Punjab

Sangrur

CC/347/2017

Kamalpreet - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

Sh.Sanjeev Garg

12 Dec 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                       

                                                Complaint No.  347

                                                Instituted on:    19.07.2017

                                                Decided on:       12.12.2017

 

Kamalpreet son of Sh. Johri Ram Jindal, R/O H.No.235, Guru Nanak Colony, Near Bus Stand, Sangrur.

                                                        …Complainant

                                Versus

1.             Oriental Insurance Co. Ltd. Nabha Gate, Sangrur through its Branch Manager.

2.             Oriental Insurance Co. Ltd. Sai Market, Lower Mall, Patiala through its Divisional Manager, Patiala.

3.             Punjab National Bank, Patiala Gate, Sangrur through its Branch Manager.

4.             Raksha TPA Pvt. Ltd. C/o Escorts Corporte Centre, 15/5, Mathura Road, Faridabad (Haryana) 121 003 through its Authorised Signatory.

                                                        ..Opposite parties.

 

For the complainant  :       Shri Sanjeev Garg, Adv.

For Opp.party No.1&2:     Shri Bhushan Garg, Adv.

For Opp.Party No.3  :       Shri Parmod Saxena, Adv.

For OP No.4             :       Exparte.

 

 

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Kamalpreet, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant availed the services of the OP number 3 by opening a saving bank account bearing number 0419000100405886, as such on the allurement of OP number 3, the complainant also took a medi claim insurance policy from OP number 1&2 through OP number 3 bearing number 233500/48/2017/1561 for the period from 26.7.2016 to 25.7.2017 by paying the requisite premium of Rs.6990/-. The case of the complainant is that on 26.10.2016, the complainant suffered with fever and as such he was admitted in Mata Kaushalya Memorial and Polyclinic Hospital Sangrur, where he was found to be a case of dengue as such he was referred to Rai Hospital, Sangrur, where he was treated by Dr. R..S.Rai.  Further case of the complainant is that after completion of the treatment, the complainant submitted all the bills to the OPs for reimbursement to the tune of Rs.14,651/-, but nothing happened despite submission of the bills to the OPs. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.14,651/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by OPs number 1 and 2, legal objections are taken up on the grounds that there is no deficiency of service or unfair trade practice, that the complainant has not come to the Forum with clean hands, that the complaint is premature and that the complaint is liable to be dismissed with special costs. On merits, it is admitted that the complainant had obtained the policy in question for the period from 26.7.2016 to 25.7.2017 for Rs.5,00,000/-, which is subject to the terms and conditions.  It is stated that the documents were waited by the OP as well as by the OP number 4 regarding the treatment of the complainant in the said hospital, but the same were not submitted by the complainant despite reminders. The other allegations levelled in the complaint have been denied in toto.

 

3.             Record shows that OP number 4 was proceeded against exparte.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-27 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OP number 1&2 has produced Ex.OP1&2/1 to Ex.OP1&2/6 copies of documents and affidavit and closed evidence.  The learned counsel for OP number 3 has produced Ex.OP3/1 to Ex.OP3/2 copies of documents and affidavit and closed evidence.

 

5.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

6.             It is an admitted fact between the parties that the complainant was insured with the Ops number 1 and 2 through Op number 3 under medi claim insurance policy for Rs.5,00,000/- by paying the requisite premium for the period from 26.7.2016 to 25.7.2017.  It is further an admitted fact that the complainant suffered with fever and dengue, as such he took treatment from Mata Kaushalya Memorial and Polyclinic Hospital, Sangrur and Rai Hospital Sangrur, where he spent an amount of Rs.13,400/- on his treatment, as is evident from the copy of the bills on record as Ex.C-4 to Ex.C-14, Ex.C-17 and Ex.C-18 and thereafter the complainant submitted all the bills to the OPs number 1 and 2 for reimbursement of the claim amount. But, the grievance of the complainant is that the OPs repudiated the claim being not payable on the ground that the complainant did not submit the required documents to the OPs despite issuance of reminders. On the other hand, the stand of the learned counsel for the complainant is that the complainant has already submitted all the original documents to the Ops such as original claim form duly signed by the treating hospital along with the copies of the bills of medicine and treatment etc. as is evident from the documents on record as Ex.C-3 to Ex.C-14, Ex.C-17 and Ex.C-18.  It is worth mentioning here that the present complaint has been filed on 19.7.2017, but even after filing of the present complaint the OP number 1 and 2 did not make any offer to settle the claim, despite the fact that the OPs number 1 and 2 had received the copies of the documents during the present proceedings also. It is no doubt true that the complainant took treatment from the Mata Kaushalya Hospital, Sangrur and Rai Hospital, Sangrur for the period from 26.10.2016 to 30.10.2016 as is evident from the copies of the bills on record as Ex.C-3 to Ex.C-14, Ex.C-17 and Ex.C-18 and when we totalled the bills regarding treatment, lab bills and medicine bills, we found it to be Rs.13,400/-.  As such, we are of the considered opinion that ends of justice would be met if the OPs number 1 and 2 are directed to pay to the complainant an amount of Rs.13,400/-.

 

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

8.             Accordingly, in view of our above discussion, we allow the complaint and direct OP number 1 and 2 to pay to the complainant an amount of Rs.13,400/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 19.07.2017 till realisation.  We further order the OP number 1 and 2 to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.

 

 

9.             This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        December 12, 2017.

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                                                (Sarita Garg)

                                                                    Member

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member