is payable, then payment of the same be made within 40 days of receipt of report of TPA by OP1 to OP3 or any of them. Complainant not entitled to any compensation or costs of litigation because he himself failed to submit the claim in writing.

10.               As a sequel of above discussion, complaint disposed of in terms that complainant will submit the claim within 15 days from date of receipt of copy of order along with available documents and thereafter, OP1 to OP3 will get the claim processed through TPA concerned within 45 days of receipt of claim form along with available documents. After such processing, in case any amount found payable, then payment of same will be made within 40 days of receipt of report of TPA by OP1 to OP3 or any of them. No order as to costs and compensation. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                                         (Param Jit Singh Bewli)                      (G.K. Dhir)

                                         Member                                              President

Announced in Open Forum.

Dated:25.01.2017.

Gobind Ram.