DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA.

 

Consumer Complaint No. : CC/23/2019 

Date of Institution : 05.03.2019

Date of Decision : 01.10.2019

Abhey Kumar Jindal son of Dr. R.P Jindal, resident of H. No. 52, 16 Acre Scheme, behind New Bus Stand, Barnala, Tehsil and District Barnala.

...Complainant

Versus

1. Punjab National Bank Branch Main, Barnala through its Branch Manager.

2. The Oriental Insurance Company Limited, Registered and Head Office at A-25/27, Asif Ali Road, New Delhi-110002.

3. The Oriental Insurance Company Limited, Divisional Office, 4501, Bank Street, Bathinda-151005.

4. RAKSHA TPA Private Limited, SCO No. 39, First Floor, Sector 26, Madhya Marg above Barbeque Nation, Chandigarh, 160019 through its Authorized signatory.

…Opposite parties

(Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

SH.KULJIT SINGH, PRESIDENT

SH. TEJINDER SINGH BHANGU MEMBER

COUNSEL FOR THE PARTIES:

For complainant : Sh. Gagandeep Garg Advocate.

For OP No. 1 : Sh. Vinod Kumar Goyal Advocate.

For Ops No. 2 to 4 : Sh. Varinder Kumar Goyal Advocate.

 

Per KULJIT SINGH, PRESIDENT 

1. The present complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 against the Ops, on the averments that he purchased one PNB Oriental Mediclaim Policy 2017 from Ops, who issued policy bearing no. 233200/48/2018/3197 vide insured code no. 83416328 in the name of the complainant, which was valid from 20.12.2017 to 19.12.2018. During the period of said insurance policy, Nirmal Jindal wife of the complainant suffered from fever with thrombocytopenia-Dengue NSIAG and she was got admitted in Christian Medical College and Hospital Ludhiana from 22.10.2018 to 25.10.2018 for treatment, where complainant spent more than Rs. 40,000/- for the said treatment. The complainant submitted a claim application with OPs to reimburse the amount of medical claim on 02.12.2018 along with original treatment bills, discharge summary and medicine bills. But OPs failed to reimburse the amount of medical claim to the complainant and prolonged the claim of the complainant after raising false and baseless objections. This act of OPs clearly shows deficiency in service on the part of OPs, which caused a mental tension, agony and financial loss to the complainant. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to reimburse the amount of medical claim Rs. 40,000/- alongwith interest at the rate of 12% per annum till realization.    

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

3) To pay Rs. 50,000/- as litigation expenses.  

4) Any other relief this Forum deems fit. 

2. Upon notice, OP no.1 appeared and filed separate written reply and contested the complaint of the complainant by raising preliminary objections that complainant is not consumer of OP no.1. The complainant is estopped by his act and conduct from filing the complaint. On merits, it is admitted that complainant purchased policy bearing no. 233200/48/2018/3197 from OPs no. 2 to 4 which was valid from 20.12.2017 to 19.12.2018 for his spouse Nirmal Jindal and son and both were covered for medi claim. OP was never informed that Smt. Nirmal Jindal suffered from fever/thrombocytopenia/dengue nor was informed that she got admitted in CMC Hospital Ludhiana for the said disease on 22.10.2018. Rest of the averments of the complainant have been denied by OP no.1 and it prayed for dismissal of the complaint.

3. OPs no.2 to 4 appeared and filed their separate written reply and contested the complaint of the complainant by raising preliminary objections that complaint is pre mature and complaint is misconceived, without any reason and is result of afterthought. The complainant has not come to the Forum with clean hands. The complainant has no locus standi to file the present complaint. On merits, it is admitted that complainant purchased PNB Oriental Medical Claim policy 2017 and submitted claim for his wife for Rs. 40,000/- from 22.10.2018 to 25.10.2018 and submitted claim on 02.12.2018. It has been denied that OPs failed to reimburse the medical claim of the complainant. It has also been denied that it is duty of the OPs to verify the medical bills, which were claimed by claimant. It is submitted that, OPs sent query letters dated 11.12.2018, 22.12.2018, 07.01.2019, 25.02.2019, 14.03.2019, 15.03.2019 and ultimately closed the claim on 15.03.2019 and intimated to complainant as per clause 5.5 (i) final claim along with originals of hospital bills/cash memo /reports/claim forms and list of documents should be submitted to Company/TPA within 7 days of the discharge the hospital. Rest of the averments of complaint have been denied by OPs no.2 to 4 and prayed for dismissal of complaint with costs. 

4. The complainant has tendered in evidence his affidavit Ex.C-25 along with copies of documents Ex.C-1 to Ex.C-24 and closed the evidence. As against it; OP no.1 tendered in evidence affidavit of Sunil Dutt Manager PNB Main Barnala as Ex.OP-1/1 and closed the evidence. OPs no. 2 to 4 tendered affidavit of Ashwani Kumar a Ex.OP-2.3.4/1 along with copies of documents Ex.OP-2.3.4/2 to Ex.OP-2.3.4/5 and closed the evidence. 

5. We have heard learned counsel for the parties and have also examined the record of the case very carefully. Written arguments also filed by the opposite party No. 1 and opposite parties No. 2 to 4. 

6. The complainant tendered in evidence Ex.C-1 copy of mediclaim insurance policy. Ex.C-2 to Ex.C-12 are copies of bills. Ex.C-13 is copy of discharge summary. C-14 is copy of claim form. Ex.C-15 is courier receipt. Copy of letter dated 11.12.2018 as Ex.C-16. Copy of letter from complainant dated 14.12.2018 as Ex.C-17. We have also examined other documents Ex.C-18 to Ex.C-24 on the record. 

7. To refute this evidence of the complainant, OP no.1 relied upon affidavit of Sunil Dutt Manager PNB as Ex.OP-1/1 in support of the case of the OPs. OPs no. 2 to 4 relied upon affidavit of Ashwani Kumar as Ex.OP-2.3.4/1 Divisional Manager. Copy of policy schedule as Ex.OP-2.3.4/2, copy of terms and conditions of the policy Ex.OP-2.3.4/3, copy of letter dated 14.03.2019 as Ex.OP-2.3.4/4 and copy of repudiation letter dated Ex.OP-2.3.4/5 and closed the evidence. 

8. After hearing respective pleadings of counsel for the parties we have also gone through the record of the case. It is an established fact that complainant purchased one PNB Oriental Mediclaim policy Ex.C-1 from OP no. 3, which was valid for the period of 20.12.2017 to 19.12.2018 and OPs also supplied the list of covered persons under the said policy which are complainant himself, his wife and son. During the period of said insurance policy, Nirmal Jindal wife of the complainant suffered from fever with thrombocytopenia-Dengue NSIAG and she was got admitted in Christian Medical College and Hospital Ludhiana from 22.10.2018 to 25.10.2018 for treatment which proved from the discharge summary Ex.C-13. He spent about Rs. 40,000/- for the said treatment of his wife. He submitted claim application Ex.C-14 with OPs for reimbursement of the amount of medical claim on 02.12.2018 along with original bills and documents, which required by OPs, but OPs failed to reimburse the medical claim of the complainant and ultimately Ops sent reminder to the complainant vide letter Ex.OP-2.3.4/5 to repudiate the claim of the complainant if no reply is received within 15 days and in this letter they also demanded some documents from the complainant which he already submitted with the claim form dated 2.12.2018 Ex.C-14.  

9. Firstly OPs agitated this point whether complainant is consumer of OPs or not? The complainant availed the service of OPs. The  consumer is an individual who pays some amount of money for the thing required to consume goods and services. As such, consumers play a vital role in the economic system of a nation. The definition of consumer is clear from Consumer Protection Act 1986, which is lays under :- 

(d) "consumer" means any person who—

(i)buys any goods for a consideration which has been paid or promised or partly paid and partly promised, or under any system of deferred payment and includes any user of such goods other than the person who buys such goods for consideration paid or promised or partly paid or partly promised, or under any system of deferred payment when such use is made with the approval of such person, but does not include a person who obtains such goods for resale or for any commercial purpose; or

(ii)hires or avails of any services for a consideration which has been paid or promised or partly paid and partly promised, or under any system of deferred payment and includes any beneficiary of such services other than the person who 'hires or avails of the services for consideration paid or promised, or partly paid and partly promised, or under any system of deferred payment, when such services are availed of with the approval of the first mentioned person but does not include a person who avails of such services for any commercial purposes;

Explanation.— For the purposes of this clause, “commercial purpose” does not include use by a person of goods bought and used by him and services availed by him exclusively for the purposes of earning his livelihood by means of self-employment;

In the present case, the complainant purchased the insurance policy from OPs, as such, he is consumer of OPs. He availed the services of OPs as beneficiary. Therefore, the contention of OPs that the complainant is not consumer is rejected by us.

10. The complainant purchased the insurance policy from OPs which was valid from 20.12.2017 to 19.12.2018. The wife of the complainant suffered from Fever with thrombocytopenia-Dengue NSIAG and she got admitted in Christian Medical College and Hospital Ludhiana from 22.10.2018 to 25.10.2018 i.e during the currency period of the policy. Therefore, as per terms and conditions of the policy OPs are liable to pay the same. It has also been held by National Commission New Delhi in M/s V.K. Karyana Store Vs. Oriental Insurance Company Ltd 2014(3) CLT Page 47 that parties are bound by the terms and conditions of the insurance policy and none of the parties can seek any relief beyond those terms and conditions. The High Court referred to its own judgment in the case of Oriental Insurance Co. Ltd. v. K.C. Subramanyam MANU/KA/0945/2012 : ILR 2012 KAR 5241 and held that the Hon'ble Supreme Court directed the insurance company to make payment to the claimants.

11. Further, Hon'ble Rajasthan State Commission, Jaipur in case titled Vikas Kumar Sharma Versus New India Assurance Co. Ltd. And others reported in III (2018) CPJ-125 (Raj.) held in paras No. 4, 5, 6, 7 and 10 that there is no dispute about the fact that the policy was renewed with the respondent hence, the fact that NCB was claimed was within the knowledge of the Insurance Company and appellant has rightly relied upon the judgment passed by the National Commission in Revision Petition No. 2920/2015, United India Insurance Co. Ltd. Versus M/s Jindal Poly Buttons Ltd., where after deduction of 20% of the claim was allowed as declaration regarding no claim bonus was found false. The other contention of the respondent is that the matter was reported with delay to the Insurance Company. It is not in dispute that the claim was submitted to the Insurance Company with delay of ten days but the contention of the appellant is that he immediately reported the matter to the Insurance Company on telephone. The further contention of the appellant is that when repudiation has not been made on the ground of delay, this plea cannot be allowed to the insurer now and reliance has rightly been placed on II (2017) CPJ-345 (NC) United India Insurance Co. Versus Bhundu Ram. Hence in view of the above that delay was not the ground of repudiation the insurer cannot allow to plead this ground. Further, in view of the law laid down by the Apex Court in Civil Appeal No. 15611/2017, Om Parkash Versus Reliance General Insurance Co. VII (2017) SLT-654, IV (2017) CPJ-10 (SC), the genuine claim should not be rejected on technical ground of delay only. Hence in view of the above the claim have been allowed. Further, in para No. 10 of this citation it is mentioned that in view of the above, the appeal is allowed and the order of the Forum below dated 2.11.2016 is set aside. The complainant is entitled for the insured value after deducting 20% amount from Rs. 41,094/- i.e. Rs. 32,875/-. The complainant is also entitled for 9% interest on the said amount from the date of presentation of the complaint i.e. 11.4.2011 and Rs. 10,000/- as cost of proceedings. The order be complied within one month. 

This citation is fully applicable to the facts of the present complaint as in the present matter also the claim is repudiated by the insurance company i.e. Opposite parties No. 2 and 3 only on the technical ground of delay in submission of documents, whereas as per the view of the Hon'ble Apex Court of India in Civil Appeal No. 15611/2017, Om Parkash Versus Reliance General Insurance Co. VII (2017) SLT-654, IV (2017) CPJ-10 (SC), the genuine claim should not be rejected on technical ground of delay only, opposite parties cannot repudiate the claim of complainant only on the ground of delay of submission of documents. 

12. This fact was admitted that complainant’s wife was suffering from fever with thrombocytopenia- Dengue NSIAG and she was got admitted in Christian Medical College and Hospital Ludhiana from 22.10.2018 to 25.10.2018 for treatment, where complainant spent more than Rs.40,000/- for the said treatment. The complainant purchased PNB Oriental Mediclaim policy from OP no.3, which was valid from 20.12.2017 to 19.12.2018. The complainant’s wife admitted in the hospital during the currency period of the policy and treatment given to her is also within currency period of the policy. 

13. From all the above mentioned facts and circumstances,  it is crystal clear that Ops No. 2 and 3 are deficient and negligent in not rendering proper services to the complainant by not paying the insurance claim amount by the complainant.

14. In view of the above discussion, we partly allow the present complaint against the opposite parties No. 2 and 3. Accordingly, the opposite parties No. 2 and 3 are directed to pay Rs. 35,846/- to the complainant as claimed by him in the claim form dated 2.12.2018 Ex.C-14 which he spent on the treatment of his wife alongwith interest at the rate of 6% per annum from the date of filing the present complanit till its actual  realization. The opposite parties No. 2 and 3 are also directed to pay Rs. 3,000/- to the complainant as consolidated amount of compensation on account of mental tension, harassment and litigation expenses. The opposite parties No. 2 and 3  are also directed to deposit Rs. 5,000/- as costs in the Consumer Legal Aid Account maintained by this Forum. The opposite parties No. 2 and 3  jointly and severally liable to comply with this order. Compliance of the order be made within the period of 30 days from the date of the receipt of the copy of this order. Copy of this order be supplied to the parties free of costs. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN FORUM:

    1st Day of October 2019

 

            (Kuljit Singh)

            President

 

              (Tejinder Singh Bhangu)

Member