Punjab

Ludhiana

CC/14/486

Man Singh - Complainant(s)

Versus

Reliance General Ins.Co.Ltd - Opp.Party(s)

-

19 Feb 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 486 of 14.07.2014

                                                                                                                    Date of Decision: 19.02.2015

                                                                                                                   

Man Singh Grewal, Advocate aged 84 years s/o Sh.Kaka Singh, resident of B-7- Le Palm Apartments Basant City, Pakhowal Road, Ludhiana, through its Special Attorney Sh.Gurinderpal s/o Pandit Buta Ram, r/o House No.661, Gali No.1, Jagdip Nagar, Ludhiana.

……Complainant

Versus 

1. The Reliance General Insurance, Anil Dhirubhai Ambani Group, Registered office: Reliance Centre 19, Walchand Hirachand Marg, Ballard Estate, Mumbai-400 038, through its General Manager.

2. The Reliance General Insurance, Anil Dhirubhai Ambani Group, Local office: 7^th Floor, Surya Tower, The Mall, Ludhiana-141001, through its General Manager.

 

…..Opposite parties 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                   Sh.Sat Paul Garg, Member

                   Smt.Babita, Member

 

Present:       Sh.Gurdeep Singh Salh, Advocate for complainant.

                   Sh.G.S.Kalyan, Advocate for OPs.

 

                   

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Man Singh Grewal s/o Sh.Kaka Singh, resident of B-7- Le Palm Apartments Basant City, Pakhowal Road, Ludhiana, through its Special Attorney Sh.Gurinderpal s/o Pandit Buta Ram (herein-after in short to be referred as ‘complainant’) against The Reliance General Insurance, Anil Dhirubhai Ambani Group, Registered office: Reliance Centre 19, Walchand Hirachand Marg, Ballard Estate, Mumbai, through its General Manager and others (herein-after in short to be referred as ‘OPs’)- directing them to pay the claim amount equivalent to 3469.85 $ i.e. Rs.2,08,200/- alongwith compensation of Rs.2.00 lac on account of compensation for deficiency in service and for causing mental agony and torture and harassment to the complainant alongwith any other relief for which the complainant is found entitled.

2.                Brief facts of the complaint are that complainant was to travel to USA and Canada and to cover the travel obtained the Reliance ‘Travel Care Insurance Policy’ for Senior Citizen from OP2 under policy no.2001502813000029 dated 11 August, 2010 to provide travel care coverage from 00.00 hrs on 9 November, 2010 to 10 January 2011 or date of return whichever is earlier. The geographical coverage of the policy extended to USA and Canada. For medical expenses the sum insured was $ 15,000. An amount of Rs.6840/- was paid as total premium. Mrs.Inderjit Kaur Grewal wife of the complainant also travelling with the complainant and also took travel care insurance policy under separate policy for the same period. Vide letter dated 13/17 August 2010 the complainant and his wife requested to change the coverage period from 00.00 hrs to 9 November 2010 to 10 January 2011 to 00.00 hrs on 1^st may 2011 to 30 June 2011 and night of date of return of the insurer whichever is earlier. But the policy issuing office issued policy no.2001502813000037 dated 4.12.2010 for the period 00.00 hrs on 6.2.11 to 9.4.2011 midnight. The complainant made a fresh request referring his earlier letter dated 13/17 August 2010 to issue a policy covering the period from 00.00 hrs on 1.5.11 to 30.6.11 midnight. In response to this letter the company issued 3^rd policy covering the period from 00.00 hrs on 1.5.11 to 2.7.11 midnight with no.2001512813000008 dated 31.3.11. While in the USA the complainant had a complaint in urinating with decreased force and at times urgency in urination in the first week of May, 2011, as such, he approached adhoc private walk-in preliminary health clinic run by General Practice doctors privately through one of his contact in medical line to avoid specialist costly treatment in the very initial stages of the problem. After check-up the doctor prescribed flomax as stop gap medicine and he also advised the complainant to consult the specialist urologist to get proper treatment of the problem or trouble. The complainant used the prescribed medicine and got the appointment of urologist doctor Clifton L. Williams of urology centre of Spartanburg PC South Carolina USA for 26 May, 2011. After 26 May 2011 the check-ups and treatment continued by doctor Williams which finally led to transrectal ultra sound and prostate biopsy on 3 June 2011. On visit of the complainant to the urologist on 9 June 2011 the urologist after examining Biopsy report gave his impression as ‘Prostatic Carcinoma Stage Ticnxms low volume, low risk, based off of pathology’ and advised ‘Active Surveillance Versus other treatment options”. It may be stated here that the complainant informed by telephone Europ Assistance USA about the problem before visit to the urologist on 26 May, 2011 which advised to take treatment and to pay the charges in cash to claim the amount later on. After the treatment, complainant filed the medical claim against the company, vide letter dated 14.9.11 and submitted all the bills, reports and other documents relating to the treatment with receipts for the expenses incurred by the complainant amounting to $ 3717.85, which was later on reduced to $ 3469.85 rectifying earlier mistakes and calculations. The complainant on the demand of the company attempted to provide all relevant documents available with him and which could be procured by the complainant from the doctor’s office to satisfy the requirement of claim, but the company during the process for finalizing the claim once closed the case proceedings vide letter 12.12.11 without any obvious reason being cited for this type of action. The case was reopened on the request of the complainant that half amount of the claim in full and final settlement of the claim. But the company has unilaterally stopped the proceedings, which was to be taken to finality without any reason and without any information to the complainant. Claiming the above act as deficiency in service on the part of the Ops, the complainant has filed this complaint.

3.                On notice of the complaint, OPs appeared through their counsel and filed written statement taking preliminary objections that the complaint is not maintainable; the complainant has not come to this Forum with clean hands and concealed the material facts from this Forum and present complaint is liable to be dismissed. Further stated that complainant is having Reliance Travel Insurance Policy of Senior citizens, vide policy no.200512813000008 w.e.f 1.5.11 to 2.7.11 and the complainant is claiming claim under the said policy and on receipt of the claim intimation, the Ops further sent intimation for requirement of documents for processing of claim. The complainant sent original claim form, original invoice, original bill, copy of passport, visa showing stamp of 23.8.10 (as mentioned in the letter dated 12.10.11 from 1 to 4). Thereafter the OPs sent letters dated 12.10.11, 31.10.11, final reminder dated 17.11.11 and closure of claim vide letter dated 10.12.11. But the complainant failed to reply the above said letters. As such, there is no deficiency in service on the part of the OPs in any manner at any stage. In fact the complainant has failed to supply the documents to the Ops as mentioned in the above said letters. So, the claim of the complainant was closed due to non supply of documents. So, the present complaint is liable to be dismissed on this score only. On merits, against the contents of para no.1 to 7 submitted that the detailed reply has been given above. The same be read as the part of these paras. Further denying the contents of all other paras, Ops prayed for the dismissal of the complaint.

4.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of Sh.Surinderpal s/o Sh.Pandit Buta Ram, r/o H.No.661, St. No.1, Jagdip Nagar, Ludhiana, Special Attorney of the complainant Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C53 alongwith documents Ex.C3A, C42A, C43A, C49A. On the other hand, Ld. counsel for the Ops adduced the evidence by way of duly sworn affidavit of Sh.Amit Chawla, Manager, Reliance General Insurance Co. Ltd. SCO-145-146, 2^nd Floor, Sector 9-C, Madhya Marg, Chandigarh Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and also attached documents Ex.R1 to Ex.R7.

5.                Case was fixed for arguments. Ld. counsel for complainant filed written arguments averring that the complainant availed a policy no.2001502813000029 dated 11.8.10 covering the insurance period from 9.11.10 to 10.01.11 (Ex.C3A), which was finally swapped with policy no.2001512813000008 dated 31.3.11 (Ex.C7) providing medical cover from 1.5.11 to 2.7.11 under which the treatment was taken in USA by the complainant by paying all the expenses from his own pocket for all visits, check-ups and biopsy surgery procedure of deadly disease like prostate cancer to find out as to whether the cancer was of malignant or benign type. The complainant wanted to avoid costly treatment in USA by delaying the treatment till he returns to India, but the attending urologist Doctor Cliff Williams complete ruled it out due to dangerous disease’s seriousness. After treatment, the complainant in accordance with the advise of the company filed the claim Ex.C8, C9 and C10 for US $ 3717.85 corrected to US $ 3469.85 to be converted to Indian currency at the time of payment by the company supported by all the documents from Ex.C3 to Ex.C53. The complainant also filed other documents such as copies of passport with the stamps of dates when the insured left and entered India with gate passes of airlines by which travel was done, which were asked by the company as proof of travel to USA. But the company all through continue to make inquiries demanding irrelevant information and documents piece meal. The company asked for even those documents second time which were already forwarded. The complainant with a view of settle the matter amicably made a conditional plea deal to accept half of the claim amount in satisfaction of the claim, if the payment of that amount was made immediately, without any prejudice to the right of the claimant to file the claim and demand the total amount in case the plea was not accepted and honored specifically in the court of competent jurisdiction. The company has caused lot of mental strain and torture to the complainant by making first to pay the expenses form his own pocket after paying the premium to the company and later not reimbursing the expenses. The company now is liable to pay the full amount of the claim with interest from 2.7.11 upto date on the claim amount as the company was bound to pay the expenses incurred by the complainant on 2.7.11, the expiry date of coverage.

6.                Refuting the allegations leveled by the complainant, Ld. counsel for OPs argued orally that the complainant was asked to supply all the papers regarding his mediclaim, vide letter dated 12.10.11, 31.10.11 and final reminder dated 17.11.11 and also sought closure of the claim vide letter dated 10.12.11. But the complainant failed to supply those documents, as mentioned in the abovesaid letters. So, the claim of the complainant was closed for non supply of documents. As such, there is no deficiency in service on the part of the OPs.

7.                We have gone through the pleadings and written arguments of the complainant as well as defence taken by the OPs and have also perused the entire record placed on file. After considering the preliminary objections, the complaint is found to be maintainable.

8.                It is evident that the complainant availed Reliance Travel Care Insurance Policy, vide bearing no.2001512813000008 w.e.f 1.5.11 to 2.7.11 and the complainant claimed his claim under this policy. During the coverage of the above said policy period complainant was having complaint of urinating with decreased force and taken the treatment from Doctor Clifton L. Williams of Urology Centre of Spartanburg PC. South Carolina USA, where the complainant spent $3469.85. Thereafter the complainant filed the medical claim and submitted al the document with the OPs. But the claim of the complainant was not settled by the OPs. However the complainant averred that after the treatment, complainant filed the medical claim against the company, vide letter dated 14.9.11 and submitted all the bills, reports and other documents relating to the treatment with receipts for the expenses incurred by the complainant amounting to $ 3717.85, which was later on reduced to $ 3469.85 rectifying earlier mistakes and calculations. The complainant on the demand of the company attempted to provide all relevant documents available with him and which could be procured by the complainant from the doctor’s office to satisfy the requirement of claim, but the company during the process for finalizing the claim once closed the case proceedings vide letter 12.12.11 without any obvious reason being cited for this type of action. The case was reopened on the request of the complainant that half amount of the claim in full and final settlement of the claim. But the company has unilaterally stopped the proceedings, which was to be taken to finality without any reason and without any information to the complainant.

9.                Sequel to the above, discussion, the present complaint is partly allowed and complainant is directed to supply the documents, if still required by OPs within 15 days from the receipt of the copy of the order and Ops are directed to settle and pay the claim of the complainant as per the terms and conditions of the policy within 45 days from the receipt of the requisite documents from the complainant. No order as to cost is passed. Copy of the order be supplied to the parties, free of costs. File be consigned to record room.

 

                   (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

                   Member                           Member                         President

Announced in Open Forum.

Dated:19.02.2015 

Hardeep Singh