Complainant Rajeev Puri through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that his complaint may kindly be accepted and opposite parties be directed to pay Rs.64,657/- alongwith interest @ 9% P.A. from the date of complaint till its realization alongwith Rs.20,000/- for mental agony and pain to him, in the interest of justice.
- The case of the complainant in brief is that he has taken a family health policy from the opposite party bearing policy No.233300/48/2014/5679 through the collaboration with Oriental Bank of Commerce, Gurdaspur in which he and his family members i.e. wife Choru Puri, two minor children namely Saksham Puri and Devna Puri are covered. Thus, he is consumer of the opposite parties. His daughter Devna Puri fell ill seriously due to fever of unknown origins (Cystitis) and her treatment was conducted in the Thakkar Children Nursing Home and Hospital, Ludhiana and it became difficult for the doctors to diagnose it. His daughter got admitted in the abovesaid hospital from 15 August, 2014 to 25 August 2014 and the doctor had openly told him that even after the discharge, she had to visit the hospital frequently for proper treatment. He had duly intimated the Branch Office Oriental Bank of Commerce, Gurdaspur on 18.8.2014 i.e. from where the policy was taken i.e. after three days regarding the admission of his daughter in the Thakkar Hospital. Even after the discharge from the abovesaid hospital, he visited DMC, Hospital Ludhiana for further treatment as her daugher’s life is at risk and he is at great mental harassment and her treatment continues upto November 2014. He claimed Rs.64,657/- in the office of the opposite party for the expenses of the treatment incurred upon her daughter and all the bills and the receipts regarding the treatment was submitted to the opposite parties alongwith the claim form but his claim was repudiated by the Medical Assistant, TPA Pvt.Ltd who works in collaboration with the opposite party vide letter dated 24.07.2015 on the ground that it does not fulfill the condition of the clause 5.4 and 5.5. of the policy. He approached the office of the opposite party regarding the repudiation of the claim and has also sent a letter to the office of the opposite party regarding the wrong repudiation of the claim. He also sent a request letter to the office of the opposite party through his counsel on 24.8.2015 to review the decision of the repudiation of the claim, but no reply was sent regarding that letter. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.
- Notice of the complaint was served upon the opposite parties. Opposite party no.1 appeared through its counsel and filed its written reply by taking the preliminary objections that the complainant is not entitled to any insurance claim as the claim of the insured does not fall within the purview of the policy terms and conditions. The claim is not covered/payable as per terms and conditions of ‘Oriental Bank Mediclaim Insurance Policy’. The complainant took policy on 13.03.2013 for a period from 12.03.2013 to 11.03.2014 under policy no.233300/48/2013/3896 issued by B.O. Gurdaspur. The claim of the complainant was repudiated on 24.07.2015 by the Medi Assist India TPA Pvt.Ltd. on the ground that no intimation was given to the insurance company within 48 hours from the date of hospitalization/treatment and the claim documents have not been submitted with the insurance company within 7 days from the date of discharge from the hospital. The claim was repudiated and same is not payable as it falls under Exclusion 5.4 and 5.5 of the terms and conditions of Oriental Bank Mediclaim Insurance Policy; the complaint is not maintainable; the complaint is without any cause of action and the present complaint is not maintainable for non joinder of necessary party. On merits, it was submitted that it was incorrect that the complainant had duly intimated the Branch Office Oriental Bank of Commerce, Gurdaspur on 18.08.2014 i.e. from where the policy was taken i.e. after three days regarding the admission of his daughter in the Thakkar Hospital. Actually, the complainant never intimated the opposite party within 48 hours from the date of hospitalization/treatment and the claim documents have not submitted with the insurance company within 7 days from the date of discharge from the hospital. All other averments made in the complaint have been specifically denied and lastly prayed for dismissal of the complaint with costs.
- Opposite party no.2 appeared through its counsel and filed its written reply by taking the preliminary objections that the complainant has no locus standi to file the present complaint against the opposite party; the opposite party no.1 is a separate and distinct body than the opposite party no.2 and the opposite party has got no concern or connection with the opposite party no.1. The opposite party no.2 is having separate business than the opposite party no.1. On merits, it was denied that the opposite party no.2 ever issued any policy nor the complainant has got any right to raise or demand any kind of claim from the opposite arty no.2 in any manner whatsoever. It was also denied that any such documents were delivered by the complainant to the opposite party. The question of delivering the documents does not arise when the opposite party no.2 has got no concern or connection with the opposite party no.1. All other averments made in the complaint have been specifically denied and lastly prayed for dismissal of the complaint with costs.
- Notice of the complaint was issued to opposite party no.3 but the same has not been received back. Case called several times, but none has come present on its behalf, therefore, it was proceeded against exparte vide order dated 22.4.2016.
6. Complainant tendered into evidence his own affidavit Ex.C1 along with other documents Ex.C-2 to Ex.C-19 and closed the evidence.
7. Counsel for the opposite party no.1 tendered into evidence affidavit of Sh.Karam Singh, Branch Divisional Manager Ex.OP-1/1 and closed the evidence.
8. Sh.Devinder Laroia, Chief Manager of opposite party no.2 tendered into evidence his own affidavit Ex.OP-2/1 and closed the evidence.
9. We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels to plead the prospective interests of their respective contestants. We find that the present dispute has arisen on account of the alleged ‘repudiation’ of the insurance-claim (by the OP1 insurers) as filed by the present complainant pertaining to the hospitalization/ indoor med-treatment expenses of his daughter w e f 15.08.2014 onwards (followed by further extended hospitalizations/treatments etc) on account of exclusions # 5.4 and 5.5 of terms and conditions of the applicable insurance policy.
10. We have examined the above exclusions and find that # 5.4 demands that the Notice of Claim shall be made within 48 hours of ‘admission’ to the hospital and # 5.5 desires submission of claim-documents within ‘7’ days of ‘discharge’ from the hospital. Somehow, the OP1 insurers have neither produced the date & time of the Notice of Claim nor have provided/produced the date of receipt of the insurance claim etc. They have simply pleaded that the complainant did not give the notice of claim to its agent OP2 Bank (OBC) on 18.08.2014 as alleged, in the present complaint. The OP1 insurers and the OP2 Bank have filed replies and concurrent affidavits only with no documentary evidence to support their own respective averments. The complainant produced letter Ex.C4 and OP2 Bank’s letter Ex.C5 do prove that the OP2 Bank (the OP1 insurer’s agent) was duly given Notice of 18.08.2014 and that suffices the requirements of exclusion # 5.4; whereas any violation of exclusion 5.5 has not even been attempted to be proved by the titled opposite parties. It is apparently available that the OP1 insurers and the OP3 TPA have repudiated the claim on flimsy and arbitrary grounds without having any cogent evidence available to them. Although, the OP2 Bank have (in its reply) have denied having any relation with the issuance of the related policy but the policy’s very title (Ex.C3) speaks otherwise. It is indeed intriguing that both the OP1 insurers and the OP2 Bank, in spite of being nationalized institutions have distorted the ‘facts’ in its replies/ depositions before the forum. We are, of course not pleased with the inadvertent depositions of the two opposite parties, here; however somehow, are not inclined to initiate contempt proceedings in view of the careers of the concerned officials and thus leave them off with ‘censure’, only. However, the titled OPs are for sure liable to an adverse statutory award under the applicable Act.
11. In the light of the all above, we partly allow the present complaint and thus ORDER the OP1 insurers to pay the impugned claim (on merits) strictly in terms of the related policy (to its full benefits) in accordance with the IRDA guidelines on ‘settlement of claims’ besides to pay Rs.5,000/- as compensation and Rs.3,000/- as litigation expenses to the complainant within 30 days of receipt of the copy of these orders otherwise the aggregate awarded amount shall carry interest @ 9% PA from the date of filing of the complaint till actual payment.
12. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (Jagdeep Kaur)
August 16, 2016 Member.
*MK*
