Before the District Consumer Disputes Redressal Forum, Rohtak.

                                                                    Complaint No. : 15.

                                                                    Instituted on     : 09.01.2018.

                                                                   Decided on       : 10.12.2019.

Satyender Kumar son of Sh. Dharampal resident of House no.1487/7, Goyat Panna, Meham Distt. Rothak.

                                                                             ………..Complainant.

                             Vs.

New India Assurance Company Ltd., office at Jawahar Market, near Model town, Rohtak-Delhi Road, Rohtak, through its Divisional Manager.

                                                                    ……….Opposite party.

          COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.

BEFORE:  SH.NAGENDER SINGH KADIAN, PRESIDENT.

                   DR. RENU CHAUDHARY, MEMBER.

                   MS.TRIPTI PANNU, MEMBER.

Present:       Sh. Ashwani Phougat, Advocate for the complainant.

                   Sh. Deepak Bhardwaj, Advocate for the opposite party.

                                      ORDER

NAGENDER SINGH KADIAN, PRESIDENT:

1.                          Brief facts of the case are that the complainant had availed the Mediclaim policy no.353803341628-00000001 for the period from 18.11.2016 to 17.11.2017, member ID No.9016567045. It is averred that during the period of insurance, the complainant suffered from illness with a complaint of Nausea, Vomitting, Dec appetite and gen lethargy/myalgia and was treated at BLK Super specialty Hospital, Pusa Road, New Delhi for the period 25.02.2017 to 28.02.2017, 02.07.2017 to 06.07.2017 and 11.07.2017. He incurred an amount of Rs.250000/- on his treatment, medicines etc. and is still suffering from ailment and under treatment. That complainant lodged his claim for the said amount of Rs.250000/- and submitted all the documents as desired and required by the respondent alongwith treatment documents. That complainant contacted the respondent repeatedly by personally making emails and written representations to get his genuine claim but the respondent kept in abeyance and till date has not disbursed the claim amount. It is averred that the act of opposite party is illegal and amounts to deficiency in service. As such it is prayed that opposite party may kindly be directed to make the payment of claim amount of Rs.250000/- alongwith interest, compensation and litigation expenses to the complainant.  

2.                          On notice, opposite party appeared and filed its written reply submitting therein that it is denied that the complainant intimated to the respondent about the ailment and lodged his claim for the said amount of Rs.250000/- alongwith all required documents as desired and required by the respondent alongwith treatment documents. Rather there is delay in intimating to the answering respondent. Moreover, till date required documents are yet not provided to the answering respondent by the complainant. The Raksha TPA send several number of letters dated 19.05.2017, 05.06.2017, 20.06.2017, 10.07.2017, 10.08.2017, 11.09.2017, 13.10.2017, 18.12.2017, 19.12.2017 etc. for providing the documents for final decision of the claim file but the insured did not provide the relevant information and documents to the insurance company or to the TPA required for the claim, therefore the claim of the complainant is pre-mature. It is submitted that the insured is liable to provide relevant information and documents to the insurance company for settlement of the claim as per terms and conditions of the insurance policy. That there is no deficiency in service on the part of answering opposite party and dismissal of complaint has been sought.  

3.                          Both the parties led evidence in support of their case.

4.                          Ld. counsel for the complainant in his evidence has tendered his affidavit Ex.CW1/A, documents Ex.C1 to Ex.C81 and closed his evidence on dated 31.10.2018 and has also tendered documents Ex.C82 to Ex.C90 in additional evidence and closed his evidence on dated 04.06.2019. On the other hand, ld. counsel for the opposite party has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R12 and has closed his evidence on dated 09.01.2019.

5.                          We have heard ld. counsel for the parties and have gone through the material aspects of the case.

6.                          The main objection of the respondent insurance company is that the complainant had not provided the required documents to the respondent insurance company or Raksha TPA for settlement of the claim. Several letters had been written to the complainant i.e. vide letters dated 19.05.2017, 05.06.2017, 20.06.2017, 10.07.2017, 10.08.2017, 11.09.2017, 13.10.2017, 18.12.2017 & 19.12.2017 for sending the required documents and for decision of the claim of the complainant but the same were not provided by the complainant till date. As per respondent, the claim is still pre-mature.

7.                          We have perused the documents placed on record by both the parties. In the present complainant respondent has placed on record 11 documents in his evidence. Ex.RW1/A is affidavit  of Divisional Manager of New India Assurance Company. Ex.R1 is claim form, Ex.R2 to Ex.R11 are the copy of letters written to the complainant by the insurance company/TPA Raksha for submitting the required documents and clarifications and Ex.R12 is a family floater mediclaim policy. On the other hand, as per the complainant he had already deposited documents with the respondent insurance company and the claim has not been settled till date by the respondent. To prove this fact, he has placed on record document Ex.82 and Ex.C83 which itself shows that he had written letter dated 23.06.2017 and through this letter he had deposited all the required and relevant documents for settlement of the first claim of the complainant i.e. which arose for the period 25.02.2017 to 28.02.2017. Copy of letter is Ex.C83 an another letter was also written by the complainant on dated 08.11.2017 and through this letter he has submitted that he has not received any claim amount till date and has also not received any ‘No claim letter’ to know that whether the claim has been rejected or accepted by the respondent. Through this letter he also made a complaint that respondents are not picking up his phone calls. Ex.C84 to Ex.C87 are the documents which are required for the settlement of the claim of the complainant.  As per complainant, he wrote so many mails to the respondent company for settlement of the claim of the complainant. Copy of emails are placed on record as Ex.C86 to C89 but till date the claim has not been settled by the opposite party or the Raksha TPA. 

8.                          On the other hand, as per the respondents, they have written several letters for supplying the relevant and required documents to the complainant for settlement of the claim. Perusal of the Ex.R2 to Ex.R7 shows that these letters have been written to the complainant by the TPA on different dates and demanding some documents and clarifications from the complainant regarding the treatment for the period 25.02.2017 to 28.02.2017. Ex.R9 & Ex.R10 were written by the TPA to the complainant for submitting some documents for the period 02.07.2017 to 06.07.2017 and lastly a letter dated 19.12.2017 has been written by the TPA to the complainant for the period 11.09.2017. We are very much surprised that respondent has not placed on record any postal or courier receipt on file to prove that these letters i.e. Ex.R2 to Ex.R11 have been dispatched to the complainant through registered post or courier to prove this fact. The TPA can mail these letters to the complainant because the email id of the complainant was very much in their knowledge and record but they did not take any action. Moreover, the perusal of these letters itself are suspicious as the word “Confidential” is mentioned in these letters. In our opinion, these were public letters, then why the same are confidential. How a letter can be confidential if the same is dispatched to the complainant or to the insurance company by the Raksha TPA. Meaning thereby the TPA never posted any letter or demanded any document from the complainant through these letters. It is also observed that insurance company is taking premium from the customers and handing over the rights of a customer/complainant to a third party i.e. Raksha TPA for settlement of claim. It is the duty of the insurance company to monitor the working of TPA or their consumers for settlement of the claim but in the present complaint, insurance company has not taken any initiative that they ever wrote any letter to the TPA or demanded any documents from the complainant or not intervened, which shows that there is great deficiency in service on the part of opposite party. As such, opposite party is liable to pay the claim amount to the complainant.

9.                          As per the documents placed on record by the complainant, he claimed an amount of Rs.48753/- for the treatment from the respondent for the period 25.02.2017 to 28.02.2017. Thereafter the complainant again admitted and was hospitalized on dated 02.07.2017 to 06.07.2017 and for further treatment he claimed an amount of Rs.105112/- on account of treatment expenditure and lastly he was admitted on 11.07.2017 and he claimed an amount of Rs.33446/- for the alleged treatment expenditure. The claim amount of Rs.48753/- has been mentioned in Ex.R2 for the period 25.02.2017 to 28.02.2017, claim amount Rs.105112/- has been mentioned in Ex.R9 for the period 02.07.2017 to 06.07.2017 and claim amount of Rs.33446/- has been mentioned in Ex.R11 for the period 11.07.2017. We have perused all the documents. The complainant has demanded a sum of Rs.48753/- but perusal of the document/bills shows that complainant had paid an amount of Rs.44300/- for the period 25.02.2017 to 28.02.2017 and as such he is entitled for Rs.44300/- against the demand of Rs.48753/-. He is also entitled for Rs.105112/- and Rs.33446/-.

10.                        In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite party to pay the amount of Rs.44300/- + Rs.105112/-+ Rs.33446/- i.e. total Rs.182858/-(Rupees one lac eighty two thousand eight hundred fifty eight only) alongwith interest @9% p.a. from the date of filing the present complaint i.e. 09.01.2018 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.

11.                       Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.

Announced in open court:

10.12.2019.

                                                         ................................................

                                                          Nagender Singh Kadian, President

                                                                        ………………………………..

                                                                        Renu Chaudhary, Member.

                                                                        …………………………………

                                                          Tripti Pannu, Member.