DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 439 of 1.10.2021

                                      Decided on: 9.9.2024

Mandeep Singh son of Sh.Rajinder Singh, resident of village and Post Office Kulburrchhan ,Tehsil  Samana District Patiala

                                                                    …………...Complainant

                                      Versus

1. Oriental Insurance Co. Ltd. (A Govt. of India Undertaking) Regional Office, Surendra Building, SCO 109-110-111, Sector 17-D,Chandigarh.
2. Oriental Insurance Co. Ltd. , SCO 99-100, Sector 17-B, Chandigarh, through its signatory authority.                                    …………Opposite Parties

Complaint under the Consumer Protection Act

QUORUM

                                      Sh.Pushvinder Singh, President

                                      Sh.G.S.Nagi,Member    

ARGUED BY              

                                      Sh.Ravinder Singh, counsel for complainant.

                                      Sh.Alok Mathur, counsel for OPs.                                

 ORDER

                                      G.S.NAGI,MEMBER

1. The instant complaint is filed by Mandeep Singh  (hereinafter referred to as the complainant) against Oriental Insurance Co. Ltd. (hereinafter referred to as the OP/s) under the Consumer Protection Act ( for short the Act).
2. It is averred in the complaint that the complainant is a policy holder of OPs under Nagrik Suraksha Individual policy Schedule vide policy No.231100/48/2020/1425 CL.No.230011/48/2021/00030052 i.e. 9.3.2020 to midnight 8.3.2021 for the sum assured of Rs.5,00,000/- under the claim of death or accident.
3. It is averred that the complainant met with accident on 4.10.2020 at Kalajhar, near Channo, District Sangrur. The complainant got medical treatment .So many medical tests were got conducted and due to complication a one month treatment was taken from Dr.Ajmer Singh, M.S.,F.A.M.S. at Dr.Ajmer Singh Hospital, Patiala. That intimation in this regard was given to the OPs who conducted a spot survey by deputing personal officials and the accident was found genuine. That after spot survey complainant supplied necessary and original documents to the OP who also obtained signatures on the complainant on some blank documents and some pieces of paper with the assurance that the claim will be processed soon. Thereafter complainant approached and requested the OP to make the payment of amount that was insured under the terms and conditions of the insurance policy but the OP put off the matter on pretext or the other. Complainant also wrote letters and made telephone calls to the OPs in this regard but of no avail which amounts to deficiency in service on the part of the OPs. That complainant also got served legal notice dated 3.5.2021 upon the OP but no fruitful action was taken by the OPs. That the act and conduct of the OP caused mental agony and harassment to the complainant. Hence this complaint with the prayer to accept the same by giving directions to the OPs to pay Rs.30,000/- alongwith interest @22% per annum from the date of accident till realization; to pay Rs.2,00,000/- as compensation for causing mental agony and harassment and also to pay rs.25000/-as litigation expenses.
4. Upon notice, OPs appeared through counsel and filed written reply having contested the complaint by raising preliminary objections that the complaint is not maintainable; that no cause of action as accrued to the complainant to file the present complaint; that the complainant has not come to this Hon’ble Commission with clean hands and has filed the present complaint intentionally and knowingly on totally false, wrong, concocted and misleading grounds after concealing the true and material facts and that the complainant is estopped by its act and conduct from filing the present complaint.
5. On merits, it is submitted that complainant has obtained Nagrik Suraksha Individual policy bearing No.231100/48/2020/1425 valid from 9.3.2020 to 8.3.2021 from the OPs with sum insured personal accident Section 80% to the extent of Rs.4lac, hospitalization Section 20% to the extent of Rs.1 lac with cumulative bonus of Rs.25000/-.
6. It is submitted that on receipt of intimation M/s Kalra Associates were appointed as investigator and they have submitted their independent investigation report dated 31.12.2020 but  the complainant failed to submit requisite documents, information and clarification sought by the investigator vide his letter dated 23.11.2020 followed with reminder dated 12.12.2020 and several verbal requests and the claim file of the complainant was closed vide letter dated 29.1.2021. It is alleged that reply to the legal notice was duly given by the OPs. There is no deficiency in service on the part of the OPs and the complainant is not entitled for any compensation/claim in any manner under any head. After denying all other averments of the complaint, OPs have prayed for the dismissal of complaint.
7. In evidence, complainant alongwith his  counsel has tendered his affidavit,Ex.CA alongwith documents i.e. Ex.C1 legal notice, Exs.C2 and C3, postal receipts, Ex.C4 Nagrik Suraksha Individual Policy schedule,Ex.C5 medical test and treatment of Khanna Nursing Home (three pages), Ex.C6 prescription slip Khanna Nursing Home,Ex.C7 CT scan report delta,Ex.C8 payment receipt of Khanna Nursing Home dated 5.10.2020, Ex.C9 receipt of Delthi MRI & CT Scan Centre dated 4.10.2020,Ex.C10 bill dated 5.10.2020 of Chandigarh Medical Hall, Ex.C11 treatment of Dr.Ajmer Singh Hospital dated 5.11.2020 and closed evidence.      
8. On the other hand, ld. counsel for OPs has tendered in evidence Ex.OPA affidavit of Mukesh Malhotra, Sr.DM, OIC, Ex.OPB affidavit of Vivek Kalra of Kalra Associates alongwith documents i.e. Ex.OP1 copy of insurance policy, Ex.OP2 terms and conditions of the policy, Ex.OP3 letter dated 5.1.2021, Ex.OP4 postal receipt,Ex.OP5 letter dated 29.1.2021, Ex.OP6 postal receipt,Ex.OP7 reply sent by Sahil Abhi Adv. to Ravinder Singh Adv. Ex.OP8 investigaion report of Kalra Associates ,Ex.OP9 copy of letter dated 12.12.2020,Ex.OP10 copy of postal receipt,Ex.OP11 copy of letter dated 23.11.2020 and closed evidence.
9. OPs have filed the written arguments. We have gone through the same, heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
10. The complainant was holder of Nagrik Suraksha Individual policy issued by the OPs for a sum insured of Rs.5lacs which was valid from 9.3.2020 to 8.3.2021 as per policy document,Ex.C4.The complainant has alleged that he met with an accident on 4.10.2020 and was treated by Dr.Sandeep Sharma of Khanna Nursing Home as per discharge summary Ex.C6 and was discharged on 5.10.2020 as per the hospital records which is Exs.C5 to C7.As per the said discharge summary complainant  was suffering from multiple injuries (Open injuries on his right foot with forehead) and stitches were provided on both the injuries. The complainant has alleged that various tests were conducted on him as per details,Exs.C8 & C9 i.e. the complainant had to undergo C.T.Scan as per report Ex.C7 for which payment of Rs.2400/- was paid by the complainant as per Ex.C9.The complainant was then prescribed certain medicines as per Ex.C5 for which bill of Rs.7242/- has been produced by the complainant as per Ex.C9.The complainant has also incurred expenses of Rs.12500/- at the said nursing home as per receipt,Ex.C7. The complainant has alleged that he was forced to take the treatment for two months after the accident and has produced on record copy of the OPD slip of Dr.Ajmer Hospital, which is Ex.C11. The complainant has alleged that the claim was then lodged by him with the OPs which was processed under claim No.2330000/48/2019 and the same was investigated by Kalra Associates as per report,Ex.OP8. However, the claim of the complainant was not settled. The complainant has also served a legal notice dated 3.5.2021 as per Ex.C1.Even then the claim was not settled by the OPs. The complainant has as such prayed for the settlement of his claim to the tune of Rs.30,000/- alongwith interest and also to pay compensation and litigation expenses.
11. The OPs in their written statement have admitted that the complainant was the holder of the Nagrik Suraksha Individual policy of the OPs which was valid from 9.3.2020 to 8.3.2021 strictly as per terms and conditions of the policy as per Ex.OP2 for which a premium of Rs.399/- was paid by the complainant. The OPs have submitted that on receipt of the intimation about the accident M/s Kalra Associates were deputed as Investigators and detailed report dated 31.12.2020 was submitted which is Ex.OP8.The OPs have further submitted that the complainant was then asked to submit the requisite documents and certain clarifications were also sought by the Investigator vide his letter dated 23.11.2020 and reminder dated 12.12.2020 but no response was received from the complainant. The OPs have submitted that  it is wrong that the complainant had taken the treatment for two months from Dr.Ajmer Singh at Patiala. The OPs have further submitted that the complainant was asked to submit various documents as per the letters dated 15.1.2021 which is Ex.OP3 and 29.1.2021 which is Ex.OP5 but no documents like discharge summary, detailed bills alongwith certificate from the nursing home from where treatment was taken, were submitted by the complainant .Since the complainant failed to produce the documents, so the claim of the complainant was closed as NO Claim due to non submissions of documents. The legal notice issued by the complainant was duly replied on 8.5.2021 as per Ex.OP7 and there is no deficiency in service on the part of the OPs and have prayed for the dismissal of the complaint.
12. We have gone through the rival submissions of the parties and the evidence produced on record.
13. Admittedly the complainant was holder of Nagrik Surksha Individual policy issued by the OPs for a sum insured of Rs.5lacs which was valid from 9.3.2020 to 8.3.2021 as per policy document,Ex.C4.The complainant has alleged that he met with an accident on 4.10.2020 and was treated by Dr.Sandeep Khanna, BAMS MD(ALT MED) of Khanna Nursing Home as per discharge summary Ex.C6 and was discharged on 5.10.2020 as per the hospital records which is Exs.C5 to C7.As per the said discharge summary complainant  was suffering from multiple injuries (Open injuries on his right foot with forehead) and stitches were provided on both the injuries. The complainant has alleged that various tests were conducted on him as per details,Exs.C8 & C9 i.e. the complainant had to undergo C.T.Scan as per report Ex.C7 for which payment of Rs.2400/- was paid by the complainant as per Ex.C9.The complainant was then prescribed certain medicines as per Ex.C5 for which bill of Rs.7242/- has been produced by the complainant as per Ex.C9.The complainant has also incurred expenses of Rs.12500/- at the said nursing home as per receipt,Ex.C7. The complainant has alleged that the claim was then lodged by him with the OPs which was processed under claim No.2330000/48/2019 and the same was investigated by Kalra Associates as per report,Ex.OP8. All these documents as discussed above were provided by the complainant to the Investigator as the same have been produced by the OPs alongwith report of the Investigator which is Ex.OP8. As such the arguments of the OPs that the documents were not provided by the complainant is not justified. Even the letters alleged to have been issued by the Investigator to the complainant have not been produced by the OPs.
14. As per the report of the Investigator the bills, receipts, cash memos to the tune of Rs.22142/- (treatment receipt Rs.12500/-, medicines cash memo Rs.7242/- & C.T.Scan Rs.2400/-) were provided to the Investigator by the complainant as the same have been entered in his report. As such we are of the opinion that the documents were duly provided by the complainant to the OPs and the claim of Rs.22142/- the receipt of which has been produced by the OPs has been wrongly rejected by the OPs.
15. In view of the aforesaid discussion we partly allow the complaint and direct the OPs to settle the claim of the complainant to the tune of Rs.22142/- alongwith interest @9% per annum from the date of payment i.e. 5.10.2020 till realization. OPs are also directed to pay Rs.5000/-as compensation for causing mental agony and harassment alongwith Rs.5000/-as litigation expenses to the complainant. Compliance of the order be made by the OPs within 45 days from the date of receipt of certified copy of this order
16. The instant complaint could not be disposed of within stipulated period due to heavy rush of work and for want of Quorum from long time.
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                                              G.S.Nagi                PUSHVINDER SINGH

                                              Member                          President