Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 624.
Instituted on : 31.12.2018.
Decided on : 06.11.2019.
Ramphal Singh age 62 years, son of Sh. Tara Chand resident of H.No.417/35, Prem Nagar, Kath Mandi, Janta Colony, Rohtak.
……..Complainant.
Vs.
- Oriental Royal Mediclaim Policy, Jawahar Market, D Park, Model Town, Rohtak, through its Branch Manager.
- Punjab National Bank, Vaish Complex, near Railway Station, Rohtak, through its Branch Manager.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. RENU CHAUDHARY, MEMBER.
MS. TRIPTI PANNU, MEMBER.
Present: Complainant in person.
Sh.R.K.Bhardwaj Advocate for opposite party no.1.
Sh.S.P.Gulati, Advocate for opposite party No.2.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that complainant had purchased a health policy bearing no.261200/48/2017/1447 from the respondent no.1 through the respondent no.2 covering the complainant for a sum of Rs.500000/- for a period from 26.08.2017 to 25.08.2018 with the provision of cashless facility for hospitalization. That on 11.01.2017 complainant was suffering from mouth cancer and he had taken treatment from the hospital at Delhi and had spent an amount of Rs.135000/- and other misc. expenses on his treatment. Complainant requested the opposite party to pay the above said amount but any heed was not paid to his requests. That the act of opposite parties is illegal and there is deficiency in service on the part of OPs. Hence, this complaint and the complainant has prayed for directing the opposite parties to pay Rs.135000/-alongwith interest, compensation and litigation to the complainant as explained in relief clause.
2. On notice opposite parties appeared and filed their separate written reply. Opposite party no.1 in its reply has submitted that opposite party wrote so many letters to the insured to send requisite documents for settlement of the claim but no reply was given by the complainant inspite of repeated letters dated 23.06.2017, 10.07.2017 and 27.07.2017. After waiting for reply from the insured to send the requisite documents, lastly on dated 10.11.2017 the claim was closed as “No Claim” due to non supply of relevant documents. There is no deficiency in service on the part of opposite party and dismissal of complaint has been sought.
3. Opposite party No.2 in its reply has submitted that complainant is having saving Fund account bearing no. 0948000100088390 with the opposite party No.2 and the amount of premium Rs.6991/- was paid to respondent no.1 from his above said account. That the claim was to be settled by the respondent no.1 and not by respondent no.2 bank. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Ld. counsel for the complainant has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C12 and closed his evidence on 21.06.2019. Ld. counsel for the OP No.1 tendered affidavit Ex.RW1, documents Ex.R1 to Ex.R9 and closed his evidence on dated 24.07.2019. Ld. counsel for the OP No.2 tendered affidavit Ex.RW2/A, documents Ex.RW2/1 and closed his evidence on dated 11.07.2019.
4. We have heard learned counsel for the complainant and have gone through material aspects of the case very carefully.
5. After going through the file and hearing the parties it is observed that the main plea taken by the opposite party No.1 is that complainant has not submitted the claim documents till date with the opposite party despite repeated letters and reminders issued by the opposite party to the complainant. Copy of letters Ex.R2 to Ex.R7 are also placed on record by the respondent no.1. But after perusal of the documents, it reveals that as per document/letter Rx.R3 the respondent officials have received claim documents pertaining to the captioned claim No.556221718121465. As per this document, the documents were scrutinized and some other documents were demanded by the respondent Raksha TPA Pvt. Ltd. These documents are: i)Treating Doctor certificate mentioning history of CA Tongue clearly specifying duration,
ii) Original Discharge summary for the Hospitalization dated 30.03.2017. iii) Raksha ID/E-Card of the patient.
Meaning thereby the photocopy of discharge summary is with the respondent and ID/E-card was also with the respondent because ID/E-Card was generated in the policy itself and moreover this should be provided by the insurance company to the Raksha TPA Pvt. Ltd. Now whether any document regarding the history of DCA tongue has been issued by the treating doctor, the same should be provided by the complainant to the respondent officials but perusal of the documents and treating history itself shows that any such certificate is not issued by the treating doctor to the complainant regarding the ailment.
6. Now we have also considered whether any document which is required for the disposal of the claim of the complainant has not been provided by the complainant to the respondent. We came to the conclusion that all the relevant and required documents have already been submitted by the complainant to the respondent officials. This fact has also been cleared from the perusal of the document placed on record by the complainant in his evidence and at the time of arguments. In the present complaint, the respondent No.1 has placed on record 9 documents i.e Ex.R1 to Ex.R9. Some documents have been mentioned as confidential which are Ex.R2 to Ex.R7. We are unable to understand that why these documents are confidential. Moreover as per letter Ex.C2, the complainant made a request to the respondent officials that he is ready to comply all the required formalities but such letters have never been delivered to the complainant by the respondent officials or the Raksha TPA because as per letter Ex.C2, the complainant never received any letter from the respondent or Raksha TPA Pvt. Ltd. except letter dated 10.11.2017. Letter Ex.C4/Ex.JN-C/A had been received on dated 03.04.2018 in the office of respondent insurance company and no reply has been given by the respondent or TPA to the complainant. Meaning thereby the letters Ex.R2 to Ex.R6 have never been dispatched to the complainant merely except document i.e. No Claim letter dated 10.11.2017. Hence there is grave deficiency in service on the part of opposite party i.e. insurance company and complainant is entitled for Rs.135000/- spent by the complainant on his treatment which is proved from the bill Ex.C6.
7. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite party No.1 to pay the claim amount of Rs.135000/-(Rupees one lac thirty five thousand only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 31.12.2018 till its realization and shall also pay a sum of Rs.10000/-(Rupees ten thousand only) as deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
06.11.2019.
…………………………………..
Nagender Singh Kadian, President
…...........................................
Renu Chaudhary, Member.
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Tripti Pannu, Member.
