Punjab

Sangrur

CC/60/2017

Umesh Kumar - Complainant(s)

Versus

Oriental Bank of Commerce - Opp.Party(s)

Sh.G.P.Sharma

02 Jun 2017

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    60

                                                Instituted on:      13.02.2017

                                                Decided on:       02.06.2017

 

Umesh Kumar son of Sh. Nohar Chand, resident of H.No.24, Royal Estate, Bhawanigarh, Tehsil Bhawanigarh, District Sangrur.

                                                        …Complainant

                                Versus

1.             Oriental Bank of Commerce, Branch Bhawanigarh, Tehsil Bhawanigarh, District Sangrur through its Branch Manager.

2.             Oriental Insurance Company Limited, Branch Office: Sai Market, Lower Mall, Patiala through its Branch Manager.

3.             Oriental Insurance Company Limited, Registered and Head Office: A-25/27, Asaf Ali Road, New Delhi through its Managing Director.

                                                        ..Opposite parties

For the complainant    :       Shri G.P.Sharma, Adv.

For Opp.party No.1    :       Shri Ramandeep.

For Opp.Party No.2&3:       Shri Bhushan Garg, Adv.

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Umesh Kumar, 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 is maintaining a bank account bearing number 04522010011540 with OP number 1  and on the asking of the OP number 1 the complainant purchased a mediclaim policy bearing number 233500/48/2015/1896 for the period from 18.11.2014 to 17.11.2015 for himself and his family members by paying the requisite premium of Rs.6830/- and thereafter the said policy was got renewed in November, 2015. 

 

2.             The case of the complainant is that on 20.7.2016 son of the complainant namely Mohit Goyal suffered from infection in throat and as such took treatment from Appolo Hospital, Bangalore, Mazumdar Shah Medical Centre, Bangalore, Vimalaya Hospital Bangalore, as he was studying there at Bangalore during that period.  Thereafter the complainant lodged the claim for reimbursement, but the Ops did not settle the claim despite serving of legal notice dated 7.1.2017. 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 the insurance claim of Rs.5,00,000/-  along with interest @ 18% per annum from the date of filing of the claim till realisation and further claimed compensation and litigation expenses.

 

3.             In reply filed by Op number 1, legal objections are taken up on the grounds that the complaint is not maintainable and that the complainant has got no cause of action to file the present complaint. On merits, it is admitted that the complainant is having a saving bank account and as such purchased the insurance policy in question. It is admitted that the complainant filed an application with the OP number 1 which was forwarded to Medi Assist India TPA Pvt. Ltd vide letter number CN/0452/Medi Claim/2016-17 dated 4.8.2016 for settlement and it is further averred that the complainant is not entitled to get any claim from OP number 1.  The other allegations levelled in the complaint have been denied.

 

4.             In reply of the complaint filed by OP number 2 and 3, legal objections have been taken up on the grounds that the complainant has not come to the Forum with clean hands, that the complainant has filed a false, baseless complaint to his knowledge and that the present complaint is bad for non joinder of the necessary party.  On merits, it is admitted that the complainant obtained the mediclaim insurance policy in question for the period from 18.11.2014 to 17.11.2015 for Rs.5,00,000/- subject to the terms and conditions of the policy. It is stated that the company undertakes through this policy, that if during the period stated in the schedule any person shall contract or suffer from any diseases/illness/ailment or sustain any bodily injury through accident and if such disease or bodily injury shall require any such insured person upon the advice of a duly qualified physician/medical specialist/medical practitioner to incur a hospitalisation expenses for medical/surgical treatment at any nursing home and further stated as per the policy in question, the expenses on hospitalisation are admissible only if hospitalisation is for a minimum period of 24 hours, whereas in the present case, Mohit Goyal was admitted on 26.7.2016 at 0.44 and discharged on 27.7.2016 at 11:12.  As such, it is stated that the complainant is not entitled to get any claim. Lastly, the Ops number 2 and 3 has prayed for dismissal of the complaint with special costs.

 

5.             The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-51 copies of documents and closed evidence. On the other hand, the learned counsel for the OP number 1 has produced Ex.OP-1/1 affidavit and Ex.OP1/2 to Ex.OP1/4 copies of documents and closed evidence. The leaned counsel for Ops number 2 and 3 has produced Ex.OP2&3/1 to Ex.OP2&3/7 copies of documents and affidavit and closed evidence. 

 

6.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits part acceptance, for these reasons.

 

7.             It is an admitted fact between the parties that the complainant got mediclaim insurance policy in question for the period from 18.11.2014 to 17.11.2015 from OPs number 2 and 3 and the same was further got renewed in the year November 2015 after paying the requisite premium, as is evident from the copy of insurance policy document Ex.OP2&3/1 on record. It is also not in dispute that son of the complainant Shri Mohit Goyal suffered some problem from fever and took treatment at Bangalore and thereafter lodged the claim with the Ops, but the Ops did not settle the claim of the complainant.  It is not in dispute that the complainant had already lodged the claim with the Ops.   A bare perusal of the complaint shows that the complainant has claimed an amount of Rs.5,00,000/- as claim amount from the Ops under the policy, but the complainant has not produced any such evidence to show incurring an expenditure of Rs.5,00,000/- as the total insured value is Rs.5,00,000/- under the policy.  The learned counsel for the Ops number 2 and 3 has contended vehemently that during the pendency of the present complaint, they received an email from TPA that the claim of Rs.32808/- has been passed and demanded bank account details of the complainant for transfer of the amount.    There is no explanation from the side of the Ops that why they did not pass the claim of the complainant earlier and only passed during the pendency of the present complaint.  In the circumstances of the case, we find it to be a fit case, where a direction be given to the Ops number 2 and 3 to pay to the complainant the claim amount of Rs.32808/-.

 

8.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

9.             Accordingly, in view of our above discussion, we allow the complaint and direct the OP number 2 and 3 to pay to the complainant an amount of Rs.32,808/- alo ng with interest @ 9% per annum from the date of filing of the present complaint i.e. 13.02.2017 till realisation.  We further order the OP number 2 and 3 to pay to the complainant an amount of Rs.10,000/- in lieu of consolidated amount of compensation and 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 issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        June 2, 2017.

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member