Jammu and Kashmir

Jammu

CC/431/2017

RAJ PAL SINGH - Complainant(s)

Versus

RELIANCE INSURANCE - Opp.Party(s)

JATTINDER SINGH

23 Mar 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,JAMMU

         (Constituted under J&K Consumer Protection Act,1987)

 

                                                          .

 Case File  No                 467/DFJ           

 Date of  Institution    10-02-2016

 Date of Decision         06-03-2018

 

Rajpal Singh,

S/O S.Gagan Singh,

R/O Bagh Bahin,Camp Gole Gujral,

Jammu.

                                                                                                                                Complainant

                  V/S

Reliance General Insurance Company Ltd.

TRG Building 5^th Floor Bahu Plaza,Jammu,

Through its Manager.

                                                                                                                                   Opposite party

CORAM

                  Khalil Choudhary    (Distt.& Sessions Judge)  President

                  Ms.Vijay Angral                                                Member

                  Mr.Ghulam Sarwar                                             Member.

 

In the matter of Complaint under section 10 of J&K Consumer

                              Protection Act 1987.

 

Mr. Jatinder Singh, Advocate, for complainant, present.

Mr.Vishnu Gupta,Advocate for OP, present.

 

                                                               ORDER

 

                                Grievance of complainant as disclosed in the complaint is that on the assurance of OP,complainant took health risk cover policy bearing Policy No.2006722825000212 w.e.f.09-03-2013 to 08-03-2014 for sum assured to the tune of Rs.2,00,000/-copy of policy is annexed as Annexure-A)and at the time of taking policy ,complainant was having good health, sound state of mind, but during currency of policy period suddenly he suffered health problem and felt unconscious and due to deteriorating condition, he was immediately taken to PGI Chandigarh, where he was admitted on,25-12-2013,where he was treated and operated of brain as there was hemorrhage and discharged on,03-01-2014,(copy of treatment card annexed as Annexure-A1).Complainant further submitted that he spent Rs.2.05 lacs on the treatment and medicines and OP was duly informed about the suffering of health and admission at PGI Chandigarh and bills in original were also submitted to OP.Allegation of complainant is that at the time of taking the policy he was assured that if anything happened to life, in that case complainant shall be entitled to expenditure incurred on the treatment and medicines up to Rs.2.00 lacs and for that premium was taken by OP company, but  OP did not make any payment. Constrained by the act of OP complainant served legal notice upon OP requesting  OP to make payment, but despite service of legal notice upon OP nothing was done by the OP,even not replied to the legal notice and this act of OP constitutes deficiency in service. Hence the present complaint. In the final analysis, complainant prays for reimbursement of sum of Rs.3,25,000/-alongwith interest @ 18% p.a.from 25-12-2013 till its payment.

                     On the other hand,OP filed written version and resisted the complaint on the ground that the complaint deserves dismissal for non-joinder of necessary parties R-Care Health(TPA)is necessary and proper party for just and final adjudication of the claim, as the claim was to be considered and processed by R-Care Health (TPA)medical experts. The Op further submitted that complainant was granted insurance cover as requested for the period 09-03-2013 to 08-03-2014 with express conditions that the relations between the parties shall be strictly in accordance with the terms and conditions of Insurance Policy. The complainant has intentionally withheld the complete policy and has only annexed schedule to the petition. The Op further submitted that as per complaint complainant claims to have been admitted in PGI Chandigarh on,25-12-2013 and discharged on,03-01-2014.The complainant as per medical record was old case of hypertension which is one of the main cause of hemorrhage .After discharge from PGI Chandigarh he got treated in Sadbhavna Hospital, Patiala for heart treatment even at the time of admission in PGI,Chandigarh his BP was 150/100 and all the tests got conducted like NA/K/Calipid profile,USG of kidney and eye check basically pertained to hypertension. It is submitted that OP was intimated of the incident after long delay though as per policy conditions complainant was required to intimate the same immediately before or after the admission and also provide the OP with complete original record,bills,certificate of treating doctor, record of earlier consultations with the doctors. As per contract of insurance all claiming arising out of the policy were to be settled by TPA i.e.R-Care Health. The Op further submitted that though the claim was intimated after inordinate and unexplained delay, the OP requested complainant by letter dated 09-04-2014 to provide complete medical record, discharge summary, original final bills, original investigation reports, present consultation papers, medical bills and payment receipt .He was also requested to provide certificate by treating doctor and previous consultation papers related to ailment duly filled claim form etc.but complainant failed to do the same.

             Complainant adduced evidence by way of duly sworn evidence affidavit and affidavit of Surinder Singh.Complainant has placed on record copy of policy schedule, copy of discharge and follow-up-card, copy of treatment record and copy of legal notice.

               On the other hand,OP adduced evidence by way of duly sworn evidence affidavit of Suryadeep Thakur authorized signatory Chandigarh.The OP has also placed on record copy of verification report.

           We have perused case file and heard L/Cs for the parties at length.

                    At the outset, it is to be noted that we have minutely scanned the case file, but did not find iota of material in the shape of any communication with the OP,whereby claim is either lodged or request made for processing the claim. To the contrary OP has specifically resisted the claim inter alia on the ground that complainant neither submitted duly filled claim form, record of previous consultations with the doctors, certificate from the treating doctor, original medical bills and payment receipts, we are of the opinion that, in absence of submission of requisite documents  before,Ops,it is not reasonably possible to consider the same and resultant deficiency in service. At this stage Ld. Counsel appearing for OP submits at bar that in case complainant submits requisite documents, it will consider the same.

                     So in the facts and circumstances of the case, we are of the opinion that complaint can be disposed of with a direction to OP to consider the case of the complainant afresh, after submission of requisite documents by the complainant within stipulated period.

         Therefore, in view of the aforesaid discussion  the complainant is directed to furnish requisite medical record, including, certificate from treating doctor and record of previous consultations with the doctors and also duly filled claim form to the OP within two weeks and thereafter the OP shall consider the claim of the complainant in accordance with the terms and conditions of the Policy of insurance obtained by the complainant and settle the claim of the complainant within one month, positively and the report regarding settlement of the claim of the complainant be submitted to this Forum. Copy of this order be provided to the parties. The complaint is accordingly disposed of and file after its due compilation be consigned to records.

Order per President                                              Khalil Choudhary

                                                                         (Distt.& Sessions Judge)

Announced                                                              President

 06-03-2018                                                   District Consumer Forum

Agreed by                                                                Jammu.

 

Ms.Vijay Angral          

Member        

 

Mr.Ghulam Sarwar Chauhan,

Member