BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.412 of 2018

      Date of Instt. 05.10.2018

      Date of Decision: 16.08.2022

1.       Navita aged about 51 years wife of Ashwani Kumar Narang.

2.       Ashwani Kumar Narang aged about 57 years son of late Sh. Ram      Chand Narang

          Both residents of 466, Guru Gobind Singh Avenue, Bye Pass Road, Jalandhar.

..........Complainants

Versus

1.       Oriental Insurance Company Ltd., Registered and Head Office           A-25/27, Asaf Ali Road, New Delhi-110002.

2.       Oriental Insurance Company Ltd., Registered and Branch Office        SCO-50, PUDA Complex, Opp. Tehsil Complex, Ladowali Road, Jalandhar.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)                                

Present:       Sh. R. K. Bhalla, Adv. Counsel for the Complainants.

                   Sh. Nitish Arora, Adv. Counsel for OPs No.1 and 2.

Order

Jyotsna (Member)

1.                The instant complaint has been filed by the complainants, wherein it is alleged that the complainant No.1 purchased one Happy Family Floater Policy bearing No.233108/48/2016/4155 dated 24.02.2016 valid from 02.03.2016 to 01.03.2017 from the OPs and the said policy include the coverage of all kinds of risks of medical expenses of medical treatment including major surgeries of the complainants and their family members namely Sudhi Narang (Daughter) and Yoganter Narang (Son) as fully detailed in the policy. The yearly premium of policy was Rs.16,556/- and the complainant No.1 has paid the said premium to the OPs and the said policy is to cover the risk of medical treatment upto the tune of Rs.5,00,000/- of each insured member. The present policy is the continuation of previous policies issued by the OP since 2013 and the complainant No.1 was regularly renewing the same after making of the payment of annual premium. At the time of purchase of the policy, the concerned agent assured the complainant No.1 that during the validity of the policy, if any policy holder will suffer any kind of medical problem including any kind of surgery, the OPs are liable to pay all the hospital expenses, medicine expenses as well as other connected expenses to the complainant No.1. Moreover, at the time of the issuance of the policy, all the necessary requirements were fulfilled by the complainants and after due satisfaction, the OP issued the policy in question to the complainant No.1. During the validity of said policy, the complainant No.2 was having problem of ANAL FISSURE. Due to that reason, the complainant No.2 was admitted in Apex Hospital and Maternity Home, Jalandhar on 20.06.2016 and his surgery was conducted by Dr. Ranbir Singh of the said hospital on the same day and he was also provided medical treatment as required by the hospital authority. After the surgery, the complainant No.2 was discharged from the hospital on 22.06.2016. The complainant No.1 has paid a sum of Rs.33,865/- to the Apex Hospital, Jalandhar for medical treatment, which include hospital expenses, medicines as well as other expenses. Thereafter, the complainants filed the claim of the said amount with the OP and also completed necessary formalities as required by the OP. Alongwith the claim form, all the medical bills and receipts were also sent to the OP. Thereafter, one service provider of the OP namely E-Meditek-Insurance TPA Limited seeked some information as well as documents with regard to the processing of claim of the complainant No.1 which were also complied with by the complainants. In spite of fulfillment of all the requirements of the OP as well as its service provider, the OP has not paid the claim amount to the complainants. The complainants also sent reminders and notices dated 19.02.2018 as well as 23.03.2018 by which the OP was called upon to make the payment of the amount of claim, but in spite of all these the said amount was never paid to the complainant No.1 due to the reason best known to the OP. At the time of purchase of the policy, the OPs assured that the complainants need not to bother anything, the entire amount of the treatment will be directly paid by the OPs to the complainant immediately after the submission of the claim by them. In spite of the fact that the complainants had completed all the formalities, OPs was lingering on the matter on one pretext or other which resulted into deficiency in service on the part of the OPs and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the amount of claim i.e. Rs.33,865/-, a sum of Rs.1,00,000/- as compensation for the mental tension, harassment and agony suffered by the complainants alongwith interest @ 18% and Rs.22,000/- as cost and litigation expenses.

2.                Notice of the complaint was given to the OPs, who filed written reply and contested the complaint by taking preliminary objections that the   complainant lodged a claim with the OP No.2 for the surgery for anal fissure and haemorrhoids from Apex Hospital and Maternity Home on 20.06.2016 of complainant no.2 namely Ashwani Kumar Narang. The said claim was forwarded to E-Meditek Insurance TPA Limited i.e. Claim Settling Agency of the OPs, by OP No.2.         E- Meditek Insurance TPA Limited wrote various letters/reminders to the complainant for providing history and duration of constipation, anal fissure and haemorrhoids (since when) certified by treating doctor. Despite letters and reminders to the complainant by E-Meditek Insurance TPA Limited, the complainant did not reply to the letters and not submitted the desired information to E-Meditek Insurance TPA Limited i.e. Claim Settling Agency of the opposite parties. Thus the claim of the complainant was made ‘no claim’ on account of non submission of history and duration of constipation, anal fissure and haemorrhoids (since when) certified by the treating doctor. Thus the complainants are estopped by their own act and conduct from filing the present complaint. On merits, the factum with regard to taking insurance policy by the complainant from OP No.2 is admitted and lodging of the claim by the complainant is also admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                Rejoinder not filed by the complainant.

4.                In order to prove their respective versions, both the parties have produced on the file their respective evidence.

5.                We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for the OPs, very minutely.

6.                The case of the complainant is that the complainant No.1 purchased one Happy Family Floater Policy bearing No.233108/48/2016/4155 dated 24.02.2016 valid from 02.03.2016 to 01.03.2017 from the OPs, which is evident from Ex.C-1/Ex.O-1 and the said policy include the coverage of all kinds of risks of medical expenses of medical treatment including major surgeries of the complainants and their family members. During the validity of the said policy, the complainant No.2 was having problem of Anal Fissure and the complainant No.2 was admitted in Apex Hospital and Maternity Home, Jalandhar on 20.06.2016 and surgery was conducted on the same day. The complainant was discharged from hospital on 22.06.2016 and paid a sum of Rs.33,865/- to the Apex Hospital, Jalandhar for medical treatment etc. Copy of receipts of expenses incurred by the complainants for getting the medical treatment are Ex.C-8 & Ex.C-9 and copy of treatment record are Ex.C-10 to Ex.C-23. The complainants lodged the claim of the said amount and also completed all the necessary formalities, but the OP has not paid the claim amount to the complainants and repudiated the claim of the complainant as ‘no claim’. Request has been made to allow the complaint.

7.                The OP has alleged in his written statement that the complainant lodged a claim with the OP No.2 and the said claim was forwarded to E-Meditek Insurance TPA Limited i.e. Claim Settling Agency of the OPs, by OP No.2. E- Meditek Insurance TPA Limited wrote various letters/reminders to the complainant for providing history and duration of constipation, anal fissure and haemorrhoids (since when) certified by treating doctor, which is evident from Ex.O-3. Despite letters and reminders to the complainant by E-Meditek Insurance TPA Limited, the complainant did not reply to the letters and not submitted the desired information to E-Meditek Insurance TPA Limited i.e. Claim Settling Agency of the OPs. Thus the claim of the complainant was made ‘no claim’ on account of non submission of history and duration of constipation, anal fissure and haemorrhoids (since when) certified by the treating doctor and as such, are constrained to conclude that the complainant is no longer interested in the claim lodged and the claim was closed as ‘no claim’, which is evident from Ex.O-2. In such circumstances, the complainant is directed to produce the documents, which are required for settling/deciding the claim, to the OPs, within 15 days from the date of receipt of the copy of the order and then the OPs will settle the claim of the complainant on the basis of these documents within 15 days from the date of receipt of the documents, failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then he is at liberty to file a fresh complaint. Original documents submitted alongwith the complaint be returned to the complainant for onward submission of the same to OPs for the settlement of the claim. Thus, this complaint is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.

8.                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          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

16.08.2022         Member                          Member           President