DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Complaint Case No : 33/2015
Date of Institution : 06.02.2015
Date of Decision : 5.10.2015
Sukhjeet Singh S/o Harbhajan Singh R/o Bhadalwad, Tehsil and District Barnala.
…Complainant
Versus
Oriental Insurance Company Limited through its Extension Counter, Near OBC Bank, K.C. Road, Barnala.
Punjab National Bank Sanghera Branch, Raikot Road, Sanghera, District Barnala through its Branch Manager.
Medi Assist India Pvt. Ltd. S.C.O. 61, Second Floor, Phase-7, Mohali through its authorized person.
…Opposite Parties
Complaint Under Section 12 of Consumer Protection Act, 1986.
Present: Sh. R.K. Jain counsel for complainant.
Sh. Jatinder Kumar counsel for opposite party No. 1.
Sh. J.S. Bhullar counsel for opposite party No. 2.
The opposite party No. 3 exparte.
Quorum.-
1. Shri S.K. Goel : President.
2. Sh. Karnail Singh : Member
3. Ms. Vandna Sidhu : Member
ORDER
(SHRI S.K. GOEL PRESIDENT):
The complainant namely Sukhjeet Singh has filed the present complaint under Consumer Protection Act, 1986 (hereinafter called as Act) against Oriental Insurance Company and others (hereinafter called as the opposite parties).
2. The facts emerging from the present complaint are that the complainant and his wife namely Kulwinder Kaur were insured vide policy No. PNB-ORI-ROY-233200/48/2014/291 issued by the opposite party No. 1 being account holder of the opposite party No. 2 bearing Account No. 3478000101033969 as per their scheme. It is averred that Kulwinder Kaur delivered a son on 18.7.2013 who has been named as Navjot Singh and after obtaining the birth certificate, the complainant submitted the same to opposite party No. 2 for including his name in the list of persons insured and for issuance of ID Card but the same has not been issued despite repeated visits by the complainant to opposite party No. 1 & 2. It is further averred that Kulwinder Kaur wife of the complainant suddenly fell ill and was taken to Sood Nursing Home Barnala, where she was diagnosed for ruptured ovarian cyst and an urgent surgery was undertaken to save the life of the patient. Authorization request was sent to TPA appointed by opposite party No. 1. It is further averred that complainant had claimed a sum of Rs. 27,000/- for which he could retained bills although amount spent was much more. It is further averred that since the money was to be paid into the account of the complainant, so the complaint has been filed by the complainant. It is further averred that thereafter a claim was lodged by the complainant and all the necessary papers were submitted vide registered letter No. RP247896245IN dated 7.10.2014 for the payment of claim. However, the claim has not been settled despite the lapse of sufficient period. The complainant served a notice to the opposite parties but they failed to pay the said amount. Hence, the present complaint is filed seeking the following reliefs.
To pay the claim of the complainant amounting to Rs. 27,000/-.
To provide the ID Card of Navjot Singh S/o Sukhjit Singh.
To pay Rs. 50,000/- as compensation and Rs. 5,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written version taking legal objections on the grounds interalia no cause of action or locus-standi, bad for non joinder of necessary party, estoppel, not come to the Forum with clean hands etc. On merits, it is pleaded that circle office Bathinda of opposite party No. 2 got insured the complainant alone from Divisional Office Bathinda vide PNB-Oriental Royal Mediclaim Policy No. 233200/48/2014/291 dated 17.4.2013 issued for the period from 8.5.2013 to 7.5.2014 as the complainant was maintaining Account No. 3478000101033969 with the opposite party No. 2. However, the answering opposite party denied that Kulwinder Kaur wife of the complainant was also insured by the said policy. It is further submitted that the complainant has not mentioned as to on what date the complainant submitted the birth certificate of his son Navjot Singh to them for including his name in the list of persons insured and for issuance of Identity Card in his name. Even no intimation was ever received by the answering opposite party regarding illness or admission or treatment of Kulwinder Kaur. Even no claim was submitted by the complainant with the answering opposite party and therefore no action has been taken. They have denied the other allegations of the complainant and finally prayed for the dismissal of complaint.
4. The opposite party No. 2 also filed separate written version on the same line of opposite party No. 1.
5. The opposite party No. 3 was proceeded against exparte vide order dated 15.6.2015.
6. In order to prove his case, the complainant tendered in evidence his own affidavit Ex.C-1, copy of RTI application Ex.C-2, copy of e-mails four pages Ex.C-3, copy of policy No. 233200/48/2016/81 Ex.C-4, copy of policy No. 233200/48/2015/130 Ex.C-5, copy of bank pass book Ex.C-6, copy of ID Card Ex.C-7, copy of ID Card Ex.C-8, copy of policy schedule Ex.C-9, copy of bank pass book Ex.C-10, copy of birth certificate Ex.C-11, copy of postal receipt dated 7.10.2014 Ex.C-12, copy of letter to Medi Assist Ex.C-13, copy of Medical Certificate Ex.C-14, copy of bill of Sood Nursing Home Ex.C-15 and Ex. C-16, copies of receipts Ex.C-17 to Ex.C-19, copy of prescription slip of Sood Nursing Home Ex.C-20, copy of legal notice Ex.C-21, copy of postal receipt Ex.C-22 and closed the evidence.
7. In order to rebut the case of complainant, the opposite party No. 1 tendered in evidence affidavit of A.S. Dhingra Ex.O.P-1 and closed the evidence. The opposite party No. 2 also tendered in evidence affidavit of Dilbagh Singh Ex.O.P-2/1, copy of Transfer Voucher Ex.O.P-2/2, copy of policy Ex.O.P-2/3 and closed the evidence.
8. We have heard the Ld. Counsels for the parties.
9. Coming to the first relief of the complainant qua payment of Rs. 27,000/-, the complainant has placed on record his detailed affidavit Ex.C-1 wherein he has stated that his wife Kulwinder Kaur suddenly fell ill and was taken to Sood Nursing Home Barnala, where she was diagnosed for ruptured ovarian cyst and an urgent surgery was undertaken to save her life. The complainant further stated that he has claimed sum of Rs. 27,000/- and lodged the claim with all the necessary papers to the opposite party No. 1 (insurance company) for the said amount. In the affidavit he has further stated that he has taken the policy No. 23200/48/2015/130 for the period from 8.5.2014 to 7.5.2015 from the opposite party No. 1. Apart from this, the complainant has also placed on record Ex.C-5 the insurance policy for the period 8.5.2014 to 7.5.2015. There is also no dispute that the said policy also includes the spouse and two children. Apart from the above the complainant also placed on file bill Ex.C-15 of Sood Nursing Home Barnala showing the expenditure of Rs. 25,000/-. Ex.C-17 and Ex.C-18 are the receipts of Rs. 1,000/- each i.e. Rs. 2,000/- showing the purchase of Blood from The Punjab Health Systems Corporation. Thus, on the basis of the said bills it is contended that the complainant has spent Rs. 27,000/- by virtue of the insurance policy the complainant is entitled to the reimbursement of the same from the Insurance Company.
10. It is worth mentioning here that during the pendency of this complaint the opposite party No. 1 (insurance company) has deposited an amount of Rs. 25,000/- in the account of complainant and there is no dispute regarding the payment of the said Rs. 25,000/- by the complainant. However, the complainant has specifically contended that Rs. 2,000/- are yet to be paid alongwith interest, compensation and litigation expenses. It is matter of great concern that the opposite parties paid Rs. 25,000/- to the complainant, whereas the complainant has proved the expenses of Rs. 27,000/-. No explanation was given by the opposite parties and without justification the opposite parties are not competent to deduct Rs. 2,000/- from the total expenses of the complainant, therefore this relief to the extent of Rs. 2,000/- is accepted.
11. Coming to the second relief qua the issuance of ID Card of Navjot Singh, it is mentioned in the complaint that the wife of the complainant delivered a son on 18.7.2013 named as Navjot Singh and after obtaining his birth certificate the same was submitted to the opposite party No. 2 for including his name in the list of persons insured and for issuance of ID Card but the same was not issued despite many requests. But in the written version filed by the opposite parties No. 1 & 2 they have submitted that the complainant never submitted the birth certificate of Navjot Singh for including his name in the list of persons insured by the Insurance Company. But in the affidavit of filed by the complainant Ex.C-1, the complainant has reiterated his stand that he approached many times to the opposite parties for including the name of Navjot Singh in the Insurance Policy. Apart from this, the complainant has placed record indicating that the necessary documents were supplied to the opposite parties for the issuance of said ID Card. It is also worth mentioning to refer the Prospectus Ex. O.P2/3 of the Oriental Insurance Company Limited, wherein in clause 3.14 it is mentioned as:-
“I.D. CARD: means the card issued to the insured Person by the TPA to avail Cashless facility in the Network Hospital”
Clause 3.3 of the said Prospectus lays as:-
“TPA (Third Party Administrator): means any company/body who has participate in providing cashless health services to the insured persons. The list is maintained by TPA and made available to the insured person by TPA”
12. In view of the above said clauses, the opposite party No. 3(Medi Assist India Pvt. Ltd.) is duty bound to issue the ID Card to the complainant. No contrary evidence has been produced by the opposite party No. 3 to show that they are not competent to issue the said ID Card.
13. As a result of the above discussion, the complaint of the complainant is partly accepted and the opposite party No. 3 is directed to issue the ID Card of Navjot Singh to the complainant as per rules. The Insurance Company (the opposite party No. 1) is also directed to pay Rs. 2,000/- to the complainant alongwith interest @ 10% per annum till realization and Rs. 2,100/- as litigation expenses. This order of ours shall be complied within 30 days from the date of the receipt of the copy of this order. Copy of this order be supplied to the parties free of cost. The file after its due completion, be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
5th Day of October, 2015.
(S.K. Goel)
President.
(Karnail Singh)
Member.
(Vandana Sidhu)
Member.
