Complainant Sudesh Mahajan through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has sought issuance of necessary directions to the titled opposite parties (jointly ‘the OP’ and individually as the OP1 TPA, the OP2 insurers and the OP3 Bank, in the titled order) to release/pay her the medical expenses incurred qua the insurance Claim in terms of the related Policy along with a suitable compensation for having suffered harassment as well as costs of litigation, in the interest of justice.
2. The case of the complainant in brief is that her son Manoj being an account holder at the OP3 Bank who being agents of the OP3 insurers sold him the Med claim Policy in question with the OP2 TPA mediating as the Third Party Administrators. Somehow, the Policy with its terms and conditions was never delivered to her or to her son and as such they were ignorant of the extant terms and conditions of the related Policy as sold to them. In the meantime, she had to undergo the eye-cataract surgery at Batala and filed the related insurance claim for reimbursement of Rs.27,893/- spent by her; that however was repudiated by the OP1 TPA on the ground that the treating Hospital was not registered and equipped with 10/15 Beds as was requisite in terms of the Policy. Aggrieved, the complainant preferred the present complaint with the desired relief duly prayed, as reproduced hereinabove.
3. Upon notice, the OP1 insurers appeared and filed its written reply through the counsel taking the routine preliminary objections along with the prime one that the treating Hospital was not registered with the Local authorities or had the requisite 10/15 bed capacity to be eligible for medical claims etc. Moreover, the cashless pre-authorization was already granted at the Vassan Hospital, Amritsar that somehow was not availed of by the complainant and thus the impugned claim cannot be considered to be legitimately passed and that already stood denied by the OP1 TPA as duly conveyed to the complainant under copy to them (the OP1). All other averments as made out in the complaint have been rebutted unceremoniously and lastly, the complaint has been prayed to be dismissed with costs. The OP1 TPA preferred to put up ‘absence’ despite due-service of summons/notice and thus were ordered to be proceeded against ex-parte vide Forums’ orders dated 11.09.2014. Similarly, the OP3 Bank also appeared and filed its reply through the counsel admitting the complainants’ Bank account with the Branch and also the factum of having sold the Policy in question to the complainant but as the corporate agents of the OP2 insurers and thus not liable to pay any sort of claim etc. Again, the OP3 Bank admitting to be acting only as the agent of the OP2, has expressed its inability/refusal to shoulder any responsibility/liability of the insurance claim and lastly the present complaint has been prayed to be dismissed with compensatory costs in its favor.
4. All the Parties produced their respective affidavits and documents in support and to prove their respective claims/counter claims etc. The counsel for the complainant tendered into evidence affidavit of the complainant Ex.C1 duly deposing the pleadings/averments and the evidence produced on her behalf; along with the other documents exhibited here as: Ex.C2 to Ex.C16. On the other hand, the OP2 insurers tendered into evidence the affidavit Ex.OP2/1 of its Divisional Manager Tarsem Lal duly deposing the objections raised and the evidence produced etc; and other documents exhibited as: Ex.OP2/2 to Ex.OP2/11 to prosecute the defense. Similarly, the OP3 Bank filed its affidavit Ex.OP3/1 of its Branch Manager in support of its defense. We have examined all the documents/ evidence produced on record and have also duly considered and perused the arguments duly put forth by the learned counsels of both the sides, while adjudicating the present complaint.
5. We observe that the complainants’ prime allegation of non-supply/ non-receipt of the Policy in question (along with its governing Terms & Conditions) stand categorically un-rebutted through some cogent evidence by the OP2 insurers and/ or for that matter even by the OP3 Bank. And, in the absence of the same the complainants’ plea of ignorance of the ‘indoor-beds’ minimum requirement at the treating Hospital shall aside as justified and acceptable. The OP2 insurers have not only ignored to prove the supply of the Policy (with its governing terms etc) to the complainant but even its dispatch has not been attempted to be proved. Thus, we hold the OP1 insurers guilty of deficiency in service and hence liable to an adverse award under the Act. Regarding the plea of cash-less pre-authorization of Rs. 17,000/- at the Vassan Hospital, Amritsar; the complainant shall not be bound to compulsorily undergo the Surgery there and shall be certainly at liberty to change to the Hospital of her choice and convenience nearer her home at Batala.
6. In the light of the all above, we hold the OP2 insurers’ claim repudiation-decision as arbitrary, and thus ORDER them to settle and pay to the complainant the full insurance-claim amount as eligible under the extant terms of the Policy in force at the time of the Surgery, besides to pay her Rs.3,000/- as compensation and Rs.2,000/- as cost of litigation; within 30 days of receipt of the copy of these orders, otherwise the aggregate awarded amount shall become payable with interest @ 9% PA form the date of the orders till actually paid.
7. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri) President.
ANNOUNCED: (G.B.S.Bhullar) (Jagdeep Kaur)
February 19, 2015 Member. Member.
*MK*
