Chandigarh

DF-II

CC/31/2019

Ms. Ved Nanda - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

Nirmal Singh Jagdeva Adv.

30 Aug 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	31 of 2019
Date  of  Institution	:	18.01.2019
Date   of   Decision	:	30.08.2019

 

 

 

 

Mrs.Ved Nada w/o Sh.J.L.Nanda, R/o House No.1567, Sector 38-B, Chandigarh.    

             ……..Complainant

 

Versus

 

1]  Oriental Insurance Company Limited, through Regional Manager, R.O. 109-110-111, Sector 17-D, Chandigarh.

 

2]  Raksha Health Insurance TPA Pvt. Ltd., SCO No.39, First Floor, Madhya Marg, Sector 26, Chandigarh.

 

………. Opposite Party

 

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

SMT.PRITI MALHOTRA        MEMBER

            SH.RAVINDER SINGH         MEMBER

 

For Complainant      :    Sh.Nirmal Singh Jagdeva, Advocate

For Opposite Parties :    Sh.Satpal Dhamija, Adv. for OP-1.

                           OP No.2 exparte.

 

PER RAVINDER SINGH, MEMBER

 

         Briefly stated, the complainant and her husband got Mediclaim Insurance Policy namely PNB Oriental Royal Medical Policy bearing No.231290/48/2018/1376 from Opposite Party NO.1, which was valid from 1.10.2017 to 30.9.2018 (Ann.C-1).  It is averred that in June, 2018, the complainant faced medical problem, and as such admitted in Fortis Hospital, Mohali on 10.6.2018, undergone medical treatment there and discharged on 14.6.2018 (Ann.C-4).  She applied for cashless treatment as per the policy, but the same was denied by the OPs vide letter dated 14.6.2018 (Ann.C-2 & C-3) and as such, the complainant had to make the payment of medical bill from her own pocket (Ann.C-5).  Thereafter, the complainant lodged claim with Opposite Parties and submitted all requisite documents for reimbursement of medical expenses, under the policy (Ann.C-9).  However, the Opposite Parties did not settle the claim since long despite several request.  Hence, this complaint.

 

2]       The Opposite Party No.1 has filed reply and while admitting the factual matrix of the case, stated that Opposite Party No.2 has already informed the complainant vide Ann.C-9 that it has received the claim documents and will process it and the status of the claim will be updated on the website.  It is stated that Opposite Party No.2, authorised TPA of Opposite Party No.1 has denied the cashless benefit in view of the terms & conditions of the policy and the claim of the complainant is still pending for consideration.  It is submitted that in the absence of any repudiation of the claim, the present complaint is liable to be dismissed being pre-mature.  Pleading no deficiency in service and denying other allegations, the Opposite Party No.1 has prayed of dismissal of the complaint.

         Opposite Party No.2 did not turn up despite service of notice, hence it was proceeded exparte vide order dated 28.2.2019.

 

3]       Rejoinder has been filed by the complainant reiterating the assertions as made in the complaint. 

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and perused the entire evidence on record.

 

6]       The complainant relying upon the PNB – Oriental Royal Mediclaim Policy No.231290/48/2018/1376 valid from 1.10.2017 to 30.9.2018 has claimed medical reimbursement of Rs.114970/-.  The complainant alleged to have submitted medical bills on 11.9.2018, which are still pending and no final decision thereon conveyed by the Opposite Parties.  The Opposite Party in its reply has not explained reasons for inordinate delay on its part for not deciding the claim for such a long time.

 

7]       The complainant is 74 years old and as such being a senior citizen, her claim is required to be settled on priority by the Opposite Parties, as per terms & conditions of the insurance policy.  The delay on the part of the Opposite Parties is condemnable and amounts to deficiency in service.  

 

8]       The OPs are directed to consider and decide the claim of the complainant within 15 days from the date of receipt of copy of this order. 

         In case the Opposite Parties failed to decide the claim within the given time, then they shall jointly & severally pay a compensation of Rs.50,000/- to the complainant besides the penal action as envisaged under Section 27 of The Consumer Protection Act, 1986.  The complaint stands disposed of accordingly.

         Forward copy of this order to the parties as per rules.    

Announced

30^th August, 2019                                                                  

Sd/-

(RAJAN DEWAN)

PRESIDENT

                                                                                               

Sd/-

                                                                    (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

 MEMBER