Complainant Harjinder Singh has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite party to reimburse the claim of Rs.1,00,000/- to the complainant as expenses borne and paid by him in the hospital while getting treatment alongwith 18% P.A. interest from the date of filing of this complaint till its realization and opposite party be further directed to pay compensation on account of mental as well as physical harassment to the tune of Rs.50,000/- and litigation expenses of Rs.20,000/- in the interest of justice.

2.        The case of the complainant in brief is that Harjinder Singh while taking morning walk on 13.11.2019 suffered chest pain and fell down passersby informed his family and he was taken to Arora Hospital, BSF Road, Gurdaspur. He got first aid treatment from this hospital and was diagnosed with heart problem. After few days, he was advised to take consultation from Cardiologist. Complainant was referred to CARDIONOVG Institute of Medical Science, Department of Cardiology, Jalandhar and was admitted on 23.11.2019 and diagnosed with PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA AVNRT. He was advised for operation immediately and for which he deposited Rs.1,00,000/- cash as total package offered by the hospital. Complainant was discharged on 25.11.2019 and had paid the entire package amount. Complainant is taking medicine as advised by doctor and also paying visit to the hospital off and on. Complainant was fully insured with the opposite party under medi claim insurance policy and had paid premium of Rs.15042/- and opposite party issued him Policy No.401502501910000050. Policy was valid from 30.7.2019 to 29.7.2020 so the complainant was fully covered under the said policy during the course of treatment. The complainant visited the office of opposite party on 12.12.2019 to reimburse the medial claim as per medi claim policy and handed over the bills which he had paid from his own pocket alongwith application and original documents.

3.       That after receiving the application and bills the opposite party posted letter dated 26.12.2019 to the complainant to send additional documents with consent letter to allow verification of inpatient records by authorized agency Park Medi Claim TPA Pvt.Ltd which were followed up by the complainant. Complainant replied to their letter dated 15.1.2020 reference no.NICCHI/33728 and submitted Photostat document to them on 27.1.2020 through registered letter and again posted documents on 5.2.2020 and also to Park Medi Claim Insurance Policy TPA Pvt. Ltd. through registered letter dated 21.1.2020. Complainant was surprised to receive their letter dated 30.6.2020 in which opposite party mentioned that "YOU ARE NO MORE INTERESTED TO FOLLOW THE CLAIM AND WE SHALL BE CONSTRAINED TO CLOSE THE FILE AS NO CLAIM" Thus, there is negligence on the part of opposite party in rendering the service and by harassment, mental agony as well as physical harassment to the complainant and complainant has suffered financial loss. It is pertinent to mention here that complainant was insured with opposite party for the last so many years and Photostat copies are attached with the file. Complainant made request for reimbursement of medical claim but opposite party failed to do so. Complainant also gave registered legal notice dated 28.7.2020 sent on 30.7.2020 to opposite party but they did not reply to the same. Copy of legal notice is attached with the file. Hence this complaint.

4.         Notice of the complaint was issued to the opposite party who appeared through its counsel and filed its written reply by taking the preliminary objections that the complainant has no cause of action and locus standi to file the present complaint; the complainant has concealed the material facts from this Ld.Commission and as such not entitled for any discretionary relief.; the insurance is a contract based on utmost good faith. It is the duty of the insured to disclose all the relevant facts and also to provide all the documents demanded by the Insurance Company required for finalization of the claim; the third party administrator, who has to finalize the claim has not been made part to the present complaint. The Park Mediclaim Insurance TPA Pvt.Ltd. Company is the Third Party Administrator and the present complaint is bad for non-joinder of the necessary parties. Further the complainant failed to send the requisite documents demanded by the said Third Party Administrator, due to which the claim has been rejected. The matter of fact is that the letter dated 26.12.2019 and further letter dated 04.01.2020 has been sent by the said Third Party Administrator to the complainant and made demand of documents required to finalization of the claim. But the said formalities have not been completed by the complainant. The final reminder letter dated 15.01.2020 has also been sent in which the request for the documents have been made i.e. to send the signed consent letter fully filled as detailed in the said letter, Self Attested copies of PAN Card, ID Proof, all the policy copies confirming coverage of the patient under Medi claim policy prior to 30.07.2019, if any and the record of treatment taken before hospitalization. But such formalities have not been completed and again the Special final reminder cum Closure letter dated 21.01.2020 has been sent and again the demand of documents have been made. But no such documents have been provided. Due to which the claim has been made as NO CLAIM. Even the National Insurance Company also sent letter dated 30.06.2020 in this regard to the complainant. On merits, it was admitted that the policy was issued in favour of the complainant. The coverage under the policy and period of policy are matter of record. Actually the claim has been filed but all the requisite documents, inspite of repeated requests has not been filed and the claim has been made as NO CLAIM.  All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

5.         Ld.counsel for the complainant has tendered into evidence, affidavit of complainant Ex.CW-1/A alongwith other documents Ex.C-I to Ex.C-25 including Ex.C-1/A, Ex.C-1-AA, Ex.C-1AAA, Ex.C-4A to Ex.C-9/A and Ex.C-8/AA and closed the evidence.

6.     Alongwith the written statement opposite party has filed affidavit of Sh.Kulbhushan Kumar Ex.OPW-1/A alongwith other documents Ex.OP-1/1 to Ex.OP-1/5.

7.     Rejoinder filed by the complaint.

8.     Written arguments filed by complainant.

9.     We have carefully gone through the pleadings of counsel for the parties; oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the parties for the purposes of adjudication of the present complaint.

10.     Harjinder Singh is holder of Medi-claim policy of National Insurance Company i.e. opposite party in the present complaint issued for the period 30.7.2019 to 29.7.2020. Complainant Harjinder Singh had earlier got medi claim policies and placed on record for three consecutive years placed at Ex.C-19, C-20 and Ex.C-22. Complainant Harjinder Singh got chest pain in the morning of 13.11.2019 while taking morning walk and was taken to R.P.Arora Medicity Hospital, Gurdaspur Ex.C-8/A where he got first aid and after few days he was advised to consult Cardiologist   and was referred to CARDIONOVG Institute of Medical Science, Department of Cardiology, Jalandhar on 23.11.2019. Complainant deposited Rs.1,00,000/- as part of the package vide receipt Ex.C-12 and Ex.C-13 of Rs.50,000/- each. Complainant was discharged on 25.11.2019 vide discharge slip Ex.C-9. Complainant approached opposite party regarding reimbursement of medical expenses which was well over Rs.1,00,000/- as per the receipts attached alongwith the application. Opposite party denied the claim on frivolous pretext and unnecessary and unwarranted correspondence, letter of  Park Mediclaim TPA Pvt.Ltd. in this case dated 26.12.2019 was replied by complainant on 7.1.2020 vide registered letter Ex.C-4A and also Ex.C-5A letter dated 4.1.2020,  further letter dated 15.1.2020 of opposite party was replied vide registered letter dated 27.1.2020 Ex.C-8. Thus answering all the queries of opposite party as well as Park Mediclaim TPA Pvt.Ltd insurance policy.

11.      From the above facts placed above, it is very clear that opposite party and also its Park Mediclaim TPA Pvt.Ltd did not entertain the legitimate claim of the complainant Harjinder Singh and unduly harassed the complainant on one pretext or the other and even went on to write to the complainant in their letter dated 30.6.2020 wherein threatened to close the case as NO CLAIM even though the required bills and query was duly submitted and answered.

12.    In view of the foregoing discussion, we are of the considered view from the facts and circumstances that legitimate claim of Harjinder Singh is partly allowed and opposite party is directed to reimburse the claimed amount of Rs.1,00,000/- alongwith interest @ 7% P.A. from the date of filing of the complaint till its realization  within  45 days from the date of receipt of copy of order. Opposite party is further directed to pay Rs.10,000/- as harassment and Rs.10,000/- as litigation expenses to complainant Harjinder Singh.

13.     The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

14.    Copy of the order be communicated to the parties free of charges. After compliance, file be consigned.                                                                                                                                                         

            (Naveen Puri)

                                                                            President   

Announced:                                                   (R.S.Sukhija)

January 04, 2022                                                 Member

*MK*