BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 646 of 2016
Date of Institution: 07.12.2016
Date of Decision: 17.01.2018
- Dharam Pal Rishi son of Vaishno Dass.
- Anuradha Rishi wife of Sh.Dharam Pal Rishi, both residents of House No. 59, Lane B-4, Street No.2, Sri Ram Avenue, Near Bhaba High School, Majitha Road, Amritsar.
Complainants
Versus
- Punjab National Bank, Branch Majitha Road, through its Branch Manager.
- The Oriental Insurance Company Limited, Divisional Office No.1, Dawarka Deesh Complex, Queens Road, Amritsar through its Divisional Manager.
- Hartej Maternity and Nursing Home, Ranjit Avenue, Amritsara through its Incharge/ Manager
Opposite Parties
Complaint under section 12 & 13 of the Consumer Protection Act, 1986 (as amended upto date).
Present: For the Complainants: Sh.R.C.Gupta, Advocate.
For Opposite Parties No.1 and 3: Exparte.
For Opposite Party No. 2: Sh.P.K.Mody, Advocate.
Coram
Sh.Anoop Sharma, Presiding Member
Ms.Rachna Arora, Member.
Order dictated by:
Sh.Anoop Sharma, Presiding Member
1. The complainants have brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that the complainant No.1 has been operating his saving bank account bearing account No. 3400000140758114 with Opposite Party No.1 and the complainant No.1 took the account linked mediclaim policy styled PNB-Oriental Royal Mediclaim Policy schedule sponsored by Opposite Party No. 2 against annual premium for a sum of Rs.1775/- through Opposite Party No.1 effective from 19.11.2015 to midnight of 18.11.2016 bearing policy No. 233300/48/2016/3488 with sum insured of Rs.1 lac and under this policy both the complainants were insured for the payment of hospitalization expenses for medical/ surgical treatment at any nursing home/ hospital in India as and in patient. Complainant No.1 further got the said policy renewed against the payment of annual premium for a sum of Rs.1791/- through Opposite Party No.1 for the period from 19.11.2016 to midnight of 18.11.2017 and total sum insured under this policy was also Rs.1 lac for both the complainants. The complainant No.1 was operated upon his right eye from Dr.Om Parkash Satyam Netralaya on dated 31.5.2016 and a sum of Rs.22000/- towards the hospital expenses was paid by Opposite Parties No.1 and 2 out of the sum assured Rs.1 lac thereby leaving a balance amount of Rs.78000/- being undisbursed. Thereafter complainant No.2 who is the spouse unemployed of complainant No.1 suffered head fall from stairs with cut wound on perictal with cut wound thumb of left foot and she was admitted in Hartej Maternity and Nursing Home, Amritsar and she was diagnosed RT Pneumothorax with collapse fracture and she was operated upon on in the said hospital, on 22.11.2016 and she remained under the treatment of Opposite Party No.3 Hospital and complainant No.2 is still on the bed. An amount of Rs.1,39,491/- was made payable by the Opposite Party No.3 towards the hospitalization and treatment of the complainant No.2 and she was got admitted under the cashless policy, but instead of making the entire payment, the Opposite Parties No.1 and 2 under the aforesaid cashless policy remitted only an amount of Rs.56,000/- and declined to disburse an amount of Rs.83,491/- which fact came to the knowledge of the complainant from the computer printout. Accordingly, the complainant made the said payment from their own pocket to seek a discharge from the said hospital. It is pertinent to mention over here that in the previous policy, the balance insured amount of a sum of Rs.78,000/- still remained undisbursed and she was discharged from the said hospital on 22.11.2016 when the second policy is in operation for the a period from 19.11.2016 to midnight of 18.11.2017 and the complainants are also insured for a sum of Rs.1 lac under the aforesaid policy. In this way, the complainants are entitled to claim the entire amount of Rs.1,39,491/- under both the policies. But the Opposite Parties remitted only an amount of Rs.56,000/- and declined to reimburse the amount of Rs.83,491/- and hence, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.
a) Opposite Parties No.1 and 2 may be directed to make the payment of Rs.83,491/- towards the undisbursed amount under the policies in question.
b) Opposite Parties No.1 and 2 be also directed to pay Rs.50,000/- as compensation for mental tension and harassment besides Rs.20,000/- towards cost of litigation.
Hence, this complaint.
2. Upon notice, opposite parties No.1 & 3 served, but none appeared on their behalf, hence Opposite Parties No.1 to 3 were proceeded against exparte vide order of this Forum.
3. Opposite Party No. 2 appeared and contested the complaint by filing written statement taking preliminary objections therein inter alia that there are disputed and complicated questions of facts and law involved as per allegations contained in the complaint and same can not be adjudicated by this Forum and requires adjudication from the civil court and as such, the complaint before this Forum is not maintainable; even otherwise, there is no privity of contract between the complainant or the answering Opposite Party for the alleged claim. Even otherwise keeping aside the other aspects of the merits, is not maintainable against the answering Opposite Party on the strength of the allegations, the alleged claim stated to have been lodged with M/s.Medi Assist India TPA Private Limited the alleged documents are also stated to have been deposited with said TPA and who processed the claim of the complainant and same since have been dealt as per the usual terms and conditions of the company by such TPA, it finds mention that the policy got issued for the year 19.11.2016 to 18.11.2017, the claim if any arisen was required to be processed by said TPA who was required to have been approached by the complainant even to the knowledge of the complainants by lodging the claim if any would have been arisen during the validity period of such subsequent policy, which till date has not been reported knowing well the cause of claim pertains to the previous period of policy and there remains no claim payable to the complainant from the subsequent policy. On merits, it is alleged that sum insured under alleged policy was Rs.1 lac as alleged or that the complainant No.1 or his wife complainant No.2 were both covered for the payment of hospitalisation expenses for medical/ surgical treatment at any nursing home/ hospital in India as alleged, are matter pertaining to the records, the complainant needs to prove the same and hence, there is no deficiency in service on the part of the answering Opposite Party. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
4. In his bid to prove the case, complainant tendered into evidence affidavit Ex.C1/A in support of the allegations made in the complaint and also produced copies of documents Ex.C1 to Ex.C33 and closed their evidence.
5. On the other hand, to rebut the evidence of the complainant, the Opposite Party No.2 tendered into evidence the affidavit of Sh.Ravi Gupta, Assistant Manager Ex.OP2/1 alongwith copies of documents Ex.OP2/2 and closed the evidence on behalf of Opposite Party No. 2.
6. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
7. The complainant No.1 has submitted his affidavit Ex.C1 in which he has reiterated the facts as detailed in the complaint and contended that the complainant No.1 has been operating his saving bank account bearing account No. 3400000140758114 with Opposite Party No.1 and the complainant No.1 took the account linked mediclaim policy styled PNB-Oriental Royal Mediclaim Policy schedule sponsored by Opposite Party No. 2 against annual premium for a sum of Rs.1775/- through Opposite Party No.1 effective from 19.11.2015 to midnight of 18.11.2016 bearing policy No. 233300/48/2016/3488 with sum insured of Rs.1 lac and under this policy both the complainants were insured for the payment of hospitalization expenses for medical/ surgical treatment at any nursing home/ hospital in India as and in patient. Complainant No.1 further got the said policy renewed against the payment of annual premium for a sum of Rs.1791/- through Opposite Party No.1 for the period from 19.11.2016 to midnight of 18.11.2017 and total sum insured under this policy was also Rs.1 lac for both the complainants. The complainant No.1 was operated upon his right eye from Dr.Om Parkash Satyam Netralaya on dated 31.5.2016 and a sum of Rs.22000/- towards the hospital expenses was paid by Opposite Parties No.1 and 2 out of the sum assured Rs.1 lac thereby leaving a balance amount of Rs.78000/- being undisbursed. Thereafter complainant No.2 who is the spouse unemployed of complainant No.1 suffered head fall from stairs with cut wound on perictal with cut wound thumb of left foot and she was admitted in Hartej Maternity and Nursing Home, Amritsar and she was diagnosed RT Pneumothorax with collapse fracture and she was operated upon on in the said hospital, on 22.11.2016 and she remained under the treatment of Opposite Party No.3 Hospital and complainant No.2 is still on the bed. An amount of Rs.1,39,491/- was made payable by the Opposite Party No.3 towards the hospitalization and treatment of the complainant No.2 and she was got admitted under the cashless policy, but instead of making the entire payment, the Opposite Parties No.1 and 2 under the aforesaid cashless policy remitted only an amount of Rs.56,000/- and declined to disburse an amount of Rs.83,491/- which fact came to the knowledge of the complainant from the computer printout. Accordingly, the complainant made the said payment from their own pocket to seek a discharge from the said hospital. It is pertinent to mention over here that in the previous policy, the balance insured amount of a sum of Rs.78,000/- still remained undisbursed and she was discharged from the said hospital on 22.11.2016 when the second policy is in operation for the a period from 19.11.2016 to midnight of 18.11.2017 and the complainants are also insured for a sum of Rs.1 lac under the aforesaid policy. In this way, the complainants are entitled to claim the entire amount of Rs.1,39,491/- under both the policies. But the Opposite Parties remitted only an amount of Rs.56,000/- and declined to reimburse the amount of Rs.83,491/- and hence, there is deficiency in service on the part of the Opposite Parties.
8. On the other hand, ld.counsel for Opposite Party No. 2 has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that there is no privity of contract between the complainant or the answering Opposite Party for the alleged claim. Even otherwise keeping aside the other aspects of the merits, is not maintainable against the answering Opposite Party on the strength of the allegations, the alleged claim stated to have been lodged with M/s.Medi Assist India TPA Private Limited the alleged documents are also stated to have been deposited with said TPA and who processed the claim of the complainant and same since have been dealt as per the usual terms and conditions of the company by such TPA, it finds mention that the policy got issued for the year 19.11.2016 to 18.11.2017, the claim if any arisen was required to be processed by said TPA who was required to have been approached by the complainant even to the knowledge of the complainants by lodging the claim if any would have been arisen during the validity period of such subsequent policy, which till date has not been reported knowing well the cause of claim pertains to the previous period of policy and there remains no claim payable to the complainant from the subsequent policy. On merits, it is alleged that sum insured under alleged policy was Rs.1 lac as alleged or that the complainant No.1 or his wife complainant No.2 were both covered for the payment of hospitalisation expenses for medical/ surgical treatment at any nursing home/ hospital in India as alleged, are matter pertaining to the records, the complainant needs to prove the same and hence, there is no deficiency in service on the part of the answering Opposite Party. But on the other hand, none has put their appearance on behalf of Opposite Parties No.1 to 3 and thereafter, Opposite Parties No.1 to 3 were proceeded against exparte vide order of this Forum.
9. It is not disputed that the complainants were insured with Opposite Parties No.1 and 2 for a sum of Rs.1 lac each for two individual policies. It is also not disputed that during the first policy period, the complainant No.1 was operated upon his right eye from Dr.Om Parkash Satyam Netralaya on dated 31.5.2016 and a sum of Rs.22000/- towards the hospital expenses was paid by Opposite Parties No.1 and 2 out of the sum assured Rs.1 lac thereby leaving a balance amount of Rs.78000/- being undisbursed. Thereafter complainant No.2 who is the spouse unemployed of complainant No.1 suffered head fall from stairs with cut wound on perictal with cut wound thumb of left foot and she was admitted in Hartej Maternity and Nursing Home, Amritsar and she was diagnosed RT Pneumothorax with collapse fracture and she was operated upon on in the said hospital, on 22.11.2016 and she remained under the treatment of Opposite Party No.3 Hospital and in this way, during the subsistence of first policy, complainant No.2 remained admitted in the hospital and the cause of action of second mediclaim accrued if any to the complainant during the subsistence of the first policy and in this way, the complainants at the most are entitled to the remaining amount of Rs.78,000/- in all and the complainants can not claim the amount of Rs.1,39,491/- which were allegedly to be made to Opposite Party No.3 and the complainants can not become eligible to claim any amount from the second policy.
10. Keeping in view the aforesaid facts and circumstances of the case, the maximum entitlement of the Complainant becomes Rs.1,00,000/- and consequently, we partly allowed the complaint of the complainants and direct the Opposite Parties No.1 and 2 jointly and severally to make the total claim of Rs.1,00,000/- out of the two mediclaim bills as mentioned above (if already not paid by the Opposite Parties) to the complainants on account of medical claims submitted by them with the Opposite Parties, within 30 days from the date of receipt of copy of this order, failing which the complainants shall be at liberty to claim the interest on the awarded amount from the date of filing the present complaint till its realization. Opposite Parties No.1 and 2 are also directed to pay Rs.7000/- to the complainant on account of compensation for causing them mental tension and harassment besides Rs.5000/- as costs of litigation. However, the complaint against Opposite Party No.3 stands dismissed. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum.
Dated: 17.01.2018. (Rachna Arora) (Anoop Sharma)
Member Presiding Member
