BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.461of 2017

Date of Instt. 05.12.2017

Date of Decision: 26.02.2019

Vinod Kumar aged 52 years son of Sh. Dwarka Dass R/o House No.278, Nandanpur Road, Sudarshan Park, Maqsudan, Jalandhar.

..........Complainant

Versus

1. Oriental Insurance Company Ltd. Branch Office-2, Near PUDA Complex, Jalandhar through its Branch Manager/Incharge etc.

2. M/s Raksha Health Insurance, TPA Pvt. Ltd. C/o Escorts Corporate Centre, 15/5, Mathura Road, Faridabad, Haryana through its Manager/MD/Director/Incharge etc.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Jyotsna (Member)

Present: Sh. A. P. S. Pathania, Adv Counsel for the Complainant.

Sh. A. K. Arora, Adv Counsel for OP No.1.

Opposite Party No.2 exparte.

Order

Karnail Singh (President)

1. This complaint has been filed by the complainant, wherein alleged that he is an account holder with Punjab National Bank. The complainant under the scheme having the tie-up between the PNB and the OPs that the account holders of the said Punjab National Bank can get the insurance cover note of medi-claim facilities and accordingly, the complainant has been taken insurance cover w.e.f. 28.03.2014 to 27.03.2015 by making the payment of premium of Rs.1449/-, and again w.e.f. 28.03.2015 to 27.03.2016 by making a payment of Rs.1749/- and thereafter, w.ef. 28.03.2016 to 27.03.2017 by making a payment of Rs.4709/- and subsequently, on 28.03.2017 till 27.03.2018 by making the payment of Rs.4730/-. The complainant has been provided the medical insurance facilities by its TPA i.e. OP No.2 and the member ID Card issued by the OP No.2 in this regard is also attached. Thereafter, the complainant suddenly got some trouble in his heart and he was hospitalized on 06.08.2017 in the nearby Sacred Heart Hospital, Maqsudan Area, Jalandhar and remained in ICU and under regular treatment and he was later on discharged by the said hospital on 13.08.2017. The complainant through his family members immediately informed to the OPs for providing the cashless medi-claim facilities and in this regard, the claim form and necessary documents were also submitted to the OPs, but the OPs did not bother and they failed to provide cashless medi-claim facility before his discharge from the hospital and as such, the complainant made all the payments to the hospital as well as to the medical shop regarding the purchase of the medicines and approximately the complainant bear the expenses of hospital of Rs.1,59,230/- and other expenses about Rs.1,00,000/- and thereafter, the complainant gave numerous email, but the OPs did not bother rather the claim of the complainant was refused by OP No.2, vide letter dated 14.08.2017 despite various representations and personal visits, the OPs have dilly dallied the matter on one pretext or the other and they have treated him as a rolling stone from pillar to post and have harassed him. The act and conduct of the OPs is negligent, they are indulged in unfair trade practice, deficiency in service and by doing so the complainant deserves not only the amount of insurance claim, but also for damages on account of mental pain, agony and harassment and accordingly, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the medical expenses of Rs.1,59,230/- along with interest and further OPs be directed to pay damages for mental pain, agony and harassment, caused to the complainant, to the tune of Rs.15,00,000/- and litigation expenses of Rs.33,000/- .

2. Notice of the complaint was given to the OPs, but despite service, OP No.2 did not come present and ultimately, OP No.2 was proceeded against exparte, whereas OP No.1 served and appeared through its counsel and filed a detailed reply, whereby contested the complaint by taking preliminary objections that there is no deficiency of service or unfair trade practices on the part of the OPs and that being so, the present complaint is not maintainable. It is further averred that the claim of the complainant has been settled and a sum of Rs.1,56,735/- has already been paid to the complainant through NEFT in his account. The complainant has lodged a claim of Rs.1,59,230/- with the OP. From the said claim of Rs.1,59,230/- a sum of Rs.1100/- have been deducted for dietary charges, Rs.10/- deducted for gate pass charges, Rs.910/- deducted for consumable charges and Rs.400/- deducted for admission charges, which were not payable as per the terms and conditions of policy of insurance. After deducting the aforesaid amount as referred above, the entire claim of Rs.1,56,735/- due and payable under the policy of insurance has already been paid. Thus, the present complaint is liable to be dismissed being fully redressed in view of payment of the entire claim of the complainant. On merits, it is admitted that the complainant obtained the policy and also admitted that the complainant submitted a claim, but the same was not paid under a mistaken belief qua the running of policy of insurance of the complainant. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

3. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA along with some documents Ex.C-1 to Ex.C-78 and closed the evidence.

4. Similarly, counsel for the OP No.1 tendered into evidence affidavit of Sh. Sandeep Thapa as Ex.OP1/A along with documents Ex.OP1/1 and Ex.OP1/2 and closed the evidence.

5. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

6. After considering the over all circumstances, we find that the allegations made by the complainant in its complaint has been controverted by the OP by simple taking a plea that the claim of the complainant has been settled and the amount whatsoever payable i.e. Rs.1,56,735/- has already been transferred through NEFT in the account of the complainant, regarding that the OP has brought on the file affidavit of the official Ex.OP1/A and Claim Settlement Voucher Ex.OP1/2.

7. Now, we think that the allegations of the complainant in regard to rejection of the claim and not paying the cashless medi-claim are not required to discuss because the payment has been made by the OP No.1 to the complainant. Now, we have to consider whether the payment made by the OP through NEFT in the account of the complainant is sufficient or it covers the expenses incurred by the complainant on his treatment and further, whether the delay for making a payment is reasonable, as per version of the OPs, the reasonable period of 4-6 months is to be given to the OPs for settlement of the claim.

8. Keeping in mind the above queries, we have gone through the documents and pleadings and find that the complainant has categorically took a plea in Para No.7 that the OP has refused to make the payment of the medical expenses, vide letter dated 14.08.2017 and in reply to Para No.7, the OP admitted that the claim of the complainant, under a mistaken belief has not been settled, it means that the OP has admitted that a cashless facility was not provided to the complainant at the time of his admission in the hospital and further the expenses of the treatment incurred by the complainant has also not been paid, even after submitting a claim form, by the OP for about one year because the complainant remained in the hospital from 13.08.2017 to 14.08.2017 and immediately, he submitted the claim form with the insurance company, but the payment has been made to the complainant, vide document Ex.OP1/2, on 16.01.2018, means after one year and three months. So, it is admitted that the version of the OP that a reasonable time for settlement of claim of 4 months is required, but in this case, the OP consumed more than 1 year and moreover, the OP has rejected the claim of the complainant without any reason. So, it is clear cut negligence on the part of the OPs and complainant has suffered a lot due to the harassment caused by the OPs for such a long time i.e. 1 year and 3 months and ultimately, the instant complaint filed by the complainant and during the pendency of the complaint, the OP has no other alternative except to pay the medical expenses amount just to save their skin from the payment of compensation and litigation expenses. So, with these observations, we are of the opinion that there is a negligence as well as deficiency in service on the part of the OP and as such, we reached to the conclusion that the complainant is entitled for the relief claimed, from OP No.1.

9. In the light of above detailed discussion, the complaint of the complainant is partly accepted and accordingly, OP No.1 is directed to pay the insurance claim amount of Rs.1,59,230/- with interest @ 12% per annum from the date of rejection of the claim i.e. 14.08.2017, till realization. If the OP has really paid the amount as alleged in document Ex.OP1/2 i.e. Rs.1,56,735/-, the same be deducted from the above amount. Further, the OP No.1 is directed to pay compensation for harassing the complainant, to the tune of Rs.50,000/- and litigation expenses of Rs.10,000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Jyotsna Karnail Singh

26.02.2019 Member President