BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 31 of 2021
Date of Institution : 05.02.2021
Date of Decision : 19.07.2023
Rakesh Kumar, aged 54 years son of Shri Tej Ram, resident of House No. 45, Sector 20, Part-I, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. PNB Metlife India Insurance Company Ltd., Unit No. 701, 702 & 703, 7th Floor, West Wing, Raheja Towers 26/27 MG Road, Bangalore- 560001, through its General Manager/ authorized signatory.
2. Punjab National Bank, Barnala Road, Sirsa Branch, Tehsil and District Sirsa through its Branch Manager.
…….Opposite Parties.
Complaint under Section 12 of the Consumer Protection Act, 1986.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. Satbir Godara, Advocate for opposite party no.1.
Sh. M. S. Sethi, Advocate for opposite party no.2.
ORDER
The complainant has filed the present complaint under section 12 of the Consumer Protection Act, 1986 (after amendment u/s 35 of C.P. Act, 2019) against the opposite parties (hereinafter referred as OPs).
2. In brief, the case of complainant is that complainant is having saving bank account with op no.2 bearing account number 4155240721510106 and op no.1 is the subsidiary of op no.2. That complainant purchased Metlife Major Illness Premium Back Cover Insurance Policy from the ops bearing Policy No. 21635654 and has paid insurance premium for the same up to 27.07.2020. It is further averred that now the complainant has been suffering from progressive weakness right lower lobe, low backache and he has got himself checked up from Medanta The Medicity, Gurugram and as per diagnosis done by the doctor, the complainant has been advised to undergo surgical operation at an emergent level. That said operation is a major operation and would require huge amount but complainant is not having sufficient funds to bear expenses for the same. It is further averred that as per terms and conditions of the policy, in case of any major illness, the insured will get the amount equal to sum assured and as such complainant is entitled to get the sum assured in the above policy i.e. Rs.ten lacs. That complainant has already approached vide letter dated 16.11.2019 and thereby made a request for payment of amount equal to sum assured but the ops did not pay any heed to the same. The complainant also got served a legal notice upon op no.1 on 29.01.2020 but of no use. That complainant is legally entitled to the aforesaid amount from ops and ops are under legal obligation to pay the same to the complainant. It is further averred that ops by their such act and conduct have indulged themselves in unfair trade practice and have committed gross deficiency in service towards the complainant and thereby have put the complainant to suffer unnecessary harassment and mental agony. Hence, this complaint.
3. On notice, ops appeared. Op no.1 filed written statement taking certain preliminary objections regarding cause of action, locus standi, maintainability, mis joinder and non joinder of necessary parties, estoppal and complainant is not at all covered under the definition of a consumer with answering op. On merits, it is denied that now the complainant has been suffering from progressive weakness right lower lobe, low backache and he has got himself checked up from the Medicity Gurugram and as per diagnosis done by doctor, the complainant has been advised to undergo surgical operation as alleged. It is further submitted that first of all as per the record of answering op, no intimation of any kind has ever been received by answering op from complainant regarding the alleged ailment in any manner nor as per the record of answering op any such claim form has ever been submitted by the complainant with the company and as such complaint is entirely premature in terms of provisions of Consumer Protection Act as well as per the guidelines of IRDA floated in this regard from time to time. It is further submitted that it is the prerogative of the insurance company to first of all conduct survey and investigation into the matter and only in case there is any genuine ground in the claim of the complainant, then only the answering op is bound to pay the insured amount as per the terms and conditions of the policy and prior thereto no such complaint is maintainable directly in this Commission. Remaining contents of the complaint are also denied and prayer for dismissal of complaint made.
4. Op no.2 also filed written statement taking certain preliminary objections. It is submitted that complainant has never given any information in this regard to op no.2 and matter of compensation regarding insurance policy is between complainant and op no.1. Remaining contents of complaint are also denied and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C29.
6. On the other hand, op no.2 has tendered affidavit of Sh. Rajender Singh Branch Manager as Ex.R1. OP no.1 has tendered affidavit of Sh. Chirag Choudhary, Senior Manager Legal as Ex.R2 and proposal form Ex.R3.
7. We have heard learned counsel for the parties and have gone through the case file carefully.
8. The op no.1 insurance company has not disputed the fact about obtaining of policy in question by the complainant and renewing of the policy in question by complainant. However, op no.1 has specifically asserted that as per record of the op no.1 no such claim form has ever been submitted by the complainant with the company and as such the complaint of the complainant is entirely premature. The complainant has not proved on record that he has approached the insurance company as per terms and conditions of the policy provided to him. As per clause 6 of Claims Procedure for any payment of the Critical Illness Benefit, the insured has to supply the documents i.e. original policy document, claim form prescribed by company duly completed, evidence of date of birth, proof of title to the policy where applicable, medical report confirming the occurrence of the Critical Illness, all past and present medical records, FIR, police inquest, final report, if applicable, original or a certified copy of the death certificate showing the circumstances and cause and the date of death, if applicable, a copy of the claimant’s photo identification proof, address proof and bank account details, if not provided earlier, Nominee/ Appointee/ Legal heir identification and address proof and any other documentation or information and also discharge voucher prescribed by the company. The complainant has not proved on record that complainant has completed the requirements of above said clause 6 regarding Claim Procedure of the policy in question. The op no.1 has taken the objection that complaint is pre-mature which is sustainable on record. As such the present complaint is pre-mature and no case has been submitted to the op no.1 as per terms and conditions of the policy. Moreover, the op no.1 has not repudiated the claim of the complainant. As such no cause of action arises to the complainant till filing of the claim to the op no.1 as per terms and conditions of the policy in question.
9. In view of our above discussion, the present complaint is hereby dismissed being pre-mature but with no order as to costs. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member President,
Dated: 19.07.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
