Punjab

Ludhiana

CC/22/18

Rajiv Nagpal - Complainant(s)

Versus

New India Assurance Co.Ltd - Opp.Party(s)

Prabhjot Pal Singh

12 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  18 dated 14.01.2022.                               Date of decision: 12.08.2024. 

 

Rajiv Nagpal aged 47 years son of Shri Krishan Lal, resident of House No.510-L, Model Town, Ludhiana.

                                                                                      ..…Complainant

                                                Versus

1. The New India Assurance Co. Ltd., S.C.O. 12, Near Stock Exchange, Feroze Gandhi Market, Jila Kacheri Area, Model Gram, Ludhiana, through its Manager.
2. Medi Assist Insurance TPA Pvt. Ltd., 4^th Floor, Tower D, IBC Knowledge Park, Bannerghatta Road, Bengaluru-560029, through its Director/ M.D./Chief Manager.                                                                                                                                               …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Prabhjot Pal Singh, Advocate.

For OP1                         :         Sh. Sumit Jain, Advocate.

For OP2                         :         Exparte.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant being an employee of Aditya Birla Money Limited vide employee No.006565, availed group insurance policy of the OPs having Member ID 4014862731. During continuation of the insurance policy, the complainant suffered from stone in his gallbladder and he remained admitted in R.G. Stone & Super Specialty Hospital from 21.02.2020 to22.02.2020 where his gallbladder was removed. The complainant stated that  the hospital lodged cashless claim with the OPs and the  OPs paid the entire payment directly to R.G. Stone & Super Specialty Hospital but the OPs illegally retained the amount of Rs.30,000/-. The complainant had to pay the said amount to the hospital from his own pocket under compelling circumstances. This act and conduct of the OPs in retaining the amount of Rs.30,000/- amounts to deficiency in service and unfair trade practice due to which the complainant suffered mental pain, agony, harassment etc. for which the OPs are liable to pay compensation. The complainant sent a legal notice dated 23.11.2021 to the OPs through Sh. Prabhjot Pal Singh, Advocate to which the OPs sent an evasive reply dated 02.12.2021. Hence this complaint, whereby the complainant has prayed for issuing direction to the OPs to make the payment of Rs.30,000/- along with compensation of Rs.1,00,000/- and litigation expenses of Rs.21,000/-.

2.                Upon notice, none appeared on behalf of OP2 despite service and as such, OP2 was proceeded against exparte vide order dated 02.06.2022.

3.                OP1 appeared and filed written statement and assailed the complaint by taking preliminary objections on the grounds of maintainability; the complainant has not come with clean hands; suppression of material facts; the complaint being mis-joinder and non-joiner of necessary parties; lack of cause of action etc. OP1 stated that the complainant approached it for group health insurance and the entire policy cover along with terms and conditions were explained to the complainant who after understanding the same, decided to take policy from OP1. OP1 issued and supplied health insurance policy and renewed the same subject to policy terms and conditions. The claim of the complainant was settled as per policy terms and conditions. The complainant applied for claim Firstly Cashless through the hospital and on receipt of the claim documents and after verification of the same, OP1 on recommendation of OP2 sanctioned Rs.50,000/- as cashes claim paid to the hospital. After discharge from the hospital, the complainant again applied for reimbursement but he failed to provide required documents. His claim was reviewed by the team of doctors of OP1 who found that patient Mr. Rajiv Krishna Nagpal’s claim was already settled in cashless vide cashless claim No.100311738. Patient Mr. Rajiv Nagpal was claimed for non medical expenses which are not payable as per policy terms and conditions. Hence, the claim was denied under policy Clause 2.0, “Now this policy witnesses that subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed here on the company undertakes that if during the period stated in the schedule or during the continuance of this policy by renewal any insured person shall contract any illness (herein defined) or sustain any injury (hare defined) and if such injury shall require any such insured person, upon the advice of a duly qualified Medical Practitioner(here defined) or a surgeon to incur Medical Expenses/surgery at any Hospital/day care centre (herein defined) in India as an inpatient, the company will pay to the insured person the amount of such expenses as good fall under different heads mentioned below, and as are reasonable and customarily, and medically necessarily incurred thereof by or on behalf of such insured person.”

                   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.

4.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 is the copy of his ID Card with Aditya Birla Capital, Ex. C2 is the copy of PPN Network-Declaration by Patient/Patient’s Attendant form, Ex. C3 is the copy of cashless request, Ex. C4 is the copy of bill of R.G. Stone & Super Specialty Hospital, Ex. C5 is the copy of discrepancy letter dated 22.01.2020 sent by hospital to OP2, Ex. C6 is the copy of detail of deduction, Ex. C7 is the copy of receipt dated 25.02.2020, Ex. C8 is the copy of legal notice dated 23.11.2021, Ex. C9 and Ex. C10 are the postal receipts, Ex. C11 is the copy of reply dated 02.12.2021 to legal notice dated 23.11.2021, Ex. C12 is the copy of Email  correspondence and closed the evidence.

5.                On the other hand, the counsel for OP1 tendered affidavit  Ex. RA of Ms. Punam Sharma, Manager of OP1  along with documents Ex. R1 is the copy of policy schedule, Ex. R2 is the copy of Certificate U/s.64 VB of Insurance Act, 1938, Ex. R3 is the copy of terms and conditions of New India Flexi Floater Group Mediclaim Policy 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 statement along with affidavit and documents produced on record by both the parties. We have also gone through written arguments submitted by the complainant.

7.                The complainant, a holder of New India Flexi Floater Group Mediclaim Policy Ex. R1  remained hospitalized from 21.02.2020 to 22.02.2020 at R.G. Stone & Super Specialty Hospital, Ludhiana . At the time of his admission, pre-authorization claim was submitted by the hospital vide cashless request form Ex. C3 for a sum of Rs.87,000/- and the payment was made to the hospital. The OPs processed and settled the cashless claim for Rs.45,000/- (Rs.50,000/- less TDS Rs.5000/-) on 13.03.2020 and the payment was made to the hospital directly.

8.                Now the complainant has raised his grievance regarding deduction of Rs.30,000/- by the OPs. The complainant has concealed all the material facts regarding approval of cashless claim by the OPs and just has made a reference only regarding deduction of Rs.30,000/-. The complainant has neither pleaded nor proved that how the amount of Rs.30,000/- was payable and which terms and conditions have been violated by the OPs by declaring it as non-payable. The pleadings of the complainant are also sketchy, vague and ambiguous. In this regard, reference can be made to 2022(2) Apex Court Judgments 624 (S.C.) in M/s. The New India Assurance Co. Ltd. & another Vs Shashikala J. Ayachi whereby the Hon’ble Supreme Court of India has held as under:-

“(i) Consumer Protection Act, 1986, S.2 (1) (g) – Deficiency in service – Sketchy pleadings supported by doubtful evidence- Consumer Forum not to allow the complaint.

(ii) Consumer Protection Act, 1986, S.2 (1) (g) – Insurance claim – Repudiation – Deficiency in service – Consumer Forum which has a limited jurisdiction to find out if there was any deficiency in service, could not have allowed complaint on the basis of sketchy pleadings supported by doubtful evidence – Since there was no categorical evidence of any deficiency in service on the part of Insurance Company, order of National Commission directing Insurance company to make payment under insurance policy set aside.”

Further the complainant has failed to discharge initial onus to prove the deficiency in service on the part of the OPs by any cogent and convincing evidence.  The Hon’ble Supreme Court of India in its judgment in SGS India Ltd. Vs Dolphin International Ltd. in Civil Appeal No.5759 of 2009 decided on 06.10.2021 (LL 2021 SC 544) by the Hon’ble Supreme Court of India while relying upon on its own judgment reported as Ravneet Singh Bagga v. KLM Royal Dutch Airlines & Anr. As well as Indigo Airlines v. Kalpana Rani Debbarma & Ors. (LL 2021 SC 544), has held as under:-

“19.  The onus of proof of deficiency in service is on the complainant in the complaints under the Consumer Protection Act, 1986. It is the complainant who had approached the Commission, therefore, without any proof of deficiency, the opposite party cannot be held responsible for deficiency in service.”

 

9.                As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.  

10.              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:12.08.2024.

Gobind Ram.