DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .
Complaint No. 452
Instituted on: 1.11.2018
Decided on: 15.02.2021
Raghuwar Singla son of Sh. Vidya Sagar Singla R/O H.No.12-B/28, Shivpuri Mohalla, Near Ram Murti Di atta Chakki, Dhuri, Distt. Sangrur.
…. Complainant.
Versus
1. Oriental Insurance Co. Ltd. Outside Nabha Gate, Distt. Sangrur through its Branch Manager.
2. Oriental Insurance Co. Ltd. Sai Market, Lower Mall, Patiala through its Divisional Manager, Patiala.
3. Punjab National Bank, Loha Bazar, Dhuri, Distt. Sangrur through its Branch Manager.
4. TPA Medi Assist Pvt. Ltd. # B-8, Tej Building, 2nd Floor, Bahadur Shah Zafar Marg, Next to Times New Delhi-110002 through its Manager.
….Opposite parties.
For the complainant: :Shri Sanjeev Garg, Adv.
For the OP No.1&2 :Shri Ashish Garg, Adv.
For the OP No.3 :Shri Amit Aggarwal, Adv.
For the OP No.4 :Exparte.
Quorum: Shri Jasjit Singh Bhinder, President
Shri V.K.Gulati, Member
ORDER:
Shri Jasjit Singh Bhinder, President
1. Complainant has filed this complaint pleading that the complainant has an account bearing number 3474000100164019 with the OP number 3 and as such as advised by the OP number 3 complainant took a medical health insurance policy number 233500/48/2015/1822 issued on 28.10.2015 which was valid for the period from 14.11.2015 to 13.11.2016 and the same was subsequently renewed from time to time and renewed policy was bearing number 233500/48/2018/3425 valid upto 13.11.2018 and the policy was for Rs.4,00,000/-.
2. Further case of the complainant is that during the subsistence of the insurance policy, the complainant suffered from stomach disease in February 2016 as the fluid was stored in the abdomen of the complainant and as such the complainant visited PGI Chandigarh for check up and some tests of whole body of the complainant were conducted, where he spent Rs.8400/-, but the complainant was not cured there. The complainant further visited DMCH Ludhiana and after consultation with Dr. Ajit Sood, was admitted in the DMCH on 15.7.2016 and discharged on 17.7.2016 where the complainant spent an amount of Rs.38,456/-. The complainant also hired the taxi for DMC Ludhiana and PGI Chandigarh and spent an amount of Rs.20,000/ for taxi fare. Thereafter on 15.7.2016 the complainant immediately intimated OP number 4 on his line number 18004259449 and lodged his claim. Thereafter the complainant submitted all the relevant documents to OP number 4 through courier, but the claim of the complainant was not settled. As such, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.66,856/- along with along with interest and further to pay Rs.20,000/- as compensation on account of mental agony, tension and harassment and an amount of Rs.11,000/- on account of litigation expenses.
3. In reply filed by OPs number 1 and 2, it is admitted that the complainant had taken the health insurance policy with assured sum of Rs.4,00,000/-. The policy terms and conditions were also supplied to the complainant. It is further averred that the complainant had been admitted at DMCH Ludhiana on 15.7.2016 for medical management of abdomen distention and diagnosed to have tubercular as-cities. After receiving the claim documents from the insured, the TPA, OP number 4 of Op number 2 sent a letter dated 16.8.2016 to the insured to submit the documents, such as, photo ID of the patient, pre numbered cash paid receipt for Rs.17556/- and Rs.18070/-, detailed break up for all the lab charges, letter from the treating doctor for readmission of the patient on same day, letter from the doctor containing line of treatment and reason for delay in submission of the claim, but the complainant did not send any reply as such OP number 4 closed the claim file of the complainant. Lastly, the OPs have prayed for dismissal of the complaint with special costs.
4. In reply filed by OP number 3, it is admitted that the complainant is having a saving bank account with the OP. It is stated further that the OP number 3 never allured the complainant to take the insurance policy as stated in the complaint. The other allegations leveled in the complaint have been denied.
5. The learned counsel for the parties produced their respective evidence.
6. The learned counsel for the complainant has argued that the complainant has an account bearing number 3474000100164019 with the OP number 3 and it has tie up with the OPs number 1 and 2. The learned counsel for the complainant has further argued that the complainant took a medical health insurance policy having number 233500/48/2015/1822 issued on 28.10.2015 which was valid for the period from 14.11.2015 to 13.11.2016 and the same was subsequently renewed from time to time. The learned counsel for the complainant has further argued that the complainant took treatment from PGI Chandigarh and DMC Ludhiana and spent an amount of Rs.66,856/- including taxi charges, but the Ops did not settle the claim. As such, the complainant has prayed for acceptance of the complaint.
7. On the other hand, the learned counsel for the OPs number 1 and 2 has argued that there is no evidence on the file to show that the complainant spent an amount of Rs.20,000/- as taxi charges. The learned counsel for the OPs has further stated that the complainant has submitted the bills for treatment, but it is stated that no claim is payable. As such, the Ops number 1 and 2 has prayed that the complaint be dismissed.
8. To prove his case, the complainant has produced affidavit Ex.C-52 and has deposed as per the averments in the complaint. Ex.C-1 is the claim form, Ex.C-2 to Ex.C-5 are the receipts of PGI Chandigarh, Ex.C-6 to Ex.C-32 are the receipts and bills of DMC Ludhiana. Ex.C-33 is the insurance policy and Ex.C-34 is the policy schedule. Ex.C-35 is the copy of bank passbook, Ex.C-36 is certificate, Ex.C-37 are the courier receipts, Ex.C-48, Ex.C-49 to Ex.C-51 are the request letters of the OP.
9. On the other hand, the learned counsel for the OPs has produced affidavit Ex.OP1&2/2 of Shri Mukesh Malhotra, Divisional Manager wherein he has stated that after receiving the claim documents from the complainant, they sent various letters to the complainant to supply the documents, but no reply was sent by the complainant. The OP number 3 has also submitted affidavit of Shri Ishan Mehra, Manager, Punjab National Bank and has deposed as per the written version produced on the file.
10. There are numerous documents of PGI Chandigarh Ex.C-2 to Ex.C-6 and of DMC Ex.C-7 to Ex.C-32 vide which the complainant had taken treatment from both these hospitals. The claim form is already on the file and the complainant has claimed an amount of Rs.46,835/- for the amount spent on the treatment. The complainant has also demanded an amount of Rs.20,000/- as taxi charges, but there is no document on the file to show that he spent this amount as taxi charges, so he is not entitled to this amount.
11. Admittedly, the complainant and his family members were insured with the OPs number 1 and 2 as the policy on record is Ex.C-33. When the complainant is insured with the OPs, the OPs are duty bound to pay the insurance claim to the complainant.
12. In view of our above discussion and circumstances of the case, we allow the complaint and direct OPs number 1 and 2 to pay to the complainant the amount of Rs.46,835/- along with interest @ 6% per annum from 1.11.2018 i.e. the date of filing of the present complaint till realization in full. We further direct OP number 1 and 2 to pay to the complainant an amount of Rs.5,000/- on account of compensation for mental tension, agony and harassment and an amount of Rs.5000/- on account of litigation expenses. This order be complied with by the opposite parties within 60 days from the date of receipt of certified copy of this order. A certified copy of this order be issued to the parties free of cost as per rules. File be consigned to records.
Pronounced.
February 15, 2021.
(Vinod Kumar Gulati) (Jasjit Singh Bhinder)
Member President
