Punjab

Sangrur

CC/403/2016

Neeraj Goyal - Complainant(s)

Versus

National Insurance Company Ltd. - Opp.Party(s)

Shri Rahul Sharma

07 Dec 2016

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR

                             

                                                                   Complaint no. 403                                                                                        

                                                                    Instituted on:  17.05.2016

                                                                   Decided on:    07.12.2016

 

Neeraj Goyal aged 53 years son of Shri Rajinder Pal Goyal, resident of H.No.134, Street No.6, punia Colony, Sangrur.

                                                …. Complainant.        

Versus

1.     National Insurance Company Limited Regd. Office-3 Middleton Street, Post Box No.9229, Kolkata-700 071;

2.     National  Insurance Company Limited G.T. Road Khanna, District Ludhiana ( PB) Pin-141401, Phone No.01628-232119, 231815;

3.     Ashok Dhand, Policy Agent Khanna, Mobile No.98140-42588, C/o National Insurance Company Limited G.T. Road Khanna, District Ludhiana (PB) Pin-141401;

4.     National Insurance Company through its A.S.D.M.  Sangrur Opposite Kaula Park, Sangrur.

 

      ….Opposite parties.

 

FOR THE COMPLAINANT:            Shri Rahul Sharma  Advocate                          

 

FOR OPP. PARTIES NO.1,2&4:     Shri N.S.Sahni Advocate

 

FOR OPP. PARTY NO.3               :            Exparte       

 

 

Quorum

         

                    Sukhpal Singh Gill, President

Sarita Garg, Member

                 

 

ORDER:  

 

Sukhpal Singh Gill, President

 

1.             Neeraj Goyal complainant has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that he obtained a policy  for his family members i.e. Neeraj Goyal, Neelam Goyal, Sudhant Goyal and Disha Goyal namely Parivar Mediclaim Hospitalization Benefit Policy w.e.f. 09.05.2015 to 08.05.2016 for sum insured Rs.2,50,000/-  and paid premium Rs.10993/- . The complainant Neeraj Goyal was admitted for his eye surgery  on 22.09.2015 and discharged on 23.09.2015 and incurred Rs.29150/- for his eye operation. Thereafter the complainant approached the policy agent Ashok Dhand and submitted claim application along with all necessary documents.  The complainant approached the OPs  but policy agent said that his cheque has been misplaced and again sent blank cancelled cheque which was mailed on 30.11.2015 but no response was received from the OPs. Thus, alleging deficiency in service on the part of OPs, the complainant has sought following reliefs:- 

i)      OPs be directed to pay the total due amount of Rs.29150/-  alongwith interest @18% per annum from the date of deposit till  realization,   

ii)     OPs be directed to pay to the complainant a sum of Rs.50000/- as compensation   on account of mental agony, harassment,

iii)     OPs be directed to pay Rs.15,000/- on account of deficiency in service and  Rs.5500/- as litigation expenses.

2.             In reply filed by the OPs no.1,2 and 4,  legal objections on the grounds of cause of action, maintainability, estoppal and suppression of material facts have been taken up. On merits,  It is stated that the  claim of the complainant has already been settled and an amount of Rs.20650/-  was paid to the complainant through cheque dated 7/7/2016 and the complainant has received the said cheque.  Therefore, the present complaint is liable to be dismissed. Out of the bill amount of Rs.8500/-  were deducted.  The room charges  were to be paid  to the tune of Rs.2500/-  as per policy and thus the sum of Rs.2500/-  was deducted. Similarly sum of Rs.5000/-  was added as RMO/ Nursing and the same was also not admissible as per the policy. Thus, there is no deficiency in service on the part of the OPs.   

3.             Notice was sent to the OP no.3 but despite service OP no.3 did not appear and as such  it was proceeded exparte.

4.             The complainant has tendered documents Ex.C-1 to Ex.C-7 and closed evidence. On the other hand, OPs have tendered documents Ex.OP-1/1 to Ex.OP-1/5, Ex.OP-2/1 and closed evidence.

5.             From the perusal of documents placed on the file and after hearing the arguments of the learned counsel for the parties, we find that the OPs in their written reply  has specifically stated that the claim of the complainant has already been settled  by them and a cheque dated 07.07.2016 for an amount of Rs.20650/-  has been sent to the complainant which he has received.  Further, the OPs have stated that the complainant  submitted bill of Rs.29150/-  in which the sum of Rs.5000/- was added as room charges but room charges were to be paid to the tune of Rs.2500/-  as per policy and thus the sum of Rs.2500/- was deducted and similarly  sum of Rs.5000/-  was added as RMO/ Nursing and the same was also not admissible as per the policy and sum of Rs.1000/- was added as admission fee and same was also not admissible as per the policy. From the perusal of the policy, we find that the OPs have rightly deducted the amount from the claim amount of the complainant.

6.             Another aspect of the case is that the complainant has stated in his complaint that he had submitted his claim application alongwith  all necessary/ required documents with the OPs on 23.09.2015  which is evident from application Ex.C-7. This fact has not been denied by the OPs. Rather the OPs have produced on record a letter dated 06.10.2015 wherein the OPs have referred the claim case of the complainant to M/s Raksha T.P.A. Pvt. Limited for doing needful. The OPs have themselves admitted that the claim of the complainant has been settled and a cheque dated 07.07.2016 was sent to him.  From all the facts discussed above,  we find that the  OPs have settled the claim of complainant and paid the amount after a period of  more than nine months from lodging the claim by the complainant whereas it is settled law  that a reasonable  time of two months  would be justified  for insurance company to take decision .  In  United India Insurance Company Limited Vs. M.K.J. Corporation, 1998 (2) CLT 489 the Hon'ble Supreme Court of India  has held that  a reasonable  time of two months  would be justified  for insurance company to take decision from the date of submission of report of surveyor weather the claim requires to be settled or rejected.

7.             For reasons recorded above, we find that the OPs are deficient in service  for not settling the claim of the complainant  within the stipulated period. As such we partly allow the complaint of the complainant and direct the OPs  to  pay an amount of Rs.10000/- on account of deficiency in service and Rs.5000/- as litigation expenses.

8.             This order of ours shall be complied with within 30 days from the receipt of copy of the order. Copy of the order be supplied to the parties free of charge. File be consigned to records in due course.                       

                Announced

                December 7, 2016

 

 

 

( Sarita Garg)                                           (Sukhpal Singh Gill)                                                                                      

Member                                                       President