Punjab

Sangrur

CC/646/2014

Ramesh Dewan - Complainant(s)

Versus

NIC LTD. - Opp.Party(s)

Sh. Salinder Mohan Goyal

01 Jun 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                               

 

                                                Complaint No.    646

                                                Instituted on:      08.12.2014

                                                Decided on:       01.06.2015

 

Ramesh Dewan son of Late Shri Basheshwar Nath Dewan, Dewana Street, Malerkotla.

                                                        ..Complainant

                                        Versus

1.             National Insurance Company Limited through its Branch Manager, Thandi Sarak, The Mall, Malerkotla.

2.             Vipul Medcorp TPA Pvt. Ltd. through its Branch Manager, SCI 98, FF, Industrial Area, Phase II, Chandigarh.

                                                        ..Opposite parties

 

For the complainant    :       Shri S.M.Goyal, Adv.

For OP No.1              :       Shri Sumir Fatta, Adv.

For OP No.2              :       Exparte.

 

 

 

Quorum:    Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Ramesh Dewan,  complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant obtained one medi claim insurance policy for himself, his wife and his son namely Vishal Dewan from the OPs.  The case of the complainant is that Vishal Dewan got injury on his arm and was got admitted in Grewal Hospital, Malerkotla on 11.12.2012 and had undergone surgery on 12.12.2012 and was discharged on 13.12.2012 and spent an amount of Rs.15,000/- on the treatment.  It is further stated that thereafter the complainant submitted the claim form along with all documents including prescription slips and bills to OP number 1, who assured that the payment would be made within 15/20 days, but no claim was paid.  It is further stated that the complainant sent a legal notice dated 24.6.2014 to the Ops and requested to pay the claim amount and in reply to that notice, the OPs demanded copy of policy, which was duly supplied.  It is stated further that due to non payment of the claim amount, the complainant has suffered a lot of harassment in the hands of the OPs. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant an amount of Rs.13,531/- along with interest @24% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by OP number 1, legal objections are taken up on the grounds that the complaint is not maintainable, that the complainant has no cause of action to file the present complaint and that the complainant has not come to the Forum with clean hands.  On merits, it is stated that the complainant has submitted the claim documents after the expiry of 180 days contrary to the policy conditions, whereas the claim documents are to be submitted within seven days from the date of discharge.  It is further stated that the complainant has failed to provide documents i.e. circumstances of injury at the time of admission by treating doctor, alcoholic status of the patient at the time of injury by the treating doctor, final hospital bill, prescription and numbered receipt against payment of Rs.800/- made to the hospital, but the same were not supplied despite issuance of letters dated 8.8.2013, 5.9.2013, 23.9.2013, 16.10.2013 and 20.10.2013 by the OP number 2 to the complainant, as such the claim of the complainant was repudiated on 20.12.2013.   Any deficiency in service on the part of the Ops has been denied.

 

3.                   Record shows that OP number 2 was proceeded exparte on 19.01.2015.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-2 copies of policy, Ex.C-3 copy of legal notice dated 24.6.2014, Ex.C-4 to Ex.C-5 copies of postal receipts, Ex.C-6 copy of letter dated 30.6.2014, Ex.C-7 coy of reply dated 21.7.2014, Ex.C-8 copy of postal receipt, Ex.C-9 copy of medical certificate, Ex.C-10 copy of receipt of Modi Hospital, Malerkotla, Ex.C-11 to Ex.C-13 copies of prescription slips, Ex.C-14 to Ex.C-15 copies of lab reports, Ex.C-16 to Ex.C-19 copies of medical bills, Ex.C-20 affidavit and closed evidence. On the other hand, the learned counsel for OP number 1 has produced Ex.OP1/1 copy of claim intimation, Ex.OP1/2 copy of claim processing module, Ex.OP1/3 to Ex.OP1/7 copies of letters, Ex.OP1/8 copy of claim form and Ex.OP1/9 affidavit and closed evidence.  

 

5.             We have very carefully perused the pleadings of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

6.             It is an admitted fact between the parties that the complainant, his wife Smt. Kamlesh Devi and Shri Vishal Dewan are insured under mediclaim policy for the period from 26.6.2013 to 25.6.2014 vide cover note Ex.C-2.             

 

7.             It is further case of the complainant that he lodged the claim with the Ops for reimbursement of an amount of Rs.13,531/- spent by him on the treatment of his son Vishal Dewan. Ex.C-3 is the copy of legal notice served upon the OPs for payment of the claim amount and Ex.C-4 and Ex.C-5 are the copies of postal receipts.   Ex.C-10 is the receipt of Rs.1000/- made by the complainant to Modi Hospital, Malerkotla  and Ex.C-12 is the receipt of Rs.9000/- issued by Dr. G.S.Grewal, Grewal Hospital and Nursing Home, Malerkotla and Ex.C-13 to Ex.C-19 are the copies of receipts and medicine bills.   Ex.C-20 is the affidavit of the complainant in support of his contention.   On the other hand, the case of the OPs is that the complainant submitted his claim after the delay of 180 days and further did not submit the documents to the Ops despite demanding the same from the complainant vide letters Ex.OP1/2, Ex.OP1/3, Ex.OP1/4, Ex.OP1/5, Ex.OP1/6 and Ex.OP1/7, whereby the OPs demanded numbered receipts against the payment made by the complainant to the doctor.  But, we are unable to accept such a contention of the Ops that to ask the complainant to submit the numbered receipts against the payment made by the complainant to the doctors.  It is obvious that the receipts are being issued by the doctor and the same have not been prepared by the complainant, as such the receipts issued by the doctors have been submitted by the complainant to the OPs.  We have very carefully perused the whole case file and found that the complainant has sought the genuine claim of Rs.13,531/-, the receipts and bills of which have already been submitted to the Ops and also have been produced on the complaint file. We further find that the Ops are not justified in repudiating the rightful claim of the complainant. 

 

8.             Further the Ops have not produced on record any terms and conditions or the policy governing the complainant to submit the intimation regarding accident within seven days, as such, we are unable to accept such a contention of the OPs on this score also. Assuming that the complainant had submitted the intimation about accident after 180 days, then it is open for the OPs to make an enquiry about the accident of Vishal Dewan and further to enquire the matter from the doctor concerned, who treated Shri Vishal Dewan. But, nothing like such has been done by the OPs and have out rightly rejected the claim of the complainant.

 

9.             In view of our above discussion, we find it to be a case of deficiency in service on the part of the OPs. As such, we allow the complaint and direct OPs to pay to the complainant an amount of Rs.13,531/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 8.12.2014 till realisation.  Further Ops are directed to pay to the complainant an amount of Rs.2000/- on account of litigation expenses.

 

10.            This order of ours be complied with within a period of thirty days of its communication. A copy of this order be supplied to the parties free of cost. File be consigned to records.

                Pronounced.

                June 1, 2015.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                                (K.C.Sharma)

                                                                    Member

 

                                                          

                                                                (Sarita Garg)

                                                                   Member