Punjab

Ludhiana

CC/22/170

Krishna Devi - Complainant(s)

Versus

National Insurance Co. - Opp.Party(s)

Jishu Dhir

18 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 170 dated 21.04.2022.                                                        Date of decision: 18.07.2024. 

 

Krishna Devi aged about 44 years Wife of Sh. Gurdev Singh, Resident of VPO Bajwa Kalan, Tehsil Shahkot (Punjab), District Jalandhar. PIN Code 144702, M. No.80540-17044. Email: jishudheer@gmail.com.

                                                                                      ..…Complainant

                                                Versus

1. The National India Insurance Company Ltd., Regional office at Fourth Floor, Grand Walk, Ferojpur Road, Ludhiana-141012 (Punjab) through its Regional Manager/Authorized Signatory.
2. The Central Bank of India, Regional Branch Office at Ferojpur Road, Gurdev Nagar, Adjoining Hotel Park Plaza, Ludhiana-141001 (Punjab) through its Regional Manager/Authorized Signatory.                                                                                                         …..Opposite parties 

Complaint Under Section 36 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Jishu Dhir, Advocate.

For OP1                         :         Sh. M.S. Jassal, Advocate.

For OP2                         :         Sh. Rajan Arora, Advocate.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant is the employee of OP2 bank and she through the said bank purchased policy No.251100502010000260 from OP1 for covering medical expenditure reimbursement scheme to the employee of OP2 Central Bank of India. On 10.04.2021, the complainant suffered from chronic abdominal pain and she approached Ckosmic Surgical Centre, Thapar Hospital, G.T. Road, Moga. After investigations, the complainant was diagnosed with Menorrhagia (Bulky Uterus with Fibroid with Fatty Infiltration live grade-1) final diagnosis surgical operate of Fibroid Uterus. The complainant remained admitted in the hospital from 01.04.2021 to 05.04.2021 and she spent Rs.46,602/- on her treatment from her own pocket. The complainant stated that thereafter, she approached OP2 at Regional Office, Ludhiana who assured her to pay off all the hospital expenses etc. on submission of hospital discharge slip and medicine bills to OP1. The complainant submitted all the documents with the OPs as per their requirement but they postponed the matter on one pretext or the other. The complainant further stated that she kept awaiting for reimbursement and settlement of her claim but no reply was received. Then she contacted the OPs but they did not give any reply regarding settlement of her claim and thereafter, they stopped responding her. The complainant claimed to have suffered mental tension, pain agony, harassment due to deficiency in service on the part of the OPs for which she is entitled for compensation. The complainant issued a legal notice dated 24.05.2021 through Sh. Jishu Dhir, Advocate but to no effect. Hence this complaint, whereby the complainant has prayed for issuing direction to the Ops to pay the claim amount of Rs.46,602/- along with compensation of Rs.25,00/- and litigation expenses of Rs.20,000/-.  

2.                Upon notice, OP1 appeared and filed written statement and assailed the complaint by taking preliminary objections on the ground of maintainability etc. OP1 stated that the complaint is liable to be dismissed against it as its name has been wrongly written as National India Insurance Company instead of National Insurance Company. OP1 further stated that Indian Banks Association had taken an Insurance Policy No.251100502010000260 w.e.f. 01.10.2020 to 30.09.2021 for a sum of Rs.11,30,91,00,000/- for estimated annual premium for Rs.57,16,12,469/- from it. The complainant has not submitted the claim regarding her hospitalization from 01.04.2021 to 05.04.2021 at Ckosmic Surgical Centre, Thapar Hospital, G.T. Road, Moga for her treatment  along with all the hospital records and medical bills. As such, she is not legally entitled for the claim.

                   On merits, OP1 reiterated the crux of averments made in the preliminary objections. OP1 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                OP2 filed separate written statement and assailed the complaint by taking preliminary objections on the ground of maintainability; concealment of material facts; the complainant being not a consumer; the dispute in question is of civil nature; lack of jurisdiction and cause of action etc. OP2 stated that the complainant submitted the claim documents for an amount of Rs.58,102.69 to them for her hospitalization which was forwarded to OP1 on 08.07.2021. The official of OP1 has also received the claim file from OP2 under his signatures on 08.07.2021. After forwarding the claim of the complainant, OP2 is not duty bound to deal with the claim of the complainant and has nothing to do with the claim of the complainant. There is no lapse on the part of OP2.

                   On merits, OP2 reiterated the crux of averments made in the preliminary objections. OP2 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

4.                In evidence, the complainant tendered her affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 is the legal notice dated 20.01.2022, Ex. C2 to Ex. C4 are the postal receipts, Ex. C5 is the copy of insurance identity card of the complainant, Ex. C6 is the copy of forwarding letter dated 05.07.2021 of OP2 to OP1, Ex. C7  is the copy of receipt of Rs.40,000/- dated 05.04.2021 to Ekosmic Surgical Center, Ex. C8 to Ex. C11 are the copies of Claim Form, Ex. C12 to Ex. C24 are the copies of medical bills/receipts and closed the evidence.

5.                On the other hand, the counsel for OP1 tendered affidavit  Ex. RA of Sh. Lalit Mohan Bansal, Senior Divisional Manager of OP1 along with documents Ex. R1 is the copy of insurance certificate and closed the evidence.

 

                   Learned counsel for OP2 tendered affidavit Ex. R2/A of Ms. Sumiti, Assistant Manager (Management Specialist-HRD) of OP2 along with documents i.e. Ex. R2/1 is the copy of authority letter and closed the evidence. 

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statements along with affidavits and documents produced on record by the parties.

7.                Undisputably, the complainant being an employee of OP2 Central Bank of India, was covered under a Group Mediclaim-Tailormade policy Ex. R1 for covering the employees of the bank. The relevant remarks of policy Ex. R1 is reproduced as under:-

“1) Sum insured for Critical illness for Employees only: Rs.1,00,000/- per employee

2) Sum insured for Group Health Insurance on Family Floater Basis: Officer: Rs.4,00,000/- per family

          Clerical Rs.3,00,000/- per family

          Sub Staff: Rs.3,00,000/- per family

3) Room Charges Rs.5000/- per day

4) ICU Charges Rs.7500/-.”

It is further an admitted fact that the complainant remained admitted at Ckosmic Surgical Centre, Thapar  Hospital, Moga from 01.04.2021 to 05.04.2021  where she was diagnosis of having Fibroid Uterus for which Total LAP hysterectomy procedure was done on 02.04.2021. The complainant was discharged on 05.04.2021.  After her discharge from the hospital, the complainant submitted claim with OP2 bank along with documents for reimbursement of claim of Rs.46,602/-. OP1 in their written statement  in para No.2 of the preliminary objections stated that the complainant has not lodged the claim with it along with all the hospital records and medical bills. However, OP2 in its written statement in para No.7 of the preliminary objections has stated that it has received the claim documents from the complainant vide letter reference No.BO:HRD:2020-21:1 dated 05.07.2021, which were forwarded to the insurer i.e. OP1 vide letter reference No.RO:LUDH:HRD:2021-22:300 dated 08.07.2021 and the said documents were duly received by the officials of OP2 on 08.07.2021 and now it has nothing to do with the claim of the complainant. So it seems that there was some communication gap between the parties due to which the claim of the complainant could not be registered and settled as per terms of the policy. In the given set of circumstances, it would be just and appropriate if the complainant is directed to submit the claim along with documents afresh with OP1 within 15 days from the date of receipt of copy of order and thereafter, OP1 shall settle and pay claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. 

8.                As a result of above discussion, the complaint is partly allowed with an order that the complainant is directed to submit the claim along with documents afresh with OP1 within 15 days from the date of receipt of copy of order and thereafter, OP1 shall settle and pay claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. OP1 shall pay a composite compensation of Rs.10,000/- (Rupees Ten Thousand only) to the complainant within 30 days from the date of receipt of copy of order. However, the complaint as against OP2 is hereby dismissed. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.       

9.                Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:18.07.2024.

Gobind Ram.