Punjab

Faridkot

CC/17/307

Swaran Singh - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

Amit Kumar Mittal

04 Feb 2019

ORDER

      DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :                307

Date of Institution:  8.09.2017

Date of Decision :    4.02.2019

Swaran Singh aged about 49 years son of Tejinder Singh resident of Baba Farid Nagar, Street No. 3, Faridkot Road, Kotkapura, Tehsil Kotkapura, District Faridkot.

...Complainant

Versus

1. The Oriental Insurance Company Ltd, Registered & Head Office A-25/27, Asaf Ali Road, New Delhi-110002.
2. Medi Assist India, TPA Pvt Ltd. 8-B, IInd Floor, Tej Building, Bahadur Shah Jaffer Marg, New Delhi 110002.
3. Oriental Bank of Commerce, having its Branch Office at Satta Bazar, Kotkapura, through its Bank Manager.

.....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt Param Pal Kaur, Member.

 

Present: Sh Amit Mittal, Ld Counsel for complainant,

              Sh Vinod Monga, Ld Counsel for OPs-1  and 2,

              Sh Sandeep Tayal, Ld Counsel for OP-3.

 

ORDER

(Ajit Aggarwal, President)

                                      Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of Rs.61,000/- on account of Mediclaim of complainant and for further directing OPs to pay Rs.20,000 as compensation for harassment, inconvenience, mental agony suffered by complainant besides litigation expenses of Rs.15,000/-.

2                               Briefly stated, the case of the complainant is that complainant purchased a Mediclaim insurance policy valid for period from 24.07.2015 to 23.07.2016 and both complainant and his wife and their children were covered under said Mediclaim insurance policy to the tune of Rs.5 lacs. It is submitted that on 24.01.2016 wife of  complainant suffered from Hepatitis ‘C’ and she was admitted in Deepak Hospital, Sarabha Nagar, Ludhiana and during her stay in hospital, she was also given treatment and discharged on 25.01.2016. Complainant spent Rs.61,000/- for treatment of his wife. Intimation regarding hospitalization was given to OPs on 24.01.2016 as per terms and conditions of the insurance policy and thereafter, complainant lodged the claim OPs and completed all the requisite formalities for obtaining insurance claim on account of her treatment, but OPs have not cleared his claim despite repeated requests. Complainant also served legal notice to OPs through his counsel on 31.07.2017, but OPs neither gave any reply nor paid any heed to his requests to make payment of insurance claim.

3                                          It is further submitted that complainant completed all the formalities to obtain insurance claim and paid several visits to the office of Ops, but all in vain. Due to non payment of insurance claim by OPs, complainant has been suffering great economic loss and hardships. This act of OPs amounts to deficiency in service and has caused harassment and mental agony to complainant for which he has prayed for accepting the complaint alongwith compensation and litigation expenses. Hence, the present complaint.

4                                       The counsel for complainant was heard with regard to admission of the complaint and vide order dated 15.09.2017, complaint was admitted and notice was ordered to be issued to the opposite parties.

5                     On receipt of the notice, OPs No. 1 and 2                                                                                                                                              filed written statement taking objections that complainant has no cause of action to file the present complaint as complainant himself failed to submit the requisite documents to them. However, it is admitted by OP-1 and 2 that complainant purchased the mediclaim insurance policy in question from them and it was valid from 24.07.2015 to 23.07.2016. It is also admitted that complainant, his wife and children were covered under said insurance policy.  It is averred that complainant did not submit the documents required for processing the claim of complainant. It is further averred that vide letters dated 9.08.2016; 23.08.2016 and 1.09.2016, complainant was asked to supply letter from Hospital mentioning time of admission and discharge alongwith final bill with detailed breakup for same with case paid receipt, but complainant did not furnish these documents with them and therefore, claim of complainant was closed as ‘No Claim’. It is asserted that complainant cannot be given benefit of his own wrong. He himself did not supply the requisite documents, which were  required for processing the claim to OP-1 and 2  and therefore his claim was rightly closed and thus, there is  no deficiency in service on the part of answering OPs. All the other allegations and allegations with regard to relief sought too were refuted with prayer to dismiss the complaint with costs.

6                                       OP-3 filed written statement through counsel wherein took preliminary objections that complaint against them is not maintainable as they acted only as a facilitator and they have been wrongly impleaded as party in present complaint and therefore, complaint in hand is not maintainable and is liable to be dimsised. However, on merits OP-3 has denied all the allegations of complainant being wrong and incorrect but admitted before the Forum that complainant availed the mediclaim insurance policy in question from them. it is averred that they acted only as facilitator after issuance of policy, they have no concern with complainant. it is further averred that never approached them regarding his insurance claim in question. Complainant never supplied any document to them nor submitted his claim to them. all the other allegations alongwith allegation for relief sought too are refuted with prayer to dismiss the complaint with costs.

7                                        Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to 17 and then, closed his evidence.

8                               In order to rebut the evidence given by complainant, the ld Counsel for OPs tendered in evidence, affidavit of Ashwani Kumar as Ex OP-1,2/1 and documents Ex OP-1,2/2 to Ex OP-1, 2/4 and then, closed the same on behalf of OP- and 2. Ld counsel for OP-3 tendered in evidence affidavit of Rajinder Kumar as Ex OP-3/1 and closed the same on behalf of OP-3.

9                                              We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

10                                       The case of complainant is that he alongwith his wife and children, was insured with OPs for sum of Rs.5 lacs vide policy issued by OP-1 and 2 and during the period of subsistence of insurance policy, wife of complainant suffered from Hepatitis C and she was admitted in Deepak Hospital, Ludhiana on 24.01.2016. During her stay in said hospital, his wife was also treated there and she was discharged on 25.01.2016. Complainant spent Rs.61,000/- on treatment and gave due intimation regarding same to Ops and also lodged claim with them. Complainant duly submitted his claim with OPs alongwith all relevant documents required for processing the claim, but till now, they have not made a single penny on account of expenditure incurred by him on treatment. Despite several requests and Legal notice issued by complainant to OPs, they did not make payment of claim amount of Rs.61,000/-. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of claim amount to him which amounts to deficiency in service. He has prayed for accepting the complaint alongwith compensation and litigation expenses. He has also stressed on documents produced by him as Ex C-1 to C-17. In reply, OP-1 and 2 stressed mainly on the point that complainant  has no cause of action to file the present complaint as the claim of complainant was not passed due to his own act of non submission of requisite documents. Vide letter dated 9.08.2016, 23.08.2016 and 1.09.2016 complainant was asked to furnish them letter from Hospital where treatment was done clearly showing the date of admission and date of discharge alongwith bill with detail break up and receipts for cash paid by him, but complainant did not supply the same to OP-1 and 2 and therefore, his claim was closed as ‘No Claim’ and thus, there is no deficiency in service on their part. OP-3 stressed mainly on the paint that they acted only as a facilitator and after issuance of insurance policy in question, complainant never approached them. Complainant neither lodged any  claim with them nor submitted any documents to them. There is no deficiency in service on their part and also prayed for dismissal of complaint with costs.

11                     To prove his case complainant has relied upon documents Ex C-2 copy of letter written by complainant to OP-2 wherein he has clearly mentioned the point that he has already submitted requisite documents to them for making settlement of his claim. Ex C-3 is the copy of correspondence occurred between complainant and OP-2 wherein complainant has again mentioned that required documents have already been supplied by him to OPs and in it he has made requests to OPs to pass his  claim. Ex C-11 is copy of discharge summary placed on record by complainant which itself speaks the date of admission i.e 24.01.2016 and date of discharge of wife of complainant as 25.01.2016.    through Legal Notice Ex C-12 complainant has again made requests to OPs  to process his insurance claim. Complainant has produced sufficient and cogent evidence to prove his pleadings. There is no iota of doubt that during the subsistence of mediclaim insurance policy in question, wife of  complainant suffered from some problem and being insured under the said policy, they were entitled to get insurance claim on account of expenses incurred by them on her treatment.

12                                                From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant and his wife with OPs. Ops have themselves admitted that he alongwith his wife and children was insured with them as per Mediclaim Insurance Policy issued by them. OP-1 and 2 argued that as per policy terms and conditions, complainant failed to supply requisite documents showing detail of admission and discharge of his wife from the hospital, but from document Ex C-11 produced by complainant, which is self explanatory and in it,  it is clearly mentioned that wife of complainant was admitted in hospital on 24.01.2016 and she was discharged therefrom on 25.01.2016. Therefore, plea taken by OP-1 and 2 for not passing the claim of complainant and declaring it as ‘No Claim’ has no legs to stand upon. Act of non payment of insurance claim by OP-1 and 2 amounts to deficiency in service on their part.

12                                         From the above discussion, we are of considered opinion that OP-1 and OP-2 have wrongly and illegally repudiated the genuine claim of complainant on false grounds, which amounts to deficiency in service and trade mal practice on their part. Complainant has fully succeeded in proving his case, therefore, complaint in hand is hereby allowed against OP-1 and OP-2. OP-3 acted only as facilitator and has no role in making payment of insurance claim. Therefore, complaint against OP-3 stands hereby dismissed. OP-1 and OP-2 are directed to make payment of mediclaim insurance claim amount of Rs.61,000/-to complainant for the expenditure incurred by him on treatment of his wife alongwith interest at the rate of 9 % per anum from the date of filing the present complaint till final realization. They are further directed to pay Rs.5,000/- to complainant as consolidated compensation for harassment and mental agony suffered by him including litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 4.02.2019

 

     (Param Pal Kaur)        (Ajit Aggarwal)

                                    Member                          President