BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 132 of 2017
Date of Institution : 8.6.2017
Date of Decision : 25.1.2018
Vijay Singh Verma son of Shri Dev Dutt, resident of Bhagat Singh Park Street, Near Shiv Chowk, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
- The Oriental Insurance Company Private Limited, through its Branch Manager, Opposite Janta Bhawan Sirsa, District Sirsa.
- Medi Assist India TPA Private Limited, 8 ‘B’ Tej Building, 2nd Floor, Bahadurshah Zafar Marg, Next to Times of India, Delhi-110002 through its Incharge.
- Punjab National Bank, Circular Road, Sirsa, through its Branch Manager.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI R.L. AHUJA……………….. PRESIDENT. SHRI MOHINDER PAUL RATHEE……MEMBER.
Present: Sh. Kapil Sharma, Advocate for complainant.
Sh. JBL Garg, Advocate for opposite party no.1.
Sh. S.L. Sachdeva, Advocate for opposite party no.3.
Opposite party no.2 exparte.
ORDER
In brief, the case of complainant is that complainant purchased a mediclaim policy called PNB-Oriental Royal Mediclaim Policy, through its Agent/Broker Punjab National Bank, Circular Road, Sirsa vide insurance policy no.261500/48/2016/930 for the period 14.1.2016 to 13.1.2017 issued by op no.1 covering the risk of Rs.4,00,000/- for the entire family members of the complainant, which includes Alka verma-wife and Akshay Verma-son. It is further averred that Akshay Verma met with an road side accident by falling from the Bike on 10.6.2016 and sustained knee injury (ACL Break)LT. After initial treatment at Sirsa, he was treated by Dr. Rajiv Aggarwal, Surya Hospital, Hisar. X-ray and MRI revealed major knee injury (ACL Break) LT and doctors advised for operation. Then he was shifter to Chawla Nursing Home, Hisar for surgery on 16.7.2016 and was discharged on 19.7.2016. That complainant lodged a claim to the ops no.1 and 2 for reimbursement of treatment charges and bills to the tune of Rs.66,996/- on 2.9.2016 with claim ID No. 13194188 and submitted all the required documents as per the satisfaction of the ops no.1 and 2. The complainant approached and requested to pay the above said amount but all in vain and the officials of ops no.1 and 2 postponed the matter with one pretext or the other. It is further averred that the claim of the complainant was repudiated on 7.2.2017 by Medi Assist TPA India Private Limited-op no.2 on the ground that Akshay Verma/patient is not a bonafide student (not doing any full time degree) and he is preparing for SSC(short service commission) competitive Examination since 2015, so not eligible for coverage under mediclaim as a dependent. Under Policy 1.1 clause male child upto the age of 26 years if he is a bonafide regular student and fully dependent on proper is only covered, hence this claim is denied. The above said repudiation letter is wrong and incorrect, against law and facts, against the provisions and clauses of the insurance policy and the same is not binding upon the complainant and liable to be set aside and quashed and the ops are liable to pay the above said amount to the complainant along with interest till its payment and incidental charges. That Akshay Verma is the regular student of Guidance Academy Sirsa since 2015 and was/is dependent upon his father. All the documents were sent to the op no.1 along with the claim but all in vain and the op no.1 did not care about the same malafidely. That the act and conduct of the ops amounts to deficiency in service as well as unfair trade practice due to which the complainant is suffering serious recurring financial losses, harassment and mental agony. Hence, this complaint
2. On notice, opposite parties appeared. Opposite party no.1 filed written statement taking certain preliminary objections regarding maintainability, cause of action, suppression of material facts, estoppal, jurisdiction and that the liability of the answering op to indemnify the insured is subject to certain terms and conditions as laid down in the insurance policy and moreover, from the bare reading of the complaint, no consumer dispute is made out between the parties and that there was/is no deficiency in service on the part of the answering op. On merits, it is submitted that the claim lodged by the complainant was entrusted by the answering op no.1 to op no.2, which is authorized agency for settlement of such claim. The said claim lodged by complainant was minutely scrutinized and inquired into by op no.2. It is further submitted that the claim lodged by complainant has been repudiated by op no.2 in a legal and lawful manner and also within the scope of provisions/ terms and conditions of the insurance policy. As per terms and conditions and scope of the insured policy purchased by the complainant, the definition of family is (a) the proposer i.e. PNB Account holder or employee (b) his /her spouse and (c) two dependent children (i.e. legitimate or legally adopted children) aged 3 completed months onwards. The female child until she is married, immediately consequent upon her marriage, she shall be ceased to be covered under the policy and no claim shall be payable; and male child up to the age of 26 years if he is a bonafide regular student and fully dependent on proposer i.e. the PNB account holder. In this case, son of the complainant namely Akshay Verma was not a bonafide student and not doing a full time degree, so he was/is not eligible for coverage under the mediclaim as a dependent upon the complainant. In this manner, claim complainant has been repudiated by the op no.2 in a legal and lawful manner. The repudiation letter is perfectly legal and valid and the same has been issued as per terms and conditions and scope of the insurance policy and the same is not liable to be set-aside. Remaining contents of complaint are also denied.
3. Opposite party no.2 did not appear despite issuance of notice through registered cover and was proceeded against exparte.
4. Opposite party no.3 in its separate reply raised preliminary objections that complainant has failed to serve prior notice to the answering op before filing the present complaint and also regarding estoppal, maintainability, cause of action, suppression of material facts, jurisdiction etc. On merits, the contents of the complaint have been denied in toto by submitting that same do not relate to the answering op and that there has been no deficiency in service on the part of answering op towards the complainant.
5. The complainant produced his affidavit Ex.C1, copies of mediclaim policy documents Ex.C2 to Ex.C5, copy of repudiation letter Ex.C6, copies of applications Ex.C7, Ex.C8, copy of receipts Ex.C9, Ex.C10, copy of claim form Ex.C11, copy of application Ex.C12, medical bills Ex.C13 to Ex.C25, copies of medical record Ex.C26 to Ex.C28, copy of identity card of Akshay Verma issued by Guidance Academy Ex.C29 and copy of aadhar card of complainant Ex.C30. On the other hand, op no.1 produced affidavit of Sh. Sushil Kumar, Senior Manager as Ex.R1, copy of mediclaim policy schedule Ex.R2 and copy of mediclaim insurance policy Ex.R3. Ld. counsel for op no.3 suffered a statement that written statement filed on behalf of op no.3 be read as evidence on behalf of op no.3.
6. We have heard learned counsel for the parties and have perused the case file carefully.
7. The perusal of the evidence of the parties reveals that it is undisputed fact between the parties that complainant had purchased a medi claim policy called PNB- Oriental Royal Mediclaim policy bearing No.261500/48/2016/930 for the period 14.1.2016 to 13.1.2017 issued by op no.1 covering the risk of Rs.4,00,000/-. It is further admitted case of the parties that son of the complainant namely Akshay Verma met with an accident by falling from the bike on 10.6.2016 and he sustained injuries on his knee and he was treated by Dr. Rajiv Aggarwal of Surya Hospital, Hisar and then was operated in Chawla Nursing Home, Hisar on 16.7.2016 and was discharged on 19.7.2016. The complainant lodged a claim to the tune of Rs.66,996/- on 2.9.2016 with ID No.13194188 but however same was repudiated by the op no.2 on 7.2.2017 on the ground that Akshay Verma patient is not a bonafide student (not doing any full time degree) and he is preparing for SSC (short service commission) competitive examination since 2015, so not eligible for coverage under mediclaim as a dependent. Though during the course of arguments, learned counsel for ops has strongly contended that son of the complainant namely Akshay Verma was aged of 26 years but he is not a bonafide regular student and fully dependent on proposer is only covered in order to cover his claim under clause 1.1 of the policy. The complainant in his affidavit Ex.C1 has specifically deposed that Akshay Verma is a regular student of Guidance Academy Sirsa since 2015 and was/is dependent upon his father and he sent all the documents to op no.1 with the claim in this regard. The perusal of the copy of the policy Ex.C4 reveals that this policy was obtained by complainant for himself and his family which covers complainant himself, Alka Verma his spouse unemployed and Akshay Verma dependent child. It is no where mentioned in the policy that child should be a bonafide regular student. However, it is proved fact on record that Akshay Verma son of complainant is aged of 26 years and was fully dependent upon his father and further he is a student of Guidance Academy, Sirsa, so from the evidence of complainant, the case of the complainant stands proved and it appears that ops have arbitrarily and illegally repudiated the claim of the complainant.
8. In view of the above, we allow the present complaint and direct the opposite parties to settle and pay the claim amount of Rs.66,996/- to the complainant within a period of one month from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @9% per annum from the date of order till actual payment. We also direct the ops to further pay a sum of Rs.5000/- as composite compensation and litigation expenses to the complainant. All the ops are jointly and severally liable to comply with this order. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:25.01.2018. Member District Consumer Disputes
Redressal Forum, Sirsa.
