Haryana

Kurukshetra

CC/171/2019

Shakuntla Bhatia - Complainant(s)

Versus

Rakesh Health Ins - Opp.Party(s)

Asish Deswal

04 Jul 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KURUKSHETRA

 

                                                                    Complaint No.:    171 of 2019.

                                                                   Date of institution:         08.05.2019.

                                                                   Date of decision: 04.07.2022

 

Shakuntla Bhatti w/o Shri Satpal Bhatti, aged about 55 years, r/o village Sarai Sukhi, H.No.196, Post Office Haripur, Kurukshetra and also r/o H.No.2166, Housing Board Colony, Phase-2, near Ratgal Sector-7, Kurukshetra.

                                                                                                …Complainant.

                                                     Versus

 

1. Raksha Health Insurance TPA Pvt. Ltd., 1^st Floor, 14/3, Main Mathura Road, Faridabad-121003, through its Manager.
2. Punjab National Bank (erstwhile Oriental Bank of Commerce), S.K. Road, Indri Chowk, Ladwa, District Kurukshetra through its Manager.
3. Punjab National Bank (erstwhile Oriental Bank of Commerce), Corporate Office- Plot No.5, Industrial Area, Sector-32, Gurgaon-122001, through its Managing Director.
4. United India Insurance Company Ltd., 24, Whites Road, Chennai-600014, through its Managing Director.

                                                                                      ...Respondents.

 

CORAM:   NEELAM KASHYAP, PRESIDENT.    

                   NEELAM, MEMBER.

                   ISSAM SINGH SAGWAL, MEMBER.           

 

Present:       Shri Ashish Deswal, Advocate for the complainant.

                   Opposite Party No.1 ex-parte, vide order dated 02.07.2019.

                   Shri R.K. Singhal, Advocate for Opposite Parties No.2 to 4.

ORDER:

 

1.                This is a complaint under Section 12 of the Consumer Protection Act, 1986.

2.                It is alleged in the complaint that the complainant is wife of Satpal. The husband of complainant namely Satpal (since deceased) was a regular employee in the Oriental Bank of Commerce and was posted at OBC Bank, Ladwa, Kurukshetra i.e. OPs No.2 & 3 and retired from the service on 30.04.2019 from Ladwa. OPs No.2 & 3 purchased the group health insurance policy from OP No.4 for the benefits and welfare of its employees and their family members from OP No.1. The term of insurance was one year and its premium was paid by OPs No.2 & 3. The complainant along with his family members was insured for Rs.4,00,000/- per member under the said policy bearing No.5001002818P109905620 valid from 01.10.2018 to 30.09.2019. The OP No.1 allotted a unique member ID No.UIC54556601OBCA. The complainant suffered from abdomen related problems for long time and was on medication. In November 2018, complainant No.1 was treated by Dr. Anurag Kaushal, Shri Balaji Aarogyam Hospital, Kurukshetra for the severe abdominal pain and other related diseases. The condition of complainant become serious, therefore, she was got admitted in Shri Balaji Aarogyam Hospital, Kurukshetra on 12.11.2018 to 16.11.2018. During this period various tests were conducted and it was diagnosed that complainant was suffering from acute pancreatitis. On 16.11.2018, Dr. Anurag Kaushal referred the complainant to higher centre for further management. Thereafter, husband of complainant took complainant to PGI Chandigarh in an ambulance and she remained under treatment from there for few days and in this regard, the complainants spent Rs.44359/- on medication, hospital fees, various medical tests and ambulance etc. On 29.11.2018, when the health of complainant deteriorated, in her hometown, she was taken to LNJP Hospital and various tests were advised by the doctors, which was got conducted from private laboratories. She remained admitted there from 29.11.2018 to 01.12.2018, as there was no improvement, she was referred to PGI Chandigarh by the doctors and she was shifted there in ambulance. Complainant was admitted there and received further treatment and discharged on 04.12.2018. Husband of complainant took her to Sanjeev Bansal Hospital, Karnal on 07.12.2018, wherein, special treatment for the disease was available and was under treatment from there. This time, the complainant spent Rs.20,287/- on her medical treatment etc. Since the complainant along with her family members was insured from OP No.4, therefore, from time to time, he had applied for the reimbursement of the amount spent on the medical treatment of his family members and claims were settled by the OPs No.1 & 4, but claim Nos.545221819284961 and 545221819377299 were wrongly repudiated by OPs No.1 & 4 on the ground of non supply of documents, which had already been supplied to them. The husband of complainant requested various times to the OPs to release his genuine claim, but they failed to redress their grievance, which is an act of deficiency in service on the part of OPs, due to which, they suffered great mental agony, hardship and financial loss, constraining them to file the present complaint against the OPs.

3.                Upon notice of complaint, OPs No.2 to 4 appeared and filed their respective written statements, whereas, OP No.1 failed to appear before this Commission on 02.07.2019, despite receipt of notice from this Commission and was proceeded against ex-parte, by this Commission on that date.

4.                OPs No.2 & 3, in their written statement stated the complainant No.2 Satpal Bhatti was an employee of OPs and he had retired on 30.04.2019 as a regular employee. The OPs had taken a health policy from OP No.4 for its employees for one year, under which, the husband of complainant and his family was insured for Rs.4,00,000/- for the period from 01.10.2018 to 30.09.2019. Under the said policy, the claim was to be lodged by the concerned employee with the insurance company and the OPs No.2 & 3 had no concern with the payment of claim. In the present case also, the claim was lodged by the complainant with OP No.4 and same was allegedly repudiated by it and OPs No.2 & 3 are not liable to pay any compensation. As such, the present complaint is not maintainable against them, as there was no deficiency in service on their part.

5.                OP No.4 in its written statement stated that the policy of insurance was issued by the OP No.4 for the period 01.10.2018 to 30.09.2019 in favour of OP No.3 insuring its employees. The claims under the policy of were to be processed and dealt by the OP No.1 as per terms and conditions of the policy of insurance. The intimation regarding the admission of complainant No.1 was received by OP No.1 and the complainants were asked to submit the necessary papers. The claim regarding admission of complainant for the period from 12.11.2018 to 16.11.2018 has already been settled and paid to the complainant on 04.06.2019. As far as claim regarding the admission and treatment in Shri Balaji Arogyam Hospital and LNJP Hospital for the period from 29.11.2018 to 01.12.2018 is related, the same was repudiated, as complainants failed to submit the necessary documents despite repeated reminders. The OP No.1 had issued final reminder on 12.03.2019 to complainant requesting to submit necessary documents for processing the claim, but they had not submitted the same. It is important to mention here that it was clearly mentioned in the final reminder that if the reply was not received within 15 days, the claim will be repudiated. The complainant failed to submit the same, thus the claim stands repudiated. There was no deficiency in service on the part of OPs No.4 and prayed for dismissal the present complaint.

6.                It is pertinent to mention here that during the pendency of complaint, complainant No.2 was died and as such, counsel for the complainants given up him from the array of complainants. Moreover, the Oriental Bank of Commerce has been merged with Punjab National Bank, as such, the complainant filed an application for amendment of title of complaint, which was allowed and title of the complaint case was amended as such.

7.                In support to support her case, complainant tendered affidavit Ex.CW1/A along with documents Ex.C-1 to Ex.C-7 and closed the evidence.

8.                On the other hand, the OPs No.2 to 4 tendered affidavits Ex.RW1/A, Ex.RW2/A along with documents Ex.R-1 to Ex.R-4 and closed their evidence.

9.                We have heard the learned counsel of the parties and carefully gone through the case file.

10.              Learned counsel for the complainant argued that the complainant No.2 was a regular employee in the Oriental Bank of Commerce and was posted at OBC Bank, Ladwa, Kurukshetra i.e. OPs No.2 & 3 and retired from the service on 30.04.2019 from Ladwa. OPs No.2 & 3 purchased the group health insurance policy from OP No.4 for the benefits and welfare of its employees and their family members from OP No.1. The husband of complainant along with his family members was insured for Rs.4,00,000/- per member under the said policy valid from 01.10.2018 to 30.09.2019 vide unique member ID No.UIC54556601OBCA. The complainant suffered from abdomen related problems for long time and was on medication. In November 2018, complainant No.1 was treated by Dr. Anurag Kaushal, Shri Balaji Aarogyam Hospital, Kurukshetra for the severe abdominal pain and other related diseases. The condition of complainant become serious, therefore, she was got admitted in Shri Balaji Aarogyam Hospital, Kurukshetra on 12.11.2018 to 16.11.2018. During this period various tests were conducted and it was diagnosed that complainant was suffering from acute pancreatitis. On 16.11.2018, Dr. Anurag Kaushal referred the complainant to higher centre for further management. Thereafter, complainant took complainant No.1 to PGI Chandigarh in an ambulance and she remained under treatment from there for few days and in this regard, the complainants spent Rs.44359/- on medication, hospital fees, various medical tests and ambulance etc. On 29.11.2018, when the health of complainant deteriorated, in her hometown, she was taken to LNJP Hospital and various tests were advised by the doctors, which was got conducted from private laboratories. She remained admitted there from 29.11.2018 to 01.12.2018, as there was no improvement, she was referred to PGI Chandigarh by the doctors and she was shifted there in ambulance. Complainant was admitted there and received further treatment and discharged on 04.12.2018. Complainant No.2 took her to Sanjeev Bansal Hospital, Karnal on 07.12.2018, wherein, special treatment for the disease was available and was under treatment from there. This time, the complainant spent Rs.20,287/- on her medical treatment etc. Since husband of complainant along with his family members was insured from OP No.4, therefore, from time to time, he had applied for the reimbursement of the amount spent on the medical treatment of his family members and claims were settled by the OPs No.1 & 4, but claim Nos.545221819284961 and 545221819377299 were wrongly repudiated by OPs No.1 & 4 on the ground of non supply of documents, which had already been supplied to them. The husband of complainant requested various times to the OPs to release his genuine claim, but they failed to redress their grievance.

11.              The learned counsel for OPs No.2 & 3 argued that husband of complainant Satpal Bhatti was an employee of OPs and he had retired on 30.04.2019 as a regular employee. The OPs had taken a health policy from OP No.4 for its employees for one year, under which, the husband of complainant and his family was insured for Rs.4,00,000/- for the period from 01.10.2018 to 30.09.2019. Under the said policy, the claim was to be lodged by the concerned employee with the insurance company and the OPs No.2 & 3 had no concern with the payment of claim. In the present case also, the claim was lodged by the complainant with OP No.4 and same was allegedly repudiated by it and OPs No.2 & 3 are not liable to pay any compensation. As such, there was no deficiency in service on their part.

12.              Learned counsel for OP No.4 argued that the policy of insurance was issued by the OP No.4 for the period 01.10.2018 to 30.09.2019 in favour of OP No.3 insuring its employees. The claims under the policy of were to be processed and dealt by the OP No.1 as per terms and conditions of the policy of insurance. The intimation regarding the admission of complainant No.1 was received by OP No.1 and the complainants were asked to submit the necessary papers. The claim regarding admission of complainant for the period from 12.11.2018 to 16.11.2018 has already been settled and paid to the complainant on 04.06.2019. As far as claim regarding the admission and treatment in Shri Balaji Arogyam Hospital and LNJP Hospital for the period from 29.11.2018 to 01.12.2018 is related, the same was repudiated, as complainants failed to submit the necessary documents despite repeated reminders. The OP No.1 had issued final reminder on 12.03.2019 to complainant requesting to submit necessary documents for processing the claim, but they had not submitted the same. It is important to mention here that it was clearly mentioned in the final reminder that if the reply was not received within 15 days, the claim will be repudiated. The complainant failed to submit the same, thus the claim stands repudiated. There was no deficiency in service on the part of OPs No.4 and prayed for dismissal the present complaint.

13.              There is no dispute between the parties that husband of complainant was regular employee of OPs No.2 & 3 and he along with his family members were insured for Rs.4,00,000/- per member with OP No.4 through OP No.1, valid from 01.10.2018 to 30.09.2019 vide ID Card Ex.C1 & Ex.C2.

14.              Coming to the first grievance of the complainant. In this regard, learned counsel for the complainant argued that the complainant took the treatment from Shri Balaji Aarogyam Hospital, Kurukshetra and then from PGI Chandigarh from 12.11.2018 to 16.11.2018 and spent total Rs.44,359/- on her treatment and submitted the claim with OPs No.1 & 4, but they initially illegally repudiated the same, but then OP No.1 emailed to OP No.4 Ex.R-3, vide which, they settled their claim to the tune of Rs.30995/-, after deducting Rs.13364/- and as such, the OPs No.1 & 4 are liable to pay the said balance amount to them. In this regard, the learned counsel for the OPs No.2 to 4 drawn attention of this Commission towards Claim Settlement Voucher Ex.R-2 and contended that Rs.800/- were deducted as USG report not attached; Rs.4230/- (Medication Charges) and Rs.1099/- (Pre & Post-Hospitalization Charges) were deducted as these price of these items were mentioned doubled and Rs.500/- (Ambulance Charges) was deducted as Ambulance Limit Exhaust. In this regard, learned counsel for the complainant argued that Rs.800/- has been wrongly deducted by the OPs on the ground that USG report not attached, but this report has been submitted to the OPs and also attached the same with the case file as Ex.C7 (page No.239). From perusal of case file, we found that the said report was attached in the case file as part of Ex.C-7, as such, the contention of OPs No.2 to 4 that USG report not attached, has no force, hence rejected. As such, the OPs are liable to pay Rs.800/- as Ultrasound report charges to the complainant. Now coming to the other deductions i.e. Rs.4230/-, Rs.6735/-, Rs.500/- and Rs.1099/-, made by the OPs in Ex.R-3 and after perusing the entire case file, we found that the OPs No.1 & 4 had rightly made the above-mentioned deductions from the claim amount of the complainants. Moreover, in this regard, learned counsel for the complainant also failed to convince this Commission that the OPs wrongly made these deductions. So, in view of above submissions, we found that the OPs wrongly deducted Rs.800/- (USG report), which is an act of deficiency in service on their part and as such, they are liable to pay the same to the complainants.

15.              Now coming to the second grievance of the complainant. In this regard, learned counsel for the complainant argued that the complainant No.1 again took treatment from PGI Chandigarh from 12.11.2018 to 16.11.2018 and spent total Rs.44,359/- on her treatment. The complainant again took treatment from LNJP Hospital, PGI Chandigarh and Sanjeev Bansal Hospital, Karnal and this time spent Rs.20,287/- on treatment and submitted his claim along with all requisite documents with the OPs No.1 & 4, but they wrongly and illegally repudiated the same. In this regard, learned counsel for OPs No.2 to 4 alleged that the complainants failed to submit the necessary documents despite repeated reminders as well as final reminder on 12.03.2019, as such, their claim was rightly repudiated. The learned counsel for the complainant contended that the complainants had sent the entire requisite documents to OP No.1 through registered posts to OP No.1 two times i.e. firstly on 13.02.2019 and then on 27.02.2019, but even then, they repudiated the claim of complainants on the ground of non-submission documents. In this regard, he firstly drawn attention of this Commission towards postal receipts Ex.C6 (page No.5 & 7 respectively). From perusal of these postal receipts, we found that complainant had sent some items/parcel through registered posts to OP No.1 firstly on 13.02.2019 and then on 27.02.2019 respectively. The learned counsel for the complainant further contended that the OPs wrongly and illegally repudiated this claim of complainants vide email dated 28.3.2019 Ex.C-4 on the ground of non-submission of requisite documents, but they had not mentioned those documents in that email, which they had not received. From perusal of email dated 28.03.2019, we found that “Claim No.545221819377299 has been repudiated, due to non-submission of the below mentioned documents, but OP No.1 had not mentioned below those documents in that email and without mentioning about that documents, it cannot be gathered that which documents they had not received from the complainant, due to which, they repudiated their claim. If OP No.1 had mentioned those documents which it had not received from the complainants due to which they repudiated their claim, then we can blame the complainants for not supplying those documents and in this regard repudiation of their claim could not justified, but the OPs did not do so and by not doing so, the OPs cannot be held justify in repudiating the claim of the complainants on this very ground.

16.              Learned counsel for the complainant further argued that vide letter dated 12.03.2019 Ex.C6 (Page No.23), the OPs demanded original treatment records at Sr. No.1 to 8, but these original treatment records cannot be provided to them as the same was in the custody of PGI, Chandigarh and they did not give the original treatment records to anyone. The complainant received the copy of that treatment records through RTI and sent the same to the OPs through registered posts on 13.02.2019 and thereafter, 27.02.2019 respectively and this Commission found force in this contention of the complainants. As such, the OPs No.1 & 4 are liable to pay the claim amount of Rs.20,287/- to the complainant.

17.              Keeping in view the above detailed facts and circumstances of the case, we are of the considered opinion that the OPs No.1 & 4 have not been able to prove the allegations, on the basis of which, they had refused to pay the genuine claim of the complainant, whereas, on the other hand, the version of the complainant was duly corroborated with cogent and convincing evidence. Thus, the repudiation of the claim done by the OPs, is held to be unjustified and amounts to deficiency in services on their part.

18.              Now the question which arises for consideration is what should be the quantum of indemnification? Coming to the first claim amounting to Rs.44,359/-, and as already observed, the complainant shall be liable to receive Rs.800/- i.e. charges of USG report, from this claim amount, from the OPs. Now coming to other claim amounting Rs.20,287/-. In the complaint, complainant contended that she spent Rs.20,287/- on the treatment of complainant No.1, and in this regard, he produced bills as Ex.C6 (page 29 to 98 respectively) on the case file and from these bills, it is evident that complainant incurred expenses of Rs.20,287/- on her treatment, and since as per Insurance Policy, the sum assured in the policy was Rs.4,00,000/-, therefore, the OPs No.1 & 4 are liable to reimburse the amount of Rs.20,287/- + Rs.800/-, to complainant No.1. They are also liable to compensate the complainant for the mental agony and physical harassment suffered by the complainants, alongwith litigations expenses. The complainant No.2 was the employee of OP No.2 & 3 and since there are no specific allegations against OPs No.2 & 3 nor the same was proved, and even they have no role to play in the dispute in question, therefore, complaint qua OPs No.2 & 3 are liable to be dismissed.

19.              In view of our above discussion, we partly accept the present complaint against OPs No.1 & 4 and direct them severally and jointly to pay the claim amount of Rs.21,087/- (20287+800), to the complainant. The OPs No.1 & 4 are further directed to pay Rs.10,000/- to the complainant, as compensation for mental agony and physical harassment, caused to the complainants, due to an act of deficiency in service, on their part, along with Rs.5,000/-, as litigation expenses. The OPs No.1 & 4 are further directed to make the compliance of this order within a period of 45 days from the date of preparation of certified copy of this order, failing which, the award amount of Rs.21087/- shall carry on interest @6% simple per annum, from the date of this order, till its actual realization and the complainant shall be at liberty to initiate proceedings under Section 25/27 of the Act, against OPs No.1 & 4. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

Announced in open Commission:

Dated:04.07.2022.

 

    

                                                                                        (Neelam Kashyap)               

(Neelam)                   (Issam Singh Sagwal)                              President,

Member.                    Member.                                                  DCDRC, Kurukshetra.           
 

 

 

Typed by: Sham Kalra, Stenographer.