DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.

 

Complaint Case No : CC/102/2019

Date of Institution : 05.08.2019

Date of Decision : 26.11.2019

1.  Vinay Kumar Garg son of Rishi Kumar son of Sh. Mehar Chand resident of H. No. B-V/1611, First Floor, Sandhu Patti, Opposite Patwar Khana, Barnala, District Barnala. 

2. Rishi Kumar son of Sh. Mehar Chand residing with his son Vijay Kumar at resident of H. No. B-V/1611, First Floor, Sandhu Patti, Opposite Patwar Khana, Barnala, District Barnala.                      …Complainant

Versus

1. Punjab and Sind Bank, Branch Tapa Tehsil and District Barnala through its Branch Manager. 

2. MD India Healthcare Service (TPA) Pvt. Ltd., S. No. 46/1, ESPACE, A-2, Building Third Floor, Pune Nagar Road Vadgaonsheri P.O. Pune-411014.

3. United India Insurance Co. Ltd. Through Managing Director, Regd. And Head Office 24M, White Road, P.O. Chennai-600014.

4. United India Insurance Co. Ltd., through Branch Manager, Dhanaula Road, Barnala District Barnala. 

…Opposite Parties

Complaint Under Section 12 of the Consumer Protection Act.

Present: Sh. Varinder Kumar Goyal counsel for complainant.

Sh. AK Jindal counsel for opposite party No. 1. 

Opposite party No. 2 exparte.

Sh. NK Singla counsel for opposite parties No. 3 and 4.

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

 (ORDER BY KULJIT SINGH, PRESIDENT):

    The complainant namely Vinay Kumar Garg has filed the present complaint under Consumer Protection Act 1986 as amended up to date (hereinafter referred as Act) against Punjab and Sind Bank, Branch Tapa, District Barnala and others. (hereinafter referred as opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that complainant No. 1 is serving in Punjab and Sind Bank and joined at Barnala branch on 17.8.2012 and transferred from Barnala to Sekha Branch and now in Tapa Branch as Officer and both the complainants have their residence at Barnala. 

3. It is further alleged that the father of the complainant No. 1 i.e. Complainant No. 2 namely Rishi Kumar is dependent on the complainant No. 1 who insured alongwith other employees by the bank vide Group Health Policy bearing No. 5001002816P111932941 w.e.f. 1.10.2016 to 30.9.2017. The opposite parties No. 3 and 4 being insurance company issed Health Cards bearing No. MD15-0029722957 in the name of the complainant No. 1 and father of the complainant No. 1 Rishi Kumar. 

4. It is further alleged that on 30.7.2017 the father of the complainant No. 1 suffered a problem of C/C pain while walking and admitted in DMCH, Ludhina for his treatment. The intimation was sent to TPA i.e opposite party No. 3 on 30.7.2017 by DMCH Ludhiana which was received by TPA and sent reply on the same day that all relevant investigations reports to support the diagnosis and need for hospitalization. Details of treatment given with name of medication and drug charts. The complainant No. 2 sent again email to TPA on 3.8.2017 vide which he requested the opposite party No. 2 to reimburse the amount of Rs. 33,141/- spent by him up to 2.8.2017. On 5.8.2017 the complainant received email from opposite party No. 2 that they have denied the claim of Rs. 50,750/- of the complainant with the reason that the cashless hospitalization is denied, as investigation and treatment does not support the need for hospitalization. The complainants made several requests to the opposite parties to reimburse the claim but to no result, which amounts to deficiency in service and unfair trade practice on the part of the opposite parties. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay the claim of Rs. 33,141/- alongwith interest at the rate of 18% per annum.   

2) To pay Rs. 1,00,000/- on account of mental tension, agony and  harassment.           

3) To pay Rs. 11,000/- as litigation expenses.  

4) Any other relief this Forum deems fit. 

5. Upon notice of complaint, opposite party No. 1 initially not appeared before this Forum and proceeded exparte vide order dated 10.9.2019 but later on vide order dated 29.10.2019 the opposite party No. 1 was allowed to join the proceedings on their request and they only filed the written arguments. The opposite party No. 2 not appeared before this Forum despite service so the opposite party No. 2 was proceeded against exparte vide order dated 10.9.2019. 

6. The opposite parties No. 3 and 4 filed written version taking preliminary objections on the grounds of maintainability, complaint is bad for non joinder and misjoinder of necessary parties, concealment of material facts, not come to the Forum with clean hands, complainant No. 2 not consumer of the opposite parties and estoppal. The opposite parties No. 3 and 4 further objected that this Forum has no jurisdiction to entertain and try the present complaint as has been held by the District Consumer Forum, Sri Ganganagar that cause of action if any has occurred at Mumbai or at Pune. 

7. On merits, the opposite parties No. 3 and 4 admitted that complainant No. 1 is the employee of Punjab and Sind Bank and his employer purchased Tailormade Group Mediclaim Policy for the period from 1.10.2016 to 09.09.2017 for its employees. It is also admitted that complainant No. 2 was admitted in DMCH, Ludhiana for his treatment. It is further admitted that policy was cashless and intimation was also sent to opposite party No. 2 by DMCH, Ludhiana. They further submitted that cashless hospitalization was rightly denied as investigation and treatment does not support the need for hospitalization. Lastly, they prayed that there is no deficiency in service on the part of the answering opposite parties so present complaint be dismissed with costs. 

8. In support of his complaint, the complainant tendered into evidence copy of policy Ex.C-1, copy of insurance card Ex.C-2, copy of cashless intimation Ex.C-3, copy of letter dated 30.7.2017 Ex.C-4, copy of letter dated 1.8.2017 Ex.C-5, copy of letter dated 5.8.2017 Ex.C-6, copy of final bill Ex.C-7, copy of voter card Ex.C-8, copy of certificate Ex.C-9, copy of order dated 3.7.2019 Ex.C-10, affidavit of Rishi Kumar Ex.C-11  and closed the evidence.

9. To rebut the case of the complainant, the opposite parties No. 3 and 4 tendered in evidence copy of insurance policy Ex.OP-3.4/1, copy of treatment sheet as Ex.OP-3.4/2, copy of investigation flowsheet Ex.OP-3.4/3, copy of denial of authorization letter Ex.OP-3.4/4, affidavit of Baldev Singh Ex.OP-3.4/5 and closed the evidence.

10. We have heard the learned counsel for the parties and have gone through the record. Written arguments also filed by opposite parties. 

11. It is admitted by the opposite parties No. 3 and 4 employer of the complainant No. 1 purchased the Group Mediclaim Policy for the period from 1.10.2016 to 9.9.2017 vide policy Ex.C-1. In this policy Ex.C-1 it is also mentioned that under this policy the Employee himself, spouse, dependent children +2 dependent parents Or in laws were covered which proved that complainant No. 2 was also covered under the present mediclaim policy being dependent father of complainant No. 1. This fact is also proved from copy of card of complainant No. 2 Ex.C-2 that he was insured under the policy in question. It is also admitted by the opposite parties No. 3 and 4 i.e. Insurance company that complainant No. 2 remained admitted in DMCH, Ludhiana for conservative treatment of Neurogenic claudication. Further, from the treatment record of complainant No. 2 Ex.C-7 it is proved on the record that complainant No. 2 has taken the treatment at Dayanand Medical College and Hospital, Ludhiana within the validity period of the insurance policy i.e. From 30.7.2017 to 2.8.2017. 

12. The opposite parties mainly raised two objections in the present complaint out of which firstly is that this Forum has no jurisdiction to try the present complaint as District Consumer Forum, Sri Ganganagar held that cause of action has arose only at Mumbai and Pune. To rebut this objection of opposite parties the complainant mainly relied upon copy of certificate Ex.C-9 in which it is specifically mentioned that Mr. Vinay Kumar son of Rishi Kumar was posted as an officer in Sekha Branch from 19.2.2014 to 16.8.2018 and then after he was transferred to Tapa Branch. This document duly proved that when this policy Ex.C-1 was issued from 1.10.2016 to 30.9.2017, then the complainant No. 1 was posted at Sekha Branch District Barnala so partly cause of action arose within the jurisdiction of this Forum, so this Forum has the territorial jurisdiction to try and decide the present complaint under Section 11 (2) of the Consumer Protection Act, 1986. Further, we are also of the view that this complaint is also within the period of limitation even if we do not deduct the period which has been lapsed by the complainant at District Consumer Forum, Sri Ganganagar. 

13. The second objection of the opposite parties is that the investigation and treatment does not support the need for hospitalization so they repudiated the claim of the complainants. To prove this objection opposite parties only relied upon copy of treatment sheet Ex.OP-3.4/2 and copy of investigation flow sheet Ex.OP-3.4/3 but opposite parties No. 3 and 4 have not filed affidavit of any doctor or para medical person to prove these documents without which there is no value of these documents. On the other hand complainant duly proved on the file vide copy of In-Patient Final Bill Ex.C-7 that complainant No. 2 had taken the treatment from Dayanand Medical College, Ludhiana from 30.7.2017 to 2.8.2017 within the currency period of the policy in question and spent Rs. 33,141/- for his treatment. 

14. Hon'ble Punjab and Haryana High Court at Chandigarh in case titled New India Assurance Company Limited Versus Smt. Usha Yadav and others 2008(3) RCR (Civil) Page-111 held as under.-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs. 5,000/- for luxury litigation being rich.”

This citation is also fully applicable to the facts of present case as in the present matter also the opposite parties earned premium of crores of rupees under Group Insurance Policy but at the time when complainant lodged insurance claim then opposite parties repudiated the claim of the complainants on baseless grounds, so the opposite parties are liable to pay the claim of the complainants. Further, as in the present case also insurance company repudiated the claim of the complainant unnecessarily without any strong grounds despite his repeated requests which is clear cut deficiency in service and unfair trade practice on their part. 

15. In view of the above discussion and citation of the Hon'ble Punjab and Haryana High Court at Chandigarh, present complaint is allowed against the opposite parties No. 2 to 4. Accordingly, the opposite parties No. 2 to 4 are directed to pay Rs. 33,141/- to the complainant on account of insurance claim alongwith interest at the rate of 6% per annum from the date of the repudiation of the claim of the complainants i.e. 5.8.2017 till actual realization and also to pay Rs. 5,000/- as consolidated amount of compensation on account of mental tension, harassment and litigation expenses. The opposite parties No. 2 to 4 are also directed to deposit Rs. 4,000/- as costs in the Consumer Legal Aid Account maintained by this Forum. The opposite parties No. 2 to 4 are jointly and severally liable to comply with this order. Compliance of the this order be made within the period of 30 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.

ANNOUNCED IN THE OPEN FORUM:

  26th Day of November 2019

 

 

            (Kuljit Singh)

            President

 

            (Tejinder Singh Bhangu)

Member