Punjab

Faridkot

CC/17/309

Balbir Raj - Complainant(s)

Versus

Oriental Insurance co. Ltd - Opp.Party(s)

Bharat Bhushan

21 Aug 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      309 of 2017

Date of Institution:   13.09.2017

Date of Decision :    21.08.2019

 

Balbir Raj aged about 63 years son of Ram Dhan r/o House No.1/1100, Jatinder Chowk, Faridkot.

                                                                           .........Complainant

Versus

1. The Oriental Insurance Company Ltd through its Branch Manager, Near Jublie Chowk, Faridkot.
2. Park Mediclaim Insurance TPA Pvt Limited, 702 Vikrant Tower, Rajindera Place, New Delhi.

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt. Param Pal Kaur, Member.

 

Present:  Sh Ashok Kumar, Ld Counsel for Complainant,

               Sh Vinod Monga, Ld Counsel for OPs.

ORDER

(Ajit Aggarwal, President)

                                             Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make payment of insurance claim of

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Rs.40,000/-with interest and for further directing OPs to pay Rs.20,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.10,000/-.

2                                   Briefly stated, the case of the complainant is that complainant no.1 purchased a mediclaim insurance policy bearing no.233707/48/2017/311 from OP-1 valid from 25.07.2016 to 24.07.2017 for a sum of Rs.2,00,000/- and said policy covered the risk of complainant and his wife. It is submitted that on 4.05.2017 complainant slipped by chance and he got fracture in his left femur and other injuries. He was first taken to Bikram Joint and Trauma Hospital Centre, Faridkot where he was given first aid and then he was admitted in Guru Gobind Singh Medical College and Hospital, Faridkot where he was operated and implant was put on his left leg. He remained admitted there from 4.05.2017 to 11.05.2017 and spent about Rs.40,000/-on his treatment as cost of implant and after getting discharge therefrom, he lodged claim with OPs and submitted all the requisite documents to them. Vide letter dated 19.06.2016, OP-2 demanded x-ray film and reports of before and after surgery from complainant. Complainant submitted the x-ray report to Ops on 1.09.2017 and pleaded that x-ray film is deposited by hospital authorities in their record room from which it cannot be released, but meanwhile, OPs closed the claim of complainant as no claim on 10.08.2017. Despite repeated requests, OPs have not made a single penny on account of insurance claim of complainant, which amounts to deficiency in service and has caused harassment and mental tension to

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complainant. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                    The counsel for complainant was heard with regard to admission of the complaint and vide order dated 25.09.2017, complaint was admitted and notice was ordered to be issued to the OPs.

4                                     On receipt of the notice, the OPs filed written statement wherein asserted that there is no deficiency in service on the part of OPs and have denied all the allegations of complainant being wrong and incorrect. It is averred that complainant himself did not provide the requisite documents to them. OP-2 issued letters dated 3.06.2017, 19.06.2017, 6.07.2017 and 15.07.2017 to complainant vide which they requested him to supply the requisite documents for processing his insurance claim, but complainant failed to supply the said documents and therefore, claim of complainant was filed as no claim due to non cooperation of complainant and it was closed. Complainant neither approached them nor submitted any documents to them. It is further averred that they never refused to pay the claim of complainant.            It is reiterated that there is no deficiency in service on the part of OPs. All the other allegations and allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

 

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5                                              Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-33 and then, closed their evidence.

6                                              In order to rebut the evidence of the complainant, ld counsel for OPs tendered in evidence affidavit of Ashwani Kumar Ex OP-1 and document Ex OP-2 to 5 and then, closed the same on behalf of OPs.

7                                              We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

8                                            The case of the complainant is that he is insured under the policy in question and during the subsistence of said policy, he slipped and due to this he got fracture in his left femur. He underwent treatment at Guru Gobind Singh Medical College and Hospital, Faridkot where he was operated upon and implant was put on his left leg. He remained admitted there from 4.05.2017 to 11.05.2017 and spent about Rs.40,000/-on his treatment and thereafter, he lodged claim with OPs, completed all the formalities and also submitted all the requisite documents to them. Vide letter dated 19.06.2016, OP-2 demanded x-ray film and reports. Complainant submitted the x-ray report to Ops on 1.09.2017 and pleaded that x-ray film is deposited by hospital authorities in their record room from which it cannot be

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released, but meanwhile, OPs closed the claim of complainant as no claim on 10.08.2017. Grievance of the complainant is that despite repeated requests, OPs have refused to pay the insurance claim to him which amounts to deficiency in service and has caused mental agony to him. he has prayed for accepting the present complaint. In reply, OPs stressed mainly on the point that despite issuance of several letters to complainant, he did not supply x-ray films regarding treatment of complainant before and after surgery to them and therefore, due to non cooperation on the part of complainant, his claim was closed as no claim and there is no deficiency in service on the part of OPs.

9                                     To prove his pleadings, he has placed on record copy of insurance policy documents Ex C-5 to Ex C-10 that clearly proves the pleadings of complainant that he has been purchasing the said policy since 2011 and was getting renewed the same. From document Ex C-10 it is clear that said policy in question was valid from 25.07.2016 to 24.07.2017 and as per pleadings of complainant he got fracture on 4.05.2017 which occurred during the subsistence of policy in question and he underwent treatment during the cover period of said policy. Careful perusal of Discharge and Follow up Card Ex C-11 further clears the pleadings of complainant that he was admitted in Guru Gobind Singh Medical College and Hospital, Faridkot on 4.05.2017 and was discharged therefrom on 11.05.2017. Ex C-14 to Ex C-32 are copies of bills and receipts that reveal the fact that complainant spent amount on his treatment from his own pocket.

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11                    From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that complainant and his wife were insured with them for cashless treatment under the policy in question. It is also admitted that complainant suffered fracture in left leg and he underwent treatment in the Guru Gobind Singh Medical College and Hospital, Faridkot for the period from 4.05.2017 to 11.05.2017. Plea taken by OPs that complainant did not supply requisite documents to them has no legs to stand upon as complainant has placed on record all the documents required for processing the claim. Requisition for x-ray film raised by OPs is unreasonable as that x-ray film is in the possession of hospital authorities and hospital authorities do not allow the same to be given to anyone. All other documents required for processing the claim have already been furnished by complainant to them and nothing more is required to be submitted by complainant to OPs. Act of OPs in not passing the claim of complainant amounts to deficiency in service on the part of OPs.

12                           Ld Counsel for complainant argued that the OPs cannot deny the amount in dispute regarding claim of complainant on the ground of non submission of that document which is not in the possession of complainant. It is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR

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(Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims.

13                     From the above discussion and case law produced by the complainant, we are of considered opinion that OPs  have wrongly and illegally not processed the claim of complainant, which amounts to deficiency in service. Therefore, present complaint is hereby accepted against OPs. OPs are directed to pay the claim amount of Rs.29,084/-to complainant, which as per essentiality certificate, he incurred on his treatment alongwith interest at the rate of 9% per anum from the date of filing the present complaint till final realization. They are further directed to pay Rs.5,000/-to complainant as consolidated compensation for harassment and mental agony suffered by them and for litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 21.08.2019

                                      (Param Pal Kaur)              (Ajit Aggarwal)

                                       Member                                   President