DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/18/2022

Date of Institution : 14.01.2022

Date of Decision : 20.01.2023

1. Asha Rani aged about 50 widow of Gulshan Kumar. 

2. Sheena aged about 28 years daughter of Gulshan Kumar.

3. Rishav aged about 26 years son of Gulshan Kumar. 

All residents of B-XIV/12841, Street No. 4, Akalgarh Basti, Barnala, Tehsil and District Barnala, Punjab, legal representatives of deceased Gulshan Kumar son of Hari Chand resident of Barnala.   

…Complainants

Versus

1. Oriental Insurance Company Limited, Branch Barnala, at KC Road, Barnala through Branch Manager.

2. M/s Raksha Health Insurance, 15/5, Mathura Road, Faridabad-121003 through its Manager.

3. Punjab National Bank, Main Branch, Shaheed Bhagat Singh Road, Barnala through its Branch Manager.

…Opposite Parties

Complaint under Consumer Protection Act, 2019

Present: Sh. Dhiraj Kumar Adv counsel for complainants.

Sh. Varinder Goyal Adv counsel for opposite party No. 1.

Opposite party No. 2 exparte.

Sh. Gagandeep Garg Adv counsel for opposite party No. 3. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Smt. Urmila Kumari : Member

3. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The complainants Asha Rani and others filed the present complaint under the Consumer Protection Act 2019 against Oriental Insurance Company Limited, Barnala and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the deceased Gulshan Kumar obtained a PNB Oriental Royal Mediclaim Policy bearing No. 233200/48/2020/2626 through opposite party No.  3 valid from 27.11.2019 to 26.11.2020. Said Gulshan Kumar died on 19.7.2020 so the complainants being legal representatives of deceased Gulshan Kumar are the consumers of the opposite parties. 

3. It is further alleged that the deceased Gulshan Kumar feels fever from 3-4 days alongwith breathing difficulty and he was admitted in DMC (H) Ludhiana on 18.7.2020 and was died on 19.7.2020. The complainant No. 1 applied for medical claim of Gulshan Kumar of Rs. 31,742/- alongwith claim form, original bills, copy of policy and other documents but opposite parties linger on the matter. Some letters were issued by the opposite parties for supply of original documents which were already supplied to the opposite parties by the complainant No. 1 and claim of Gulshan Kumar was rejected by the opposite parties No. 1 and 2 which amounts to deficiency in service and negligence on the part of the opposite parties. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay the said claim amount of about Rs. 31,742/- alongwith interest.

2) To pay Rs. 30,000/- on account of compensation for mental agony and harassment and Rs. 10,000/- as litigation expenses. 

3) Any other fit relief may also be given. 

4. Upon notice of this complaint, opposite party No. 1 filed written version taking preliminary objections that the complaint is premature as complainant have not submitted any documents as required for settlement of claim. The opposite party No. 1 issued letter dated 22.9.2020 and requested to submit the documents for processing the claim and again issued letter dated 8.10.2020 with a request to submit the documents as referred in earlier letters dated 3.9.2020, 8.10.2020, and 22.9.2020 for processing the claim and the opposite party No. 2 also issued a letter dated 11.12.2020 to the answering opposite party with the observation that there is deficiency of the documents. The insured have not provided the receipt of balance of payment of Rs. 15,152/-, affidavit of Legal nominee, cheque with beneficiary name printed on the cheque and bank details alongwith NEFT form, original investigation reports, reason for delay in submission of claim documents and not share the reason for no intimation at the time of hospitalization. Query reply not even submitted after the final reminder. Therefore, claim recommended for the repudiation as per 5.2 (i) and 5.2 (v) condition of the policy. The complainant has not come to this Commission with clean hands and concealed true facts from this Commission. The complainant has no locus standi or cause of action to file the present complaint and is premature so also complaint is liable to be dismissed. 

5. On merits, it is admitted that deceased Gulshan Kumar obtained a PNB Oriental Royal Mediclaim policy bearing No. 233200/ 48/2020/2626 through opposite party No. 3 valid from 27.11.2019 to 26.11.2020 and Gulshan Kumar got insured himself and the complainants through the said policy from the opposite party No. 1. Rest of the submissions already submitted in the preliminary objections so there is no need to reiterate the same. However, lastly the opposite party No. 1 prayed for the dismissal of the present complaint with special costs. 

6. The opposite party No. 2 preferred to remain exparte.

7. The opposite party No. 3 also filed written version taking legal objections that the opposite party No. 3 is not doing the business of insurance and only doing the business of banking and insurance policy is issued by the opposite party No. 1. So, the complainant has no locus standi and cause of action to file the present complaint against the opposite party No. 3and not liable to pay any amount of insurance to the complainant. Further, this Commission has no jurisdiction to entertain and adjudicate the dispute involved in the present complaint. The dispute raised by the complainant is outside the preview of the said Act. The complaint is abuse of process of law to harass the opposite party No. 3. The present complaint is not maintainable and barred by limitation.

8. On merits, it is admitted that the complainant's husband namely Gulshan Kumar was having one saving account with the answering opposite party. The premium was also paid through the opposite party No. 3 which has been charged by the opposite party No. 1 and insurance policy also issued by the opposite party No. 1. Rest of the submissions of the complaint are denied by the opposite party No. 3 and lastly prayed for the dismissal of the present complaint against the answering opposite party No. 3 with costs. 

9. In support of his complaint, the complainants tendered into evidence affidavit of  Asha Rani Ex.C-1, copy of policy Ex.C-2, copy of death certificate Ex.C-3, copy of claim form Ex.C-4, copies of bills Ex.C-6 to Ex.C-19, copy of death summary Ex.C-20, copy of final reminder  Ex.C-21, copy of repudiation letter dated 23.2.2021 Ex.C-22, copy of repudiation letter dated 11.12.2020 Ex.C-23 and closed the evidence. 

10. To rebut the case of the complainant the opposite party No. 1  tendered in evidence affidavit of Mukesh Malhotra Ex.OP-1/ and closed the evidence. The opposite party No. 3 also tendered in evidence affidavit of Arjun Vinayak Ex.OP-3/1, copy of statement of account Ex.OP-3/2, copy of General Power of attorney Ex.OP-3/3 and closed the evidence on behalf of opposite party No. 3.   

11. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments also filed by the complainants and opposite party No. 1. 

12. The complainants alleged in the complaint that complainants are the legal heirs of deceased Gulshan Kumar and the said Gulshan Kumar obtained the medical insurance policy bearing No.  233200/48/ 2020/2626 valid from 27.11.2019 to 26.11.2020. The complainants further alleged that the said Gulshan Kumar feels fever from 3-4 days alongwith breathing difficulty and he was admitted in DMC, Ludhiana on 18.7.2020 where he died on 19.7.2020. The complainant applied for the mediclaim insurance of Gulshan Kumar amounting to Rs. 31,742/- and same was wrongly rejected by the opposite parties No. 1 and 2 which is deficiency in service and negligence on the part of the opposite parties.

13. On the other hand, the opposite party No. 1 filed the written version and mainly taken the objection that the complainants failed to provide the documents which were demanded by the opposite party No. 1 vide various letters. The opposite party No. 1 further alleged in the written version that the insured has not provided the receipt of balance  payment of Rs. 15,152/-, affidavit of Legal nominee, cheque with beneficiary name printed on the cheque and bank details alongwith NEFT form, original investigation reports, reason for delay in submission of claim documents and not share the reason for no intimation at the time of hospitalization. Therefore, the claim recommended for repudiation as per 5.2 (i) and 5.2 (v) conditions of the policy, 

14. The opposite party No. 2 remained exparte. The opposite party No. 3 filed written version and mainly taken the objection that the complainant has no locus standi and cause of action against the opposite party No. 3 and opposite party No. 3 is not liable to pay any amount of insurance to the complainants.

15. On the perusal of the file and evidence produced by the complainants, it established that the deceased Gulshan Kumar was insured from opposite party No. 1 and they have also produced the policy as Ex.C-2. This fact is also not denied by the opposite party No. 1. The only dispute in the present case is that the complainant has not supplied the documents and receipt of balance payment of Rs. 15,152/-. The learned counsel for the complainant argued that the complainants have produced the detailed bills as Ex.C-19 vide which he had paid the amount of Rs. 15,152/- to Dayanand medical College and Hospital Managing Society. It is clear in the Ex.C-19 that the complainant paid Rs. 15,152/- in cash to the DMCH, Ludhiana and the said document was well within the knowledge of the opposite parties. The complainant has also produced the other medical and pharmacy bills from Ex.C-5 to Ex.C-19 vide which it established that the complainants spent Rs. 31,742/- on the treatment of deceased Gulshan Kumar. The complainant has produced Ex.C-23 vide which the claim of the complainant was recommended for repudiation as per Condition No. 5.2 (i) and 5.2 (v) of the policy issued by the Raksha TPA opposite party No. 2. The learned counsel for the complainant further argued that the opposite parties wrongly repudiated the genuine claim of the complainants. The complainants have supplied the relevant documents to the opposite parties. The learned counsel for the complainant further argued that the claim of the complainants was repudiated under the conditions, were also not produced by the opposite parties on the Commission file. 

16. From the above discussion, it established that the complainants proved their case, therefore present complaint is partly allowed against the opposite party No. 1 and the opposite party No. 1 is directed to pay the amount of Rs. 31,742/- to the complainants alongwith interest at the rate of 7% per annum from the date of filing the present complaint till actual realization. The opposite party No. 1 is also directed to pay Rs. 10,000/- to the complainants as compensation for mental tension and harassment and Rs. 5,500/- as litigation expenses. The opposite  party No. 1 is directed to pay all the above mentioned amounts to the complainants in equal share. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to its records after its due compliance.

ANNOUNCED IN THE OPEN COMMISSION:

        20th Day of January 2023 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member