Jammu and Kashmir

Jammu

CC/203/2018

SUBASH CHANDER BHAT - Complainant(s)

Versus

NATIONAL INSURANCE CO. - Opp.Party(s)

NISHI KOUL

25 Oct 2018

ORDER

DISTRICT    CONSUMER     DISPUTES   REDRESSAL  FORUM, JAMMU

                (Constituted under J&K Consumer Protection Act,1987)

                                                         

 Case File  No.:               74/DFJ         

 Date of  Institution   :  29-05-2018

 Date of Decision      :    12-10-2018

 

Subash Chander Bhat,

S/O Late Sh.Janki Nath Bhat,

R/O H.No.29/2-A,Sector-2,

Durga Nagar,Jammu.

                                                                                                                                                Complainant

                 V/S

1.National Insurance Co.Ltd.

 Divisional Office-1 Shalimar Road,Jammu,

Through its Divisional Manager.

2.Park Mediclaim TPA Pvt.Ltd.

  New Delhi.

                                                                                                                                                                Opposite parties

     CORAM

                           Mr.Khalil Choudhar(Distt,& Sessions JudgePresident

                           Ms.Vijay Angral                                                     Member

                           Mr.Ghulam Sarwar Chauhan                           -  Member

 

In the matter of: Complaint under section 10 of J&K Consumer Protection Act 1987.

 

MS Nishi Sangra nee Koul , Advocate for complainant, present .

Mr.Sanjay K.Dhar,Advocate for OP1,present.

 

 

                                                                     ORDER

                  

                                  Shorn of unnecessary details, allegation of complainant is that,      complainant has been obtaining health insurance policies continuously from OP1 since year 2014 wherein risk of complainant and his family is covered and OP2 is appointed as Third Party Administrator(TPA)in the said policy for processing and settlement of claims under the said policy and the complainant got the Mediclaim Insurance Policy renewed vide Policy No.420800/50/17/10000051 from OP1 w.e.f.January,2018 till January,2019 and during the subsistence of said policy complainants wife,namely,Naresh Kumari also insured under the said policy vide Card No.021824677 having Park ID No.PQ21714265 was not well and she was hospitalized on,09-03-2018 for treatment in JK Medicity Hospital Pvt.Ltd.Bye Pass Narwal Jammu where she had to undergo surgery called as Lapcholecystectomy.That complainant incurred an amount of Rs.41,500/on the treatment of his wife during hospitalization, therefore, claim was intimated to OP2 via mail and thereafter complainant submitted all requisite documents as demanded by OPs for settlement of the claim(copies of all such documents are annexed as Annexure-A)That thereafter in the month of April,2018 OPs informed him that his claim has been settled by crediting the claim amount directly to his bank account as given in the claim form, but when he approached to his banker i.eJ&K Bank Bantalab Jammu in order to confirm, as to whether claim amount has been credited  to his account, but to the utter shock and dismay, it was informed that no such amount has been credited to said bank account. That complainant immediately apprised OPs about the non settlement of his claim, since no amount stood credited to his bank account as per information provided earlier to him, but OPs did not respond till date, resultantly claim of complainant has remained un settled till date and this act of Ops constitutes un fair trade practice and deficiency in service on the part of Ops.Hence the complaint. In the final analysis complainant prays for reimbursement of Rs.45,858/alongwith interest  12 p.a.from the date of hospitalization and in additional also prays for compensation of Rs.50,000/-on account of mental torture,agony,physical inconvenience and harassment caused to the complainant.

                On the other hand,OP1 filed written version and resisted the complaint on the ground that instant complaint is not maintainable and deserves out right dismissal in view of the fact that complainant’s claim under Medi Claim Insurance Policy has already been settled in full and final on,31-03-2018 for Rs.45,858/-in accordance with the terms and conditions as would be applicable and the amount was directly credited to bank account of complainant by OP2 who is an authorized TPA for Mediclaim insurance claims. The complainant is not a consumer and there is no relationship of consumer and service provider or privities of contract after the claim was settled and amount was credited to his bank account, as such, complaint is not maintainable.

              In so far as OP,2 is concerned, despite notice did not take any action to represent the  case in this Forum, either to admit the claim of complainant or to deny the same within stipulated period, provided under the Act. Thereafter, the right of the OP,2 to file reply was closed, vide order dated, 09-10-2018.

                      We have perused case file and heard L/Cs for the parties at length.

                    Counsel for complainant submits that in fact OPs have not credited the claim amount in bank account of complainant and the correct account number was mentioned in claim form which was provided to OPs and on the other hand, the amount has been credited to account of some other person maintained with J&K Bank Ban Talab as complainant was informed by bank as such claim of complainant has remained unsettled.

                            Counsel for OP1 through asserted in its objections that amount has been credited to complainant’s account by OP2, but when confronted with situation that amount has been credited to Bank A/C of some other person in place of complainant’s a/c,no clarification or explanation has been given except that in fact it is OP2 (TPA)who processes the claims under Mediclaim Insurance Policy and it appears that OP2 might have committed mistake. We have considered the submissions made by L/Cs for parties & also perused the material on record. It is admitted position that claim under Mediclaim Policy has been settled, however, the only and short controversy lies that amount of claim has not been paid to the complainant, but paid to some other person through Electronic Fund Transfer, thus it can safely be concluded that OPs have remained negligent while crediting the amount of claim made particularly when complainant has provided complete particulars of his Bank Account as also mentioned in claim form attached with the complaint. It is established that claim in favour of complainant has not been settled & amount has not been reimbursed to the complainant as such OPs have committed deficiency in service and accordingly are liable.

               On the other hand, OP,2 despite being duly served, failed to take any action to represent the case in this Forum, either to admit the claim of the complainant or to deny it, so there is no reply filed by OP,2 in this complaint and there is also no evidence to rebut the case of the complainant. The present case of the complainant is covered by Section 11 (2) (b) (ii) of the Consumer Protection Act, 1987, which provides that in a case where the Op2 omits or fails to take any action to represent the case within the time given by Forum, in that situation the Forum shall settle the consumer dispute on the basis of evidence brought to its notice by the complainant. Sub-Clause (ii) of the Section 11, of Act of 1987, clearly, provides that when OP,2 omits or fails to take any action to represent their case before the Forum, the dispute has still to be decided on the basis of the evidence brought to its notice by the complainant.

                 After going through the whole case with the evidence on record what reveals here is the case of complainant is genuinely filed with speaking reasons and merit as being consumer as per the purport of section 2(d) of Consumer Protection Act and Ops are the service providers having failed in their statutory duty to provide adequate and effective services. The purport of legislation is well defined and statutorily takes care of consumer rights and cannot legally afford to a situation like the one confronted herewith in a manner where they are deprived of their rights as of consumer. The consumers have to come forth and seek for redressal of his grievance. The case of the complainant is also genuinely filed for seeking determination of his right by this Forum.

                     Therefore, in view of aforesaid discussion, we are of the opinion that the complainant has succeeded in proving deficiency in service on the part of OP1,as such,OP 1 is directed to reimburse Rs.45,558/alongwith interest  7% p.a.w.e.f09-03-2018(i.e. from the date of admission)till its realization. OP2 is directed to pay Rs.25,000/-as compensation for causing  mental agony and harassment and litigation charges of Rs.15,000/-to the complainant. The awarded amount be deposited in this Forum within one month from the date of receipt of this order. The complaint is accordingly disposed of and file be consigned to records after its due compilation.

Announced                                                 (Khalil Choudhary)                                         

 12-10-2018                                                (Distt.& Sessions Judge)

 Agreed by                                                      President                                                      

                                                                       (District Consumer Fourm)

Ms.Vijay Angral                                                 Jammu.

Member

 

Mr.Ghulam Sarwar Chauhan

Member