Sh.Anoop Sharma, Presiding Member

1.       Sh.Pankaj Kumar has brought the instant complaint under section 11 and 12 of the Consumer Protection Act, on the allegations that  he is having salary bank account in Punjab National Bank, Cant Branch, Amritsar and said bank has tie up with Opposite Party No.1 for effecting medi claim policies and complainant had been obtaining the medi claim policies from Opposite Party No.1 since the year 2014 and lastly the complainant obtained a medi claim policy bearing No.233300/48/2017/1884 for a period of one year from 31.7.2016 to 30.7.2017 from Opposite Party No.1 against requisite premium of Rs.5916/- covering the risk of himself and his spouse namely Mrs.Teena Monga and his two children for a sum of Rs.4 lacs. Opposite Party No.2 is investigative agency of Opposite Party No.1. During the validity period of the policy in question, the wife of complainant slipped on the floor on 22.10.2016 and she got her left knee cap fractured and accordingly, the complainant  took his wife to Biala Orthopedic Hospital for the treatment where the wife of the complainant remained admitted on 22.10.2016 and was operated on he same day and on the very same day, the complainant informed the TPA mentioned on the cashless card about the hospitalization of his wife and Opposite Party No.2 gave intimation  and said TPA asked the complainant to send al the bills and other medical record at their Delhi Office after the discharge of his wife. The wife of the complainant was discharged from the hospital on 28.10.2016 and during her treatment in the said hospital, the complainant incurred about Rs.73000/- in the said hospital for the treatment of his wife as hospital charges, medicines, tests and x-rays and other charges. It is pertinent to mention over here  that after the discharge of the wife of the complainant from the hospital, the complainant sent all the relevant documents i.e. claim form, copy of insurance policy, OPD receipt, copies of medicine bills, hospital main bill, copy of cancelled cheque of PNB bank copy of ID proof and copy of health card and other relevant documents which were required for the reimbursement of the genuine claim of the complainant with the Opposite Party No.2 vide DTDC courier  receipt No.08233732 dated 2.11.2016 to their Delhi Office  vide intimation No. 10397526 which were received by Opposite Party No.2 at their Delhi Office on 4.11.2016 and they even provided tracing number D1188981202 and the complainant even sent e-mail to Opposite Party No.2 on 3.11.2016 and the Opposite Parties assured the complainant that the amount of claim would be duly settled and reimbursed to him within shortest period. Now surprisingly, the Opposite Party No.1 sent one e-mail to the complainant while informing him that the policy in question bears the name as TPA as M/s.Raksha TPA and not Medi Assistant which ground is not at all sustainable under the law.  It is further pertinent to mention over here that all the relevant record regarding the claim like hospital bills, medicine bills, original x-ray reports and other documents are lying with Medi Assist India New Delhi and they are not returning the documents to the complainant even after making so many requests and reminders to the Opposite Party No.2. The act of Opposite Party No.1 in not settling and reimbursement of the genuine and legitimate claim of the complainant on flimsy ground and without any just and sufficient cause, amounts to deficiency in service, Unfair Trade Practice  as well as gross negligence on the part of the Opposite Parties.    Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to settle and reimburse the claim amount of Rs.73,000/- alongwith interest @ 18% per annum from the date of lodging of claim till payment.

b)      Opposite Party No.1 may kindly be directed to pay compensation of Rs.20,000/- to the complainant.

c)       Opposite Party No.1 may kindly be directed to pay the costs of the present claim.

d)      Complainant may kindly be awarded any other relief to which he is found legally entitled to under the law, equity and justice.

  Hence, this complaint.

2.       Upon notice, Sh.Sandeep Khanna, Advocate appeared on behalf of the Opposite Party and also made statement that  that the claim in question is still pending with the Opposite Party No.1 and is under process. However, the Opposite Party No.1 is ready to decide the claim case of the complainant within 45 days from the date of receipt of order. The claim shall be decided subject to furnishing of all the relevant documents and fulfilment of requisite formalities by the complainant and as per the terms and conditions of the insurance policy and on the basis of decision of the competent authority.  

3.       On the other ld.counsel for the complainant has orally opposed the contention of the ld.counsel for Opposite Party No.1 on the ground that the complainant has already    sent all the relevant documents i.e. claim form, copy of insurance policy, OPD receipt, copies of medicine bills, hospital main bill, copy of cancelled cheque of PNB bank copy of ID proof and copy of health card and other relevant documents which were required for the reimbursement of the genuine claim of the complainant with the Opposite Party No.2 vide DTDC courier  receipt No.08233732 dated 2.11.2016 to their Delhi Office  vide intimation No. 10397526 which were received by Opposite Party No.2 at their Delhi Office on 4.11.2016 and they even provided tracing number D1188981202 and the complainant even sent e-mail to Opposite Party No.2 on 3.11.2016 and the Opposite Parties assured the complainant that the amount of claim would be duly settled and reimbursed to him within shortest period and at present there are no documents regarding the treatment of wife of the complainant with the complainant as all these documents have already been sent to TPA through courier under receipt. Now surprisingly, the Opposite Party No.1 sent one e-mail to the complainant while informing him that the policy in question bears the name as TPA as M/s.Raksha TPA and not Medi Assistant which ground is not at all sustainable under the law.

4.       We have also heard both the counsel and have carefully gone through the unexhibited documents placed on record by the complainant and we have also considered the willingness of the Opposite Party to consider the case on merits.

5.       The contention of the Opposite Party No.1 is that claim in question is still pending with the Opposite Party No.1 and is under process. However, the Opposite Party No.1 is ready to decide the claim case of the complainant within 45 days from the date of receipt of order. The claim shall be decided subject to furnishing of all the relevant documents and fulfilment of requisite formalities by the complainant and as per the terms and conditions of the insurance policy and on the basis of decision of the competent authority. But perusal of PNB-Oriental Royal Mediclaim policy Schedule bearing policy in question shows that the TPA of Opposite Party No.1 is M/s.Medi Assist India which is duly depicted on this document itself. This Forum has also perused the letter written by Pankaj Kumar complainant dated 3 November, 2016 11.50 AM to said Medi Assist Insurance TPA Private Limited, vide which the complainant has sent the required documents (all originals), the detail of which as under:-

a)       Claim Form

b)      PNB Oriental Royal Mediclaim Policy photocopy (2016-17)

c)       Health Card photocopy.

d)      OPD receipt

e)       Hospital Advance receipt.

f)       Hospital Main Bill

g)       Hospital Discharge Summary card (Original)

h)       Pharmacy bills

i)        Cancelled cheque of PNB bank

j)        Passport copy  for ID Proof (Photocopy)]

k)       Original x-ray (2 Nos).

In the policy documents, it is clearly mentioned that the documents are to be sent to Medi Assistant TPA and accordingly, the aforesaid documents were duly sent by the complainant to Opposite Party No.2 Medi Assisant TPA through vide DTDC courier  receipt No.08233732 dated 2.11.2016 to their Delhi Office  vide intimation No. 10397526 which were received by Opposite Party No.2 at their Delhi Office on 4.11.2016 and they even provided tracing number D1188981202 and said averment of the complainant has nowhere denied or rebutted by ld.counsel for the Opposite Party No.1 in his statement or otherwise. So, there is no question of sending these documents again to the alleged M/s.Raksha TPA which are nowhere in the custody of the complainant.

6.       Hence, in view of the aforesaid facts and circumstances and the statement made by ld.counsel for Opposite Party No.1 instead of filing detailed written reply in their defence, we direct Opposite Party No.1 to process and settle the claim of the complainant, positively within 30 days from the date of receipt of copy of order. The complaint is disposed of accordingly. However, the complainant is at liberty to file the fresh complaint after the final settlement of his claim, if he still not satisfies with the decision of the OP-Insurance Company.  Opposite Party No.1 is also directed to pay Rs.5,000/- as compensation to the complainant besides Rs.2,000/- as costs of litigation. Copies of this order be supplied to the parties free of cost and the file be consigned to record room after compliance.

Announced in Open Forum