Date of decision : 17.4.2008<br /> Mohinder Pal Aggarwal son of Late Sh.Rajpal Aggarwal, resident of 290/05, Punjabi Bagh, Jalandhar Road, Kapurthala.<br /> Complainant.<br /> Versus<br /> 1. The Oriental INsurance Company Ltd. Bombay Life Bidg. , N39 Con circus, New Delhi, through its Divisional Manager.<br /> 2. Raksha TPA Pvt. Ltd. , 15/5, Mathura Road, Faridabad - 121 003.<br /> 3. The Oriental Insurance Co. Kapurthala branch, Opposite Dhian Singh Petrol Pump, Kapurthala<br /> Opposite parties.<br /> Complaint under the Consumer Protection Act.<br /> Quoram : Sh.A.K. Sharma President.<br /> Sh.Surinder Mittal, Member.<br /> Present : Sh.Anuj Anand counsel for the complainant.<br /> Sh.Ramesh Kumar sodhi counsel for opposite parties.<br /> JUDGMENT (SH.A.K. SHARMA PRESIDENT. )<br /> Present complaint under Section 12 of the Consumer Protection Act, 1986 as amended upto date has been filed by the complainant Mohinder Pal Aggarwal against opposite parties i.e. Oriental Insurance Company through its Divisional Manager New Delhi and other functionaries seeking direction against the opposite parties to settle his mediclaim or reimburse the premium amount paid to the opposite parties and also monetary compensation on account of deficiency in service.<br /> 2. Brief facts of the complaint are that complainant got mediclaim insurance policy from opposite party No.1 through opposite party No.2 being its third party administrator , as he is retired employee of Punjab National Bank and he got himself enrolled with opposite party No.1 under the PNB-mediclaim insurance Scheme for retired employees with premium of Rs.3375/-. Unfortunately he developed Cataract in his right eye for which he was operated upon on 16/11/2006 D.M.C. hospital, Ludhiana about which he informed to the opposite party No.2 telephonically and also through UPC letter dated 16/11/2006. He incurred medical expenses to the tune of Rs.11579/- on his eye operation and further intimated to opposite party No.2 alongwith requisite documents through registered post for his bonefide mediclaim. He did not receive any response from the opposite parties despite sending another registered letter dated 28/12/2006 alongwith sticker of the lens used in his eye as it is clear from the letter of opposite party No.2 dated 30/11/2006. Again opposite parties failed to settle his mediclaim despite his another request letter dated 3/3/07 through registered post. On 15/3/2007 he was stunned to receive letter from opposite party No.2 intimating that file of his claim No.556041275 has been closed giving false and flimsy ground. He never received any letter referred to in the letter dated 15/3/2007 and his enrolement number was also wrongly mentioned but the officials of the opposite party Insurance Company did not pay any heed towards his genuine and bonefide mediclaim thereby causing mental agony and physical harassment for which he is not only entitled to mediclaim insurance but also monetary compensation on account of deficiency in service.<br /> 3. Opposite parties appeared and controverted the allegations of the complainant and resisted his claim. Preliminary objection has been raised that complainant is estopped by his own act and conduct to file the present complaint. On merits this fact is not disputed that insurance claim pertaining to Cataract surgery was reported by the complainant and after scrutinizing the documents , the query was raised on 6.12.2006 for supply or original discharge summary and the IOL sticker/ sticker of the lens used in the eye operation but the same was not supplied despite sending so many reminders dated 23.1.2007, 7.2.2007 and finally on 8/3/2007 and his claimfile was closed ultimately due to non production of original discharge summary. Therefore, there is no question of any deficiency in service on the part of opposite parties so as to entitle the complainant to any mediclaim insurance amount or any monetary compensation.<br /> 4. In support of his version Mohinder Pal Aggarwal complainant has produced in evidence affidavit and documents Ex.C1 to C10<br /> 5. On the other hand opposite parties produced in evidence affidavit of Senior Divisional Manager Ex.OPA.<br /> 6. We have heard arguments of learned counsel for the parties and perused ocular as well as documentary evidence on the record. Learned counsel for complainant has vehemently urged before us that non-settlement of his genuine and bonefide mediclaim for his Cataract surgery amounting to Rs.11,579/- vide letter Ex.C10 dated 22/9/07 despite his repeated requests vide registered letters amounts to deficiency in service for which he is entitled to the reliefs claimed. Though on the other hand learned counsel for the opposite parties has counter argued that complainant himself is at fault in not producing original discharge summary despite repeated reminders so as to enable the Insurance Company to settle his claim.<br /> 7. We have considered the rival contentions of learned counsel for the parties. We find substance in the contentions of learned counsel for the complainant. These broad facts are not disputed by the opposite parties that complainant obtained medicalim insurance Scheme for retired employees vide Ex.C4 with the opposite parties Insurance Company and that complainant had also intimated about his Cataract surgery on 16/11/06. Complainant also sent registered letter on 28/12/06 alongwith sticker of the lens used in his eye as is evident from the letter Ex.C2 and further registered letters Ex.C1 and Ex.C3 dated 3/3/07 wherein complainant has complained about non receipt of his claim. Complainant has also stated in para 4 of the letter Ex.C1 dated 14/4/07 that photocopy of the discharge summary duly attested was sent to the Insurance Company alongwith his claim. The original was retained by him for follow-up with the concerned hospital/doctor and same is in his custody. We find no other reason for non settling of mediclaim of the complainant except one mentioned in Ex.C10 i.e. letter written by opposite party No.2 wherein demand of original discharge summary was made from the complainant so as to enable the Company to process his claim. Photocopy of the discharge summary Ex.C8 and Ex.C9 bill amounting to Rs.10950/- for cataract surgery has also been produced and also the same has been repeated by Satish Katyal Senior Divisional Manager in his affidavit Ex.OPA for insisting upon the complainant to produce original discharge summary vide various reminders. We cannot disbelieve this correspondence . Therefore, under the circumstances, we accept the complaint with condition that complainant shall submit photocopy of discharge summary duly attested by DMC hospital authorities and bills within a week from the date of passing of the order and opposite parties shall process and decide the claim regarding medical expenses incurred by him on his eye operation within one month from today The Forum cannot be impervious to the fact that inordinate delay was caused by the Insurance Company in settling the claim of the complainant amounting to deficiency in service and as such award monetary compensation of Rs.4000/- alongwith cost of litigation to the tune of Rs.1000/- within one month from the receipt of copy of this order .<br /> Let certified copies of judgment rendered be supplied to the parties without any unnecessary delay and threafter file be consigned to record room.<br /> <br /> Announced : ( Surinder Mittal ) ( A.K. Sharma )<br /> 17.4.2008 Member President.<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Mohinder Lal vs. Oriental Ins. Co.<br /> 17/4/08 Present : Counsel for the parties,<br /> Arguments heard. Vide separate detailed judgment of today, complaint allowed with cots. File be consigned to record room.<br /> <br /> Member President.