Order dictated by:

Sh.Anoop Sharma, Presiding Member

1.       Smt.Sudesh Bhandari has brought the instant complaint under section 12 of the Consumer Protection Act, on the allegations that  she obtained Medi claim Policy bearing No. 233300/48/2015/5893 w.e.f. 4.3.2015 to 3.3.2016 from Opposite Party No.1-Bank, whereas Opposite Party No.2 is TPA, so the complainant is a consumer qua Opposite Parties. During the validity of the policy, the complainant remained admitted in Navpreet Hospital from 4.12.2015 to 10.12.2015 and took treatment for Cholilithiasis Pancreatitis. The complainant intimated TPA immediately at the time of admission. The complainant incurred total expenses  of Rs.36,805/- on the said treatment. The complainant also submitted claim with the Opposite Parties  vide claim form dated 13.12.2015 and  sent all the original documents necessary to process the claim of the Opposite Parties  vide DTDC courier services on 14.12.2015. On 27.1.2016, the Opposite Parties  again raised demand of some documents vide e-mail and assured the complainant that after submission of the documents, the claim shall be processed expeditiously. Therefore, on 4.2.2016, the complainant again sent  the required documents, but till date, the Opposite Parties  have not paid the claim amount to the complainant despite submission of  requisite documents.   Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties  may be directed to pay Rs.36,805/- alongwith interest @ 18% per annum from the date of the submission of claim till payment.

b)      Compensation to the tune of Rs.30,000/- may also be awarded to the complainant.

c)       Litigation expenses to the tune of Rs.20,000/- may also be awarded to the complainant.

Hence, this complaint.

2.       Upon notice, none appeared on behalf of both the parties despite due service, hence Opposite Parties  ordered to be proceeded against exparte vide order of this Forum.

3.       In his bid  to prove the case, complainant tendered  his duly sworn affidavit Ex.C1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2 to Ex.C7 and closed the exparte evidence.

4.       We have heard the ld.counsel for the complainant and have carefully gone through the evidence on record.

5.       From the perusal of the evidence on record, it becomes evident that the complainant obtained Medi claim Policy bearing No. 233300/48/2015/5893 w.e.f. 4.3.2015 to 3.3.2016 from Opposite Party No.1-Bank, whereas Opposite Party No.2 is TPA, copy of insurance cover accounts for Ex.C2. During the validity of the policy, the complainant remained admitted in Navpreet Hospital from 4.12.2015 to 10.12.2015 and took treatment for Cholilithiasis Pancreatitis, copy of the discharge card accounts for Ex.C3. The complainant intimated TPA immediately at the time of admission. The complainant incurred total expenses  of Rs.36,805/- on the said treatment. The complainant also submitted claim with the Opposite Parties  vide claim form dated 13.12.2015 and  sent all the original documents necessary to process the claim of the Opposite Parties  vide DTDC courier services on 14.12.2015. On 27.1.2016, the Opposite Parties  again raised demand of some documents vide e-mail and assured the complainant that after submission of the documents, the claim shall be processed expeditiously. Therefore, on 4.2.2016, the complainant again sent  the required documents, but till date, the Opposite Parties  have not paid the claim amount to the complainant despite submission of  requisite documents. To  prove his case,  ld.counsel for the complainant has also produced the ruling titled as Oriental Insurance Company Ltd. Vs. Rajbir Kaur, in First Appeal No. 711 of 2013 decided on 27.2.2015 of Hon’ble State Commission, Punjab, Chandigarh, wherein in similar case, the Hon’ble State Commission, has set aside the order passed by District Forum and directed the Insurance Company-Appellant and stated that as per the regulations/ instructions issued by the IRDA, the claims made under the insurance policies are ordinarily to be settled within one month of the submission of the claim. The evidence produced by the complainant has gone unrebutted on record. In this way, the Opposite Parties have impliedly admitted the correctness of the allegations made in the complaint. It also shows that Opposite Parties  have no defence to dislodge the complaint. The very fact that the Opposite Party No.2 has lingered on the matter and not settle the claim of the complainant within one month in view of the judgement passed by Hon’ble State Commission, Punjab, Chandigarh (supra)  ever since 4.2.2016    shows that Opposite Party No.2 is deficient in service.   

6.       Consequently, the instant complaint succeeds  and Opposite Party No.2 is directed to settle the claim of the complainant within one month as per the regulations/ instructions issued by the IRDA, from the date of receipt of copy of this order. However, complaint against Opposite Party No.1 stands dismissed. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Forum

Dated: 07.02.2017.