Punjab

Ludhiana

CC/22/451

Sarabjit Singh - Complainant(s)

Versus

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

complaint in person

24 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No: 451 dated 25.11.2022.                              Date of decision: 24.09.2024. 

 

1. Sarbjit Singh Sidhu S/o. S. Kirpal Singh,
2. Rajwant Kaur Sidhu W/o. Sarbjit Singh Sidhu, Both R/o. HJ-54, Housing Board Colony, BRS, Ludhiana.

                                                                                      ..…Complainant

                                                Versus

1. The Oriental Insurance Company limited, Divisional Office-1, B-8 RDC, Raj Nagar, Gaziabad, Uttar Predesh-201002.
2. The Oriental Insurance Company Limited, Madhok Complex, 3^rd Floor, Ferozepur Road, Opposite Silver Arc Mall, Ludhiana.                                                                              …..Opposite parties 

Complaint U/s.35 of the Consumer Protection Act 2019 for award of Medical Claim of Rs.22,048/- in Claim Reference No.55652122005347 in medical policy No.252100/48/2020/5026 with interest @18% from date of submission of claim and special cost for harassment caused to the complainants by the Respondents along with litigation expenses.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants            :         Complainant No.1 Sh. Sarabjit Singh Sidhu in                                           person.

For OPs                          :         Sh. R.K. Chand, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainants are retired employees and are senior citizens. They purchased medical policy No.252100/48/2020/5026 from the OPs having validity from 07.03.2020 to 06.03.2021 on premium of Rs.19,587/- which was in continuity since 2014. The complainant stated that due to Corona pandemic, complainant No.2 fell ill and she was admitted in Raghunath Charitable Hospital, Agar Nagar, Ludhiana on 22.02.2021 where she was diagnosed as Corona positive and was shifted in isolation ward and was discharged on 23.02.2021 but her treatment remained continued. However, the complainants could not inform the OPs regarding this hospitalization. Thereafter, after collecting papers from the hospital, the complainants submitted medical bill of Rs.22,048/- along with other documents with the OPs for reimbursement. The Ops vide letter dated 03.04.2021 asked the complainants to provide reason for delay in submission of claim documents and reason for non-intimation at the time of hospitalization to which the complainants replied that their only son was posted in IAF as Sqd. Ldr. in very sensitive area of Jammu & Kashmir at that time and they being senior citizens were staying alone at Ludhiana. Further there was no other person to assist them during the Corona pandemic situation and they requested the OPs to condone the delay and requested to reimburse the medical claim of Rs.22,048/-.  The complainants further stated that the OPs did not take any notice of corona pandemic situation despite sending reminder Emails dated 12.06.2021, 18.06.2021, 22.06.2021, 08.07.2021, 22.07.2021, 26.07.2021, 11.01.2022, 17.01.2022, 19.02.2022 and 12.09.2022 but the OPs did not give any reply nor paid any medical claim. Even the complainants served legal notice dated 29.09.2022 upon the OPs  but to no avail. Hence this complaint whereby the complainants prayed for issuing directions to the OPs to pay medical claim of Rs.22,048/- along with compensation and litigation expenses.

2.                Upon notice, the OPs appeared and filed written statement and assailed the complaint by taking preliminary objections on the ground of maintainability; lack of jurisdiction; the complainants have not come with clean hands; concealment of material facts; the complainants being estopped by their act and conduct etc. The OPs stated that the complainants lodged the claim regarding treatment of complainant No.2 and immediately on receipt of the claim, it was dully registered, entertained and processed. The complainants were called upon to submit the documents. M/s. Raksha Health Insurance TPA Pvt. Ltd. duly scrutinized the file and found that net amount of Rs.17,331/- is payable subject to terms and conditions of the policy. The Raksha TPA  vide  its letter dated 03.04.2021 requested the complainants to provide the documents/information, which is reproduced as under:-

                   i) Provide reason for delayed submission of claim documents as                 per policy terms and conditions.

                   ii) Provide reason for no intimation at the time of hospitalization as           per policy terms and conditions.

The Ops further stated that the complainants vide said letter dated 03.04.2021 were requested to submit  original documents within 15 days but they failed to clarify the said information.

                   On merits, the OPs reiterated the crux of averments made in the preliminary objections. The OPs averred that the complainants have not given the information regarding admission in the hospital immediately which is violation of terms and conditions of the policy. The OPs have denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In evidence, complainant No.1 Sh. Sarbjit Singh Sidhu tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainants also placed on record documents Ex. C1 is the copy of legal notice dated 29.09.2022, Ex. C2 and Ex. C3 are the postal receipts, Ex. C4 is the copy of insurance policy w.e.f. 07.03.2020 to 06.03.2021, Ex. C5 is the copy of query letter dated 03.04.2021, Ex. C6 to Ex. C17 is the copy of Email correspondence and closed the evidence.

4.                On the other hand, the counsel for the OPs tendered affidavit  Ex. RW1/A of Sh. Yash Paul, Divisional Manager of the OPs along with documents Ex. R1 is the copy of  opinion report of Raksha Health TPA, Ex. R2 is the copy of query letter dated 03.04.2021, Ex. R3 is the copy of claim form Part-A, Ex. R4 is the copy of claim form Part-B, Ex. R5 is the copy of detail of hospitalization bills, Ex. R6 is the copy of bill dated 23.02.2021 of Shree Raghunath Hospital, Ex. R7 is the copy of reference slip, Ex. R8 is the copy of discharge card, Ex. R9 is the copy of insurance policy w.e.f. 07.03.2020 to 06.03.2021 and closed the evidence.                                                           

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statement along with affidavit and documents produced on record by both the parties.

6.                Undeniably, complainant No.2 Smt. Rajwant Kaur Sidhu remained hospitalized in Shree Raghunath Hospital, Ludhiana from 22.02.2021 to 23.02.2021 where she was diagnosed as Covid-19 positive as mentioned in discharge card Ex. R8. The complainants submitted claim with the OPs vide Claim form Ex. R3 and Ex. R4 for a sum of Rs.22,048/-. The OPs appointed M/s. Raksha  Health Insurance TPA Pvt. Ltd. for assessment of the claim who after scrutinizing the provided documents, sent a query letter dated 03.04.2021 Ex. C5 = Ex. R2 calling upon the complainants to provide certain information/clarification contained in the said letter. The complainants vide Emails Ex. C6 to Ex. C17 tried to made clarifications so sought by the OPs vide query letter Ex. C5 = Ex. R2 but despite that the OPs did not settle their claim nor rejected the same. However, the OPs in their written statement  in para No.1 of the preliminary objections stated that M/s. Raksha Health Insurance TPA Pvt. Ltd. after scrutinizing the file, found a net amount of Rs.17,331/- payable to the complainants subject to terms and conditions of the policy. Even in their affidavit Ex. RW1/A, the OPs have claimed that a net amount of Rs.17,331/- is payable to the complainants. Neither in written statement nor in their affidavit, the OPs have doubted the genuineness of the claim of the complainants.  But the only stand of the OPs is that the complainants have not provided the information/documents as sought by them vide letter dated 03.04.2021. However, the complainants, who are senior citizens tried to pacify the OPs by sending Emails Ex. C6 to Ex. C17 but no further proceeding was done to decide the claim of the complainants. The insurance companies are required to be more liberal in their approach without being too technical while settling the genuine claims.

7.                In this regard, reference can be made to 2022(2) Apex Court Judgment 281 (SC) in case title Gurmel Singh Vs Branch Manager National Insurance Company Ltd. whereby it has been held by the Hon’ble Supreme Court of India that the insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to    procure and furnish. Once, there was a valid insurance on payment of huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non­submission of the duplicate certified copy of certificate of registration, which the appellant could not produce due to the circumstances beyond his control. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. In the given set of circumstances, it would be just and appropriate if the OPs are directed to pay Rs.17,331/- to the complainants within 30 days from the date of receipt of copy of order along with composite compensation of Rs.5000/-.

8.                As a result of above discussion, the complaint is partly allowed with an order that the OPs are directed to pay Rs.17,331/- to the complainants within 30 days from the date of receipt of copy of order. The OPs shall further pay a composite costs of Rs.5,000/- (Rupees Five Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.       

9.                Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:24.09.2024.

Gobind Ram.