BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 170 of 2012
Date of Institution : 27.8.2012
Date of Decision : 23.8.2012
Sunil Kumar son of Sh.Krishan Kumar, c/o M/s Hans Raj Madan Lal, Cloth Merchants, Gandhi Chowk, Mandi Dabwlai, tehsil dabwali District Sirsa.
….Complainant.
Versus.
- The New India Assurance Company Ltd., Dabwali through its Branch Manager.
- E-Mediteck Solutions Ltd., SCO No.62, 2nd Floor, Sector 30 (Backside entry), Chandigarh.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI S.B.LOHIA ………………………..PRESIDENT.
SHRI RANBIR SINGH PANGHAL ……MEMBER.
Present: Sh.A.K.Gupta, Advocate for the complainant.
Sh.A.S.Kalra, Advocate for the opposite party no.1.
Opposite party no.2 exparte.
ORDER
In brief, the complainant was insured against Medi-claim insurance for himself and his family including his wife Smt.Ranju vide policy no. 353702/34/08/11/00000034 with opposite party for the period 2009-10. In May, 2009 Smt. Ranju suffered a serious injury which was diagnosed as A-Vascular Necrosis right hip and was got admitted in Sir Ganga Ram Hospital, New Delhi where she remained admitted from 18.5.2009 to 29.5.09 and underwent operation. Information was given to Opposite party and claim was lodged for reimbursement of medical bills amounting to Rs.274763, which were handed over to the Op no.1, who appointed Op no.2 as the TPA. The opposite parties started demanding unnecessary documents. The complainant sent the documents and it was also made clear that no FIR was lodged. The complainant approached Op several times, but no claim has been settled even despite issuance of legal notice. Hence, the present complaint. .
2. On notice, Opposite parties appeared and replied that claim of the complainant was treated as No claim and he was duly intimated about this vide letter dt. 26.10.2009. It is further replied that on receipt of intimation from the complainant, the matter was sent to Op no.2 alongwith medical bills etc. The claim was for Rs.274763/-, but the sum assured was Rs.1,25000/- and commutative bonus was 5%. Complainant was asked to co-ordinate with op no.2 and supply the required documents, but he failed to do so. Resultantly, his claim was treated as No claim. Ops also took the plea of limitation and denied the remaining allegations of complaint.
3. By way of evidence, complainant has produced his affidavit Ex.P1, copy of legal notice Ex.P2, postal receipt Ex.P3, discharge summary Ex.P4, letter Ex.P5, policy Ex.P6,acknowledgement Ex.P7 and Ex.P8, letters Ex.P9 to Ex.P14 and bill Ex.P15, whereas the respondents have tendered Ex.R1-affidavit of Sh.R.K.Indora, Divisional Manager, copies of various letters Ex.R2 to Ex.R15, copy of legal notice Ex.R16, reply to legal notice Ex.R17, postal receipts Ex.R18 & Ex.R19 and policy Ex.R20 & Ex.R21.
4. We have gone through the record of the case carefully and have heard learned counsel for both the parties.
5. In the plea of limitation taken by the Ops, there is no force because vide Ops letter dt. 31.8.2010 which is Ex.R5 of the Ops with reference to their earlier letter dt. 13.7.2010, they intimated the complainant regarding treating his claim as No claim. This letter was sent to the complainant through registered post and present complaint has been filed on 27.8.2012 which is in our view within the limitation. The second version of the Ops is that Op no.2 treated the claim as no Claim for want of documents required by op no.2. Through the letters Ex.P11 and Ex.P13, complainant duly informed the TPA ( Op no.2) regarding their demand of documents and furnished the requisite information well in time. As such, we are of the considered view that Ops wrongly closed the case of the complainant as No claim and they remained deficient in this respect.
6. As a result of our discussion, we accept the present complaint with the direction to the Ops to pay the medi-claim of the complainant subject to sum insured within a period of 45 days from today, otherwise complainant shall be entitled to interest @ 9% per annum from the date of filing the complaint i.e. 27.8.2012 till realization. Complainant is also hereby awarded compensation Rs.10,000/- and litigation expenses Rs.5000/-. A copy of this order be supplied to the parties free of cost. File be consigned to record room after due compliance.
Announced in open Forum. President,
Dated: 23.8.2016 Member. District Consumer Disputes
Redressal Forum, Sirsa.
