Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION PATIALA. Consumer Complaint No. 483 of 7.12.2016 Decided on: 17.2.2021 Arvinder Singh son of Manjit Singh resident of 2171, Urban Estate, Phase-2, Patiala, District Patiala. …………...Complainant Versus New India Assurance Company Ltd.,Chhoti Baradari, The Mall, Patiala through Divisional Manager. …………Opposite Party Complaint under Section 12 of the Consumer Protection Act, 1986. QUORUM Sh. Jasjit Singh Bhinder, President Sh.Y.S.Matta, Member ARGUED BY Sh.B.K.Sharma, counsel for complainant. Sh.Amit Gupta, counsel for OP. ORDER JASJIT SINGH BHINDER,PRESIDENT - This is the complaint filed by Arvinder Singh (hereinafter referred to as the complainant) against New India Assurance Co. Ltd. (hereinafter referred to as the OP/s) .
FACTS OF THE COMPLAINT - Brief facts of the complaint are that on 9.12.2015 complainant purchased for himself and for his family a health insurance policy (New India Floater Mediclaim) bearing No.36140034142800000070 valid for 10.12.2014 to 9.12.2015 for an amount of Rs.3,00,000/- and paid the premium of Rs.5686/-to the OP. The complainant got the policy renewed on 8.12.2015 and paid Rs.5794/- as premium in lieu of which the OP issued fresh policy bearing No.36140034152800000144 for the same amount of Rs.3,00,000/- for the period from 10.12.2015 to 9.12.2016.
- It is averred that on 9.12.2015, son of the complainant namely Dashamjot got injury on his upper lip and was admitted in Kuber Hospital, Patiala from where he was taken to Tricity Institute of Plastic Surgery Pvt. Ltd., Sector 34-A,Chandigarh on 10.12.2015 where the doctor operated upper lip of Dashamjot Singh and discharged him on 11.12.2015 and the complainant spent Rs.31,135/- for the treatment of his son. Complainant also informed the OP in this regard and submitted relevant documents with it but the OP vide its letter dated 8.1.2016 repudiated the claim on flimsy grounds. There is thus deficiency in service on the part of the OP. The complainant also got served legal notice dated 17.9.2016 upon the OP and also sent reminder of legal notice dated 13.10.2016 but no heed was paid by the OP. The act and conduct of the OP caused mentally, physically and financially to the complainant.
- Hence this complaint with the prayer to accept the same by giving direction to the OP to release the claim amount alongwith interest; to pay compensation of Rs.1,00,000/- and also to pay litigation expenses of Rs.5500/-.
REPLY/WRRITTEN STATEMENT - Notice of the complaint was duly served upon the OP who appeared through counsel and contested the complaint by filing written reply having raised preliminary objections that the complaint is not maintainable and that this Hon’ble Forum has no jurisdiction to entertain and try this complaint.
- On merits, it is admitted that New India Floater Medi Claim policy for the period from 10.12.2015 to 9.12.2016 was issued by the OP covering the risk of the complainant and his two children for Rs.3lac. It is submitted that on receipt of claim, all the documents were sent to M/s Raksha TPA, who after examining the papers found that the claim of the complainant was not payable because the patient was admitted with diagnosis laceration upper lip and repair done under general anesthesia and the amount charges of Rs.31,135/- are not reasonable being excess. It is further submitted that reply to the legal notice was duly given. There is no deficiency of service on the part of the OP. After denying all other averments , the OP prayed for the dismissal of the complaint.
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- In support of the complaint, the ld. counsel for the complainant has tendered Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C10 and closed the evidence.
- On the other hand, the ld. counsel for the OP has tendered in evidence Ex.OPA affidavit of Govinder Singh Walia, DM alongwith documents Exs.OP1 to OP11 and closed the evidence.
- Complainant also filed the written arguments. We have gone through the same , heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
ARGUMENTS AND FINDINGS - The ld. counsel for the complainant has argued that the complainant purchased health insurance policy for an amount of Rs.3lac on 9.12.2014 and he paid 5686/- as premium and the policy was valid from 10.12.2014 to 9.12.2015 for complainant and his family. The ld. counsel further argued that the policy was got renewed from 10.12.2015 to 9.12.2016 for the complainant and his family members. The ld. counsel further argued that on 9.12.2015 the son of the complainant Dashmjot Singh got injury of upper lip and he was admitted in Kuber Hospital, Patiala from where he was taken to Tricity Institute of Plastic Surgery Pvt. Ltd., Sector 34-A,Chandigarh.The ld. counsel further argued that the surgery was conducted and bill of Rs.31,115/- was submitted with the OP but the OP has denied the claim. So the complaint be allowed.
- On the other hand, the ld. counsel for the OP has admitted the policy of the complainant. The ld. counsel for the OP has denied that son of the complainant got injury of upper lip and he was admitted to Kuber Hospital, Patiala from where he was got admitted to Chandigarh hospital. The ld. counsel further argued that the claim of the complainant was repudiated as the amount of Rs.31,115/- was not reasonable being excessive. So the complaint be dismissed.
- To prove this case complainant Arvinder Singh has tendered his affidavit, Ex.CA and he has deposed as per his complaint;Ex.C1 is the legal notice sent to the OP dated 17.9.2016,Ex.C2 is the postal receipt,Ex.C3 is reminder of legal notice dated 13.10.2016,Ex.C4 is postal receipt,Ex.C5 is the policy from 10.12.2015 to 9.12.2016,Ex.C6 is another policy from 10.12.2014 to 9.12.2015, Ex.C7 is the receipt of Kuber Hospital, Patiala,Ex.C8 is the receipt of Tricity Institute of Plastic Surgery Pvt. Ltd., Chandigarh, where the child was admitted and treated,ExC9 is the bill of Rs.31,115. of Tricity Institute of Plastic Surgery, Chandigarh dated 12.12.2015 and Ex.C10 is the repudiation letter.
- On the other hand OP has tendered affidavit of Govinder Singh Walia, who has deposed as per the written statement, Ex.OP1 is reply to legal notice, Ex.OP2 is repudiation letter,Ex.OP3 is another letter written to Arvinder Singh,Ex.OP5 is proposal form,Ex.OP6 is policy of New India Assurance Co.,Ex.OP7 is receipt of Kuber Hospital,Ex.OP8 is the discharge summary from Tricity Institute of Plastic Surgery, where child was admitted on 10.12.2015, date of surgery 10.12.2015 and was discharged on 11.12.2015,Ex.OP9 is bill of hospital,Ex.OP11 is the insurance policy.
- Admittedly complainant was having insurance policy of the OP from 9.12.2014 to 10.12.2015 and from 10.12.2015 to 9.12.2016.As per the complainant on 9.12.2015 his son Dashamjot Singh got injury and admitted in Kuber Hospital, Patiala from where he was shifted to Tricity Institute of Plastic Surgery, Sector 34A,Chandigarh and he was operated upon there. The operation notes of this hospital are Ex.C8.After the operation, the child was discharged on 12.12.2015 and the bill of Tricity Institute of Plastic Surgery, Chandigarh is Rs.31,115/-.So it is clear from the documents produced by the complainant that child got injury of upper lip and he was operated upon from Tricity Institute of Plastic Surgery, Chandigarh and bill is on the file. The claim was repudiated on the flimsy ground and the repudiation letter is Ex.C10.
- When the complainant had taken policy for him and his children and his son got injury, the bill was duly submitted, it was the bounded duty of the insurance company to pay the claim to the complainant when all the hospital record proves that in fact the child Dashamjot got injury and he was admitted at Tricity Institute of Plastic Surgery, Sector 34A Chandigarh and surgery was conducted of his upper lip. It seen that insurance companies are always trying to repudiate the claim on the flimsy ground and there is definitely deficiency in service on its part. The OP is Govt. aided renowned company and it is not good for these companies to repudiate the claim and make the person to wait for 5-6 years. This practice should be avoided.
- So due to our above discussion, it is proved on the file beyond reasonable doubt that on 9.12.2015 son of the complainant injured and got treated from Tricity Institute of Plastic Surgery, Chandigarh and the bill of this institute of Rs.31,115/- dated 12.12.2015 is on the file. Accordingly the complaint stands allowed and the OP is directed to pay the claim amount of Rs.31,115/- to the complainant alongwith interest @6% per annum from the date of repudiation i.e. 1.8.2016 alongwith Rs.10,000/-as compensation and Rs.15000/-as litigation expenses. Compliance of the order be made by the OP within a period of 45 days from the date of the receipt of the certified copy of this order.
ANNOUNCED DATED:17.2.2021 Y.S.Matta Jasjit Singh Bhinder Member President | |