Haryana

Kurukshetra

123/2017

Narender Kumar - Complainant(s)

Versus

OIC - Opp.Party(s)

Kanwar Ji Sharma

20 Sep 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

                                                     Complaint Case No.123 of 2017.

                                                     Date of institution: 16.06.2017.

                                                     Date of decision:20.09.2018.

Narender Kumar Aggarwal son of Radha Krishan Aggarwal, resident of Mohalla Majri, House No.296/2, near Thakur Dwara Mandir, Shahabad (M), District Kurukshetra.

                                                                        …Complainant.

                        Versus

1. The Oriental Insurance Company Ltd., Saberwal Market, Railway Road, Kurukshetra.
2. M/s. Medi Assist India Pvt. Ltd., Town-D, 4^th Floor IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore-500029.

….Respondents.

BEFORE     Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Sunil Mohan Tirkha, Member.

Present:     Sh. Kanwarji Sharma, Advocate, for the complainant.   

                Sh. R.K.Singhal, Advocate for the OPs.

               

ORDER

                This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Narender Kumar against Oriental Insurance Company and another, the opposite parties.

2.            Brief facts of the present complaint are that the complainant got insured with the Ops under PNB Oriental Royal Medi-claim policy bearing No.261303/48/2016/1683 and he deposited the premium of Rs.6960/- and all the family members of the complainant were covered under the said policy.  It is alleged that the wife of complainant namely Poonam Aggarwal had got operated of his eyesight two times on 12.02.2016 for the one eye and on 05.03.2016 for the second eye and the complainant spent Rs.45,000/- for first operation and Rs.48,000/- at the time of second operation.  It is further alleged that the complainant lodged the claim with the Ops and submitted all the necessary documents but the Ops did not settle the claim of complainant.  So, it is a clear cut case of deficiency in service on the part of Ops and prayed for acceptance of complaint with the direction to Ops to pay Rs.93,000/- alongwith interest @ 18% p.a. or any other relief which this Forum may deems fit.     

3.            Upon notice, the OPs appeared before this Forum.  Op No.1 contested the complaint by filing reply raising preliminary objections with regard to locus-standi; maintainability; cause of action; jurisdiction; that the claim of complainant had already been approved by the competent authority and as such, the present complaint is not maintainable and is liable to be dismissed; that the complainant has concealed the true and material facts from this Forum.  The true facts are that the complainant was insured with the answering Op under PNB Royal Medi-claim Policy and the intimation regarding the treatment of wife of complainant was received by the answering Op and thereafter, the necessary documents were submitted by the complainant and after perusal of the documents and bills, the claim was processed and approved as per terms and conditions of the policy of the insurance.  The answering Op is ready to pay the approved claim, subject to completion of usual formalities.  There is no deficiency in service on the part of Op.  On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.

4.             Ld. Counsel for the Ops made statement on 29.11.2017 that he does not want to file separate reply on behalf of Op No.2 and the reply filed by the Op No.1 may also be read on behalf of Op No.2.

5.             To prove his case, ld. Counsel for the complainant tendered into evidence affidavit (Ex.CW1/A), copy of receipt (Ex/C1), copy of risk details (Ex/C2), copy of policy schedule (Ex.C3), copies of letters (Ex.C4, Ex.C5), copy of cheque (Ex/C6), copy of retail invoice (Ex.C7), copy of discharge ticket (Ex.C8), copy of letter dt. 16.07.2016 (Ex.C9), copy of certificate issued by Kapil Eye Hospital (Ex.C10), copy of discharge ticket (Ex.C11), copy of treatment record (Ex.C12 to Ex.C14), copy of policy (Ex.C15) and copy of bills (Ex.C16 to Ex.C19) and thereafter, closed the evidence on behalf of complainant.

6.             On the other hand, ld. Counsel for the Ops tendered into evidence affidavit (Ex.RW1/A), copy of policy (Ex.R1) and copy of terms and conditions of policy (Ex.R2) and thereafter, closed the evidence on behalf of Ops.

7.             We have heard the ld. Counsel for both the parties and perused the record carefully.

8.             From the perusal of letter dt. 11.10.2017, Ex.R2, it is crystal clear that the Ops have approved and transferred the amount of Rs.49,577/- in the account of insured on 30.08.2017.  The grievance of the complainant is that the complainant is entitled for the amount of Rs.93,000/, whereas the Ops have settled the claim to the tune of Rs.49,577/-.  So, on perusal of record and appraisal of rival contentions of both the parties, we are of the considered view that the complainant is entitled for the balance amount of Rs.43,423/- (i.e. Rs.93,000/- less Rs.49,577/-) from the Ops.  Hence, the Ops have adopted the act of unfair trade practice and are deficient on their part while rendering services to the complainant.

9.             Thus, as a sequel of above discussion, we allow the complaint and direct the Ops to pay the balance amount of Rs.43,423/- to the complainant and further to pay Rs.10,000/- as lump sum compensation on account of harassment, mental agony including the cost of litigation.  Let the order be complied with within 30 days, failing which, the complainant shall be entitled interest @ 9% p.a. from the date of order till its realization.  A copy of said order be supplied to the parties free of cost.  File be consigned to record-room after due compliance.      

Announced in open court:

Dt.:20.09.2018.  

                                                                        (Neelam Kashyap)

                                                                        President.

 

 

(Sunil Mohan Tirkha),           (Neelam)       

Member                             Member.