Punjab

Nawanshahr

CC/8/2015

Narinder kaur - Complainant(s)

Versus

New India Insurance - Opp.Party(s)

Amit Sharma

09 Jun 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

SHAHEED BHAGAT SINGH NAGAR

Consumer Complaint No.         :    8 of 15.01.2015

Date of Decision:                    :     09.06.2016

Narinder Kaur W/o Dharam Singh age 53 years R/o Dashmesh Nagar, Banga Road, Nawanshahr, District SBS Nagar.

                                                                             …Complainant

Versus

1.       New India Insurance Company Limited, DO No.120300, New India Centre, 2^nd Floor, 17-A, Cooperage Road, Mumbai, through its Director.

2.       New India Insurance Company Limited, Branch Nawanshahr, Near Raja Hospital, Chandigarh Road, Nawanshahr, through its Manager.

3.       LIC, 156 No. Branch, Mota Singh Nagar, Near Raja Hospital, Nawanshahr, District SBS Nagar, through its Branch Manager.

               …Opposite Parties

Complaint under the Provisions of Consumer Protection Act, 1986

QUORUM:

SMT.NEENA SANDHU, PRESIDENT

S.KANWALJEET SINGH, MEMBER

ARGUED BY:

For complainant                      :         Sh.Amit Sharma, Advocate,

For Ops No.1&2.                    :         Sh.S.S. Kundra, Advocate,

For OP No.3                                     :         Sh.D.B. Bhalla, Advocate

ORDER

SMT.NEENA SANDHU, PRESIDENT

1.       In brief, the case of the complainant is that she was working as employee/agent with the opposite party No.3 at Nawanshahr Branch. The OP No.3 has taken medical insurance, medical policy, as group insurance for their employees including the complainant from the OPs No.1&2 for the year 2010-11,renewed it for 2011-12 and further renewed it for the year 2012-13. The OP No.3 had been deducting the proportionate premium amount from her salary and had paid to the insurance company. In the year 2011, she was diagnosed as suffering from cancer.   She asked the OPs to bear the medical expenses for her treatment as the said disease is covered under the medical insurance policy and the OPs assured her that they will pay the medical bills for the treatment taken by her. She took the treatment from PGI and was got operated in the month of January 2013 and remained admitted in PGI for many days. She had also undergone chemotherapy treatment, electricity treatment, before and after final operation conducted in the month of January 2013. She had spent Rs.4,00,000/- on her treatment and was still under treatment. She, after her final operation in year 2013, handed over all the medical bills to the OPs for indemnification.  But the Ops have not paid a single rupee to her.  Due to this act of the O.Ps.she has suffered mental agony, physical harassment and financial loss. Hence, this complaint

2.       On being put to the notice, the learned counsel for the OPs No.1 & 2 has filed joint written version taking preliminary objections that complaint is abuse of process of law as previous complaint has already been dismissed for want of prosecution; that the complaint is not maintainable.  Complainant informed the answering OPs regarding the disease and she was asked to fill the claim form, the claim form filled in by the complainant and forwarded by LIC of India was duly processed and found that complainant was entitled for Rs.9,096/- against the claim of Rs.1,95,909/-. The complainant was informed accordingly. However, the complainant by filing representation had informed that she had received Rs.9,096/- and had protested that she had spent huge amount on her treatment. The documents submitted by the complainant were duly scrutinized and it was found that complainant was entitled only for the hospitalization and medication for, 30 days pre and 60 days post treatment only as per the policy and she was not entitled to any other claim. The claim was settled by Meddi Assist India TPA Private Limited dealing in the matter like the present case; that the complaint is bad  for non-joinder of necessary party as Meddi Assist India TPA Pvt Limited as necessary party; that the complainant is barred by her act and conduct to file the present complaint. On merits, it is admitted that complainant is club member agent as per the insurance policy entered into between the parties. Rest of the allegations made in the complaint have been denied and prayed that the complaint be dismissed with costs.

3.       The learned counsel for the OP No.3 has filed written version taking preliminary objections that; the complaint is hit by principles of res-judicata as earlier also such type of complaint was filed by the complainant and the same was dismissed on 2.1.2015; that complainant is estopped to file this complaint due to her act and conduct. On merits, it is stated that Narinder Kaur, Agency code No.1554-156 is working as an agent of LIC of India, Branch, office Nawanshahr and she is a member of the Group Medical Insurance Policy purchased from the OPs No.1 & 2 and premium has been deducted from her commission and paid to the OPs. No.1& 2. The Medi claim papers were received on 16.2.2013 from answering OP’s. branch and same was sent to Meddi Assist India TPA Pvt Ltd through registered post. On 15.7.2013, answering OP received the representation from the complainant, which was forwarded to Meddi Assist India TPA Pvt Ltd through registered post. As such, no negligence is attributable to the answering OP and is not to compensate the complainant. It had just submitted the claim papers of the complainant to the Meddi Assist India TPA Pvt Ltd, thereafter, all the correspondence has been done directly by the complainant with the Meddi Assist India TPA Pvt Ltd. Rest of the allegations made in the complaint have been denied and prayed that the complaint be dismissed.

4.       At the outset the learned counsel for the O.Ps. No.1 & 2 has vehemently argued that the complainant earlier had filed a complaint on 17.09.2014, which was dismissed for want of prosecution vide order dated 2.1.2015, by this Forum and thus the present complaint is not maintainable. In the case of Indian Machinery Company Vs. Ansal Housing and Construction limited, 2016 (II) CLT 1 Supreme Court, the Hon’ble Supreme Court has held that when the first complaint was dismissed in default or non prosecution then second complaint is  maintainable.  In view of the law laid down by the Hon’ble Apex Court, the present complaint is thus maintainable before this Forum.

5.       From the record, it is borne out that complainant was suffering from cancer.  The complainant in Para No.1 of the complaint has stated that she being employee/agent of OP No.3 was insured under group insurance scheme with Ops No.1 &2 for the first time in the year 2010-11 and was renewed for 2011-12 and 2012-13.  This fact has fairly been admitted by OP NO.1&2. From the perusal of terms and conditions of New India Flexi Floater Group Medi-claim Policy marked as ‘A’, it is evident that as per term No. 4.2 which reads as under:-

          30 days exclusion: Any illness other than those stated in clause 4.3 below, contracted by the insured person during first 30 days from the commencement date of the policy.  This exclusion will not apply if the policy is renewed with our company without any break.  The exclusion does not also apply to treatment for any injury.  Thus, this term No.4.2 is not applicable in her case because she has renewed her policy without any break.

6.       We have also gone through the diseases/aliments mentioned under term No.4.3.  Since, the complainant was suffering from cancer. Therefore, Clause No.4.3 is not applicable in the preset case.  In letter dated 18.02.2013 – Ex.OP3/3, it is evident that complainant was CM Club Member under Code No.1554-156 of B.O. Nawanshahr and from the letter dated 24.12.2012 annexed alongwith Ex.OP3/3, it is evident that various Club Members agent groups are having insurance cover of Rs.1,25,000/- under Chairman’s Club.  Thus, as per terms and conditions of the policy, the complainant was entitled to get Rs.1,25,000/- instead of Rs.4,00,000/- as prayed for,  but by not paying the said amount the Ops No.1&2 are deficient in providing services to complainant. As such OP No.1&2 are not only liable to pay the said insured amount and also liable to pay compensation on account of mental agony and physical harassment suffered by her alongwith litigation expenses.  However, the complaint against OP No.3 is liable to be dismissed because it had duly performed its duty and moreover the claim amount was to be paid by OP No.1&2.

7.       In view of the above discussion, we dismiss the complaint against OP No.3 and allow the same against OP No.1&2 and direct them in the following manner:-

          1.       To pay Rs.1,25,000/- to complainant as insurance amount.

          2.       To pay Rs.10,000/- to complainant as compensation.

          3.       To pay Rs.10,000/- to complainant as litigation expenses.    

The OP No.1&2 are further directed to comply with the aforesaid directions within a period of 30 days from the date of receipt of certified copy of this order.

8.       The certified copies of this order be supplied to the parties free of costs, as per rules and file be indexed and consigned to the Record Room.

Dated:  09.06.2016                           (NEENA SANDHU)

                                                          President

 

                                                          (KANWALJEET SINGH)

                                                          Member