Kulbhushan Singla filed a consumer case on 30 Mar 2015 against Oriental Ins.Co.Ltd. in the Ludhiana Consumer Court. The case no is CC/14/692 and the judgment uploaded on 17 Apr 2015.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.
C.C.No.692 of 01.10.2014
Date of Decision: 30.03.2015
1.Kulbhushan Singla son of Sh.Kuldeep Singla;
2.Kuldeep Singla son of Lachhman Dass;
Both r/o of 270-E, Shaheed Bhagat Singh Nagar, Pakhowal Road, Ludhiana.
… Complainants
Versus
Oriental Insurance Company Limited, Cbo-2, Ludhiana, Near Clock Tower, G.T.Road, Ludhiana, Punjab(through authorized Manager/representative.).
… Opposite Party
Complaint under section 12 of the Consumer Protection Act,1986
Quorum Sh. R.L.Ahuja, President.
Sh.Sat Paul Garg, Member.
Ms.Babita, Member.
Present Sh.C.S.Chopra, Adv. for complainants.
Sh.B.S.Rampal, Adv. for OP.
ORDER
SAT PAUL GARG, MEMBER.
1. Present complaint u/s 12 of the Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Kulbushan Singla and Kuldeep Singla(hereinafter in short to be referred to as ‘complainants’) against Oriental Insurance Company Limited, CBO-2, Ludhiana, Near Clock Tower, G.T.Road, Ludhiana, Punjab(through authorized Manager/representative)(herein-after in short to be referred to as ‘OP’)- directing them to pay the claim amount of Rs.28,321/- alongwith Rs.1 lakh as compensation and Rs.10,000/- as litigation fee besides Rs.2500/- as miscellaneous expenses and Rs.8400/- as 9% interest p.a as per the order of this District Forum and Rs.10,000/- as penalty as per Section 27 of the Consumer Protection Act as the OP had committed contempt of the court order.
2. Brief facts of the complaint are that Op had issued Happy Family Floater Policy No.234001/48/2013/547 for the period 7.6.2012 to 6.6.2013, after taking all the medical tests of the insured persons Sh.Kuldeep Kumar Singla complainant no.2 and Smt.Sharda Singla and the policy was issued without any exception clause. Thereafter, complainant no.2, father of the complainant no.1, who was covered in this policy, was admitted to DMC College & Hospital, Ludhiana on September 5, 2012 and after his treatment, he was discharged on 11.9.2012. Thereafter, the complainant no.1 submitted all the original documents to the office of OPs at Ludhiana for a total sum of Rs.54,147/- on 17.9.2012, but the Ops never gave any reply to the complainant and thereafter, when the complainant went to the office of Ops, the officials of OPs always put off the matter on one or the other false pretext by assuring the complainant that his claim is under process and he will be reimbursed his claim. Thereafter, the complainant had received the letter of Ops dated 23.1.2013 regarding repudiation of the claim. Thereafter, the complainant had issued legal notice dated 27.4.2012 to the Ops which was duly received by the Ops but they failed to reply to the legal notice. Thereafter, the complainants had filed the complaint against the OP and this District Forum passed the order against the Ops and the copy of the order was dispatched to the Ops but thereafter, the Ops did not abide with the said order within the period fixed and never paid the amount to the complainants and thereafter, execution application was filed by the complainants against the OP and where the OP paid only a partial amount of Rs.25,826/-, out of total amount of Rs.54,147/-and thus, balance amount of Rs.28,321/- was not paid to the complainants alongwith 9% interest per annum from the date of lodging of claim till its realization and further, thereafter, the execution application was withdrawn by the complainant and the complainant had received the payment under protest with liberty to sue the OP for the pending amount and this District Forum vide its order dated 16.5.2014 had granted liberty to the complainant to file fresh complaint against the OP and hence, the fresh complaint against the OP was filed by the complainant which was dismissed as withdrawn and the liberty was given to the complainant to file fresh after removing the technical defect on 24.9.2014. Hence, this complaint.
3. Upon notice of the complaint, OP was duly served and appeared through Sh.B.S.Rampal, Advocate and filed the written reply, in which, OP took up certain preliminary objections that the present complaint is not maintainable in the present form; complainants have not come to this Hon’ble Forum with clean hands; complainants are estopped by their act and conduct from filing this complaint; complaint is bad for non-joinder and mis-joinder of necessary parties and the claim of the complainants was found not payable and falling within the purview of exclusive clause 4.8 of Mediclaim Insurance Policy and claim of the complainants was not payable and was duly informed to the complainants; the complaint is time barred and the complainants intentionally filed this third complaint against the answering OP on the same cause of action which has been already decided by this District Forum. On merits, it is submitted that the policy was issued to the complainants subject to condition, clauses, warranties etc. It is denied that after taking all the medical tests of the insured persons Sh.Kuldeep Kumar Singla and Smt.Sharda Singla, the said policy was issued. Further, it is denied that the policy was issued without any exception clause. However, it is submitted that the parties are governed by terms and conditions of medi-claim insurance policy. Further, it is submitted that on receipt of the information, the answering OP sent the case for settlement of claim to the Park Mediclaim TPA Pvt. Ltd, with the consent of the complainants, who wrote one letter dated 6.9.2012 to the complainants for requirements of some documents and in response to that letter, the complainants sent some documents to the Paramount Health Service Pvt Ltd., and that Paramount Health Service Pvt. Vide letter dated 15.10.2013 informed them regarding non admissibility of the claim as claim of the complainants being under exclusion clause 4.8 of the mediclaim policy. The case of the complainants was minutely scrutinized by the Park Mediclaim TPA Pvt. Ltd, and they applied their minds and found that claim of the complainants is not payable. So, the competent authority repudiated the claim and intimation vide letter dated 23.1.2012 was duly given to the complainants repudiating their claim. Further, it was submitted that the complainants filed one complaint against the answering OP and that complaint was decided by this District Forum on 26.11.2013 and as per para no.8 of the order, this Hon’ble Forum had considered that “perusal of discharge summary Ex.C2 reveals that the complainant no.2 suffers from two diseases namely i) Recurrent Vomitings ii)Psychogenic. Though, disease Psychogenic is covered under the exclusion clause 4.8 of the policy but there is nothing mentioned that disease Recurrent Vomiting does not fall under the exclusion clause 4.8 of the policy, meaning thereby that Park Mediclaim Tpa Pvt.Ltd. had not thoroughly investigated the matter and it need re-investigation.” After considering this facts, this District Forum had directed to the answering OP to re-open and re-examine the claim of the complainant qua the disease suffered by the complainant no.2 and thereafter, to settle and pay the claim of the complainants as per the terms and conditions of the insurance policy. On receipt of the order of this District Forum, the answering OP had sent the case for re-examining to the Park Mediclaim TPA Pvt. Ltd, and they had observed that patient was not suffering from two diseases but was suffering from one disease, Recurrent Vomiting? Psychogenic which means the recurrent vomiting in this case was Psychogenic in origin. As per the observation of the Park Mediclaim TPA Pvt. Ltd., the claim of the complainants was not payable but however keeping the good health of the image of answering OP, the competent authority of insurance company settled the claim of the complainant @50% of the total expenses payable under the policy and in this regard, the insurance company had sent letter dated 10.1.2014 to the complainants for their consent and again vide letter dated 30.1.2014, the insurance company again sent letter to the complainants alongwith observation of the Park Mediclaim TPA Pvt. Ltd., for settlement of the claim but the complainants did not reply these letters and filed execution against the answering OP before this District Forum and in this execution, the Advocate of the complainant received the cheque of half claim amount that is Rs.25,826/-. It is denied that the answering OP did not abide with the order of this District Forum within the fixed period and never paid the amount to the complainant within the fixed time period. Due services have been rendered by the answering OP and there is no deficiency in service on the part of answering OP. At the end, denying all other allegations of the complainants being wrong and incorrect, answering OP prayed for dismissal of the complaint with costs.
4. Learned counsel for the complainants in order to support the case of the complainants, adduced evidence by placing on record affidavit of complainant no.1 as Ex.CW1/A, in which, he has reiterated all the allegations made by him in the complaint. Further, learned counsel for the complainants has also relied upon documents Ex.C1 to Ex.C7.
5. On the contrary, learned counsel for the OP in order to rebut the evidence of complainants, adduced evidence by placing on record affidavit Ex.RA of Sh.Rakesh Soni, its Div.Manager, in which, he has reiterated all the contents of written reply filed by OP and refuted the case of the complainants. Further, learned counsel for the OP has placed on record the documents Ex.R1 to Ex.R7.
6. During the course of arguments, learned counsel for the complainants has filed the written arguments, in which, he has again reiterated all the contents of the complaint and further, it has been specifically mentioned that since the full claim till date, has not been settled and further vide its order dated 24.9.2014, this District Forum had allowed the complainant to withdraw the complaint with liberty to file the fresh complaint, therefore its within the limitation period and further the cause of action is continuing one and the complainants suffered immense mental pain, tension and harassment by the act of the OP as the OP did not pay the balance claim amount of Rs.28,321/- alongwith other reliefs as claimed in the complaint.
7. Similarly, learned counsel for the Op has contended that present complaint is not maintainable and the same has been filed by the complainants just to harass the OP because the complainants have intentionally filed this third complaint against the OP on the same cause of action which has been already decided by this District Forum. Claim of the complainants had already been settled and paid and the counsel for the complainants had already received the cheque of settled amount of Rs.25,826/- during the pendency of the execution application.
8. We have gone through the written arguments filed by the learned counsel for the complainants as well as considered the rival contention of learned counsel for the OP and have also gone through the record on the file very carefully.
9. From the perusal of evidence and documents on record, it is evident that in the previous complaint case No.393 of 24.5.2013 which was partly allowed on 26.11.2013, wherein, the relief was granted to the complainants to the effect that OP was directed to re-open and re-examine the claim of the complainants qua the diseases suffered by the complainant no.2 and thereafter, Op was directed to settle and pay the claim of the complainants as per the terms and conditions of the insurance policy, failing which, OP was liable to pay interest @9% per annum from the date of lodging of claim till its realization and further, OP was directed to pay Rs.2000/-(Two thousand only) as litigations cost to the complainants. Keeping in view the facts and circumstances of the present case, no order as to compensation was passed. Order was to be complied within 30 days from the date of receipt of copy of the order.
10. Further, record reveals that thereafter, an execution application No.49 of 11.3.2014 U/s 27 of the Consumer Protection was filed by the complainants, wherein, some part payment of the claim was made to the complainant by the OP on the basis of 50% of the payable amount which worked out to the tune of Rs.23,826/- +2000 as litigation costs and total amount of Rs.25,826/-. Thereafter, learned counsel for the complainant/applicant Sh.C.S.Chopra, Advocate, who had suffered the statement that he had received cheque of Rs.25,826/- dated 16.5.2014 bearing No.004006 in favour of Sh.Kulbhushan Singla, drawn on Bank of India in favour of the complainant and thereafter, he had withdrawn the execution application with liberty to file fresh complaint as the cheque had been received during the course of the execution application and not as per the order of this District Forum and not as per the terms and conditions of the insurance policy. Thereafter, the order was issued to withdraw the execution application with liberty to file the fresh complaint as the cheque has been received after filing the execution application.
11. Thus, liberty was granted for filing fresh complaint by this District Forum during the execution proceedings, meaning thereby that only fresh execution application was allowed to be filed. But in the present case, the complainants have filed a fresh complaint with same facts and same cause of action which this Forum considered to be not maintainable.
12. In view of the above discussion, we hereby dismiss the complaint of the complainants being not maintainable with no order as to costs. Copy of order be made available to the parties free of costs. File be completed and consigned to record room.
(Babita) (Sat Paul Garg) (R.L.Ahuja)
Member Member President.
Announced in Open Forum
Dated:30.03.2015
Gurpreet Sharma.
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