Chandigarh

DF-I

CC/377/2023

RAMESH CHOPRA ADVOCATE - Complainant(s)

Versus

REGIONAL MANAGER ORIENTAL INSURANCE COMPANY LTD. - Opp.Party(s)

KARAN VERMA

05 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/377/2023
Date of Institution	:	03/08/2023
Date of Decision	:	05/06/2024

 

Ramesh Chopra, Advocate, aged 81 years s/o Dr. S.N. Chopra r/o House No.2295, Sector 35-C, Chandigarh.

… Complainant

V E R S U S

1. Regional Manager, Oriental Insurance Company Ltd., Batra Building, SCO No.109 to 1011, Sector 17-D, Chandigarh.
2. Senior Manager, Oriental Insurance Company Ltd., SCO No.37, Sector 30-C, Chandigarh.
3. Manager, M/s Raksha Health Insurance TPA Private Limited, Unit No.DTJ 425, 4^th Floor, Plot No.11, DLF Tower B, Jasola, New Delhi 110025.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                                                                       

ARGUED BY	:	Complainant in person
	:	Sh. Udit Garg, Advocate for OPs 1 & 2.
	:	OP-3 ex-parte

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Ramesh Chopra, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that OPs 1 & 2/insurers are engaged in the insurance sector i.e. general and health insurance whereas OP-3 is their third party administrator (TPA).  The complainant has been taking mediclaim policy from OPs 1 & 2 for the last many years and has also obtained the subject policy (Ex.C-1) which was valid w.e.f. 29.7.2022 to 28.7.2023 with sum insured of ₹2,00,000/-.  As the complainant was facing some health problem with respect to his pulse rate, he sent a letter dated 16.3.2023 (Ex.C-2) to OP-2 that he had been referred to GMCH, Sector 32, Chandigarh (hereinafter referred to as “treating hospital”). The complainant was examined by Dr. Jeet Ram Kashyap, Head of Cardiology of the treating hospital who advised ECG, ECO and hotler test.  In the hotler test some irregularity was observed, as a result of which the complainant was advised to go for angiography and for fitting of pacemaker.  Copy of the OPD card is Ex.C-3.  However, as nothing was detected in the angiography about the pulse rate irregularity, the treating doctor advised for fitting of pacemaker.  On this, complainant was admitted in the treating hospital on 28.3.2023 and angiography was done on 29.3.2023 and pacemaker device was fitted in the body of the complainant on 31.3.2023. The cost of the pacemaker device was ₹2,27,375/-  and copy of the bill is Ex.C-4. The complainant remained admitted in the treating hospital w.e.f. 28.3.2023 and was discharged on the night of 8.4.2023. The complainant spent total amount of ₹3,36,880/- on his treatment.  However, as the complainant was covered with sum insured of ₹2.00 lacs only under the subject policy, therefore, he requested OPs to pay the aforesaid amount to him. Thereafter the OPs asked the complainant to submit original bills and the complainant requested to return the photocopies before accepting the original bills from him, but, the OPs refused to return the copies of the bills on the ground that the same had become part of their case file.  As the OPs have not sanctioned the aforesaid amount in favour of complainant, he requested the Bar Council of Punjab and Haryana at Chandigarh by writing letter dated 30.5.2023 (Ex.C-7) to help him from their funds. However, as OPs did not consider the genuine claim of the complainant, therefore, he sent a legal notice dated 19.6.2023 (Ex.C-8) to the OPs with the request to settle the claim, but, nothing has been done by them. In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs 1 & 2/insurer resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action and concealment of facts. However, it is admitted that the subject policy was obtained by the complainant from the answering OPs for the sum insured of ₹2.00 lacs, but, denied that the OPs have wrongly not settled the claim of the complainant by further alleging that, in fact, the complainant was asked to submit the original bills as per clause 5.5 of the subject policy, but, since the complainant did not submit the original bills with the answering OPs, his claim could not be settled.  The complainant was even requested through several letters and reminders to submit the original bills with the answering OPs, but, he did not submit the same.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. OP-3 did not turn up before this Commission, despite proper service, hence it was proceeded against ex-parte vide order dated 5.10.2023.
4. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove his case, complainant tendered/proved evidence by way of affidavit and supporting documents. However, as OPs 1 & 2 failed to file evidence despite grant of sufficient opportunity, therefore, vide order dated 2.1.2024 of this Commission, opportunity to file the same was closed.
3. We have heard the complainant in person, learned counsel for OPs 1 & 2 and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject policy (Ex.C-1) from OPs 1 & 2/insurer which was valid w.e.f. 29.7.2023 to 28.7.2023 with sum insured of ₹2.00 lacs and the complainant remained admitted in the treating hospital w.e.f. 28.3.2023 to 8.4.2023 and during his treatment pacemaker device was inserted inside his body, as is also evident from the discharge and follow up card (Ex.C-3), for which he incurred total expenditure of ₹3,36,880/-, including ₹2,27,375/- being the cost of pacemaker, as is also evident from the tax invoice (Ex.C-4 colly.) and the claim of the complainant for ₹2.00 lacs has not been settled by the OPs, till date, on the ground that he has not submitted the original bills with them, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in not settling the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly not settled the claim and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of OPs. 
   2. The claim of the complainant is resisted by the OPs on the simple ground that he has not submitted the original bills with them and the complainant has countered the said defence of OPs 1 & 2, by alleging that, in fact, he approached them for the submission of the original bills, but, with the request that the copies of the same be given to him and since OPs 1 & 2 have not accepted his said request, the original bills could not be handed over to them.
   3. However, when it has come on record that the complainant has annexed all the original bills with the instant consumer complaint and even thereafter, OPs 1 & 2/insurer did not care to settle the claim of the complainant, knowing fully well that the original bills of the pacemaker and other treatment taken by complainant from the treating hospital are available on the case file, it is safe to hold that the said clearly amounts to deficiency in service and unfair trade practice on their part and the present consumer complaint deserves to succeed.
4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay the sum insured i.e. ₹2,00,000/- to the complainant.
2. to pay ₹15,000/-, in lump sum, to the complainant as compensation for causing mental agony and harassment as well as litigation expenses.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the aforementioned payable amounts shall carry interest @ 9% per annum from the date of this order, till realization.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

05/06/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member