DISTRICT CONSUMER DISPUTES REDRESSAL FORUM FATEHGARH SAHIB

Consumer Complaint  No.     :        39 of 05.09.2018

Date of Decision                      :         27.05.2019

Gita Rani aged about 38 years wife of Sh.Raj Kumar Resident of Village Boran, Post Office Khera, Tehsil and District Fatehgarh Sahib.

...........Complainant

Versus

1. Reliance Life Insurance Company Limited, having its registered office at H Block, 1^st Floor, DhirubhaiAmbani Knowledge City, Navi Mumbai, Maharashtra – 400710 through its authorized person.
2. Reliance Life Insurance Company Limited, having its Branch Office at Building No.3, Sector 21-C, Opposite Bus Stand, MandiGobindgarh, Tehsil Amloh, District Fatehgarh Sahib, through its Manager/ Authorized Person.

… .. Opposite Parties

Complaint Under Sections 12 to 14 of the Consumer Protection Act 1986.

Quorum

Sh. Kuljit Singh, President

Sh. Inderjit, Member

Present:       Sh.Kuldeep Singh, Adv.counsel for the complainant.

Pt.Narinder Kumar, Adv. counsel for OPs.

ORDER

By Kuljit Singh, President

1. Complainant -  Gita Rani has filed this present complaint against the Opposite parties Under Section 12 to 14 of the Consumer Protection Act 1986. The brief facts of the complaint are that on 13.06.2013, complainant purchased ‘Reliance Life Care for you Plan’ Policy from Ops bearing contract No.51035301 which was valid for three years i.e. upto 13.06.2016 and amount of sum assured was Rs.2,00,000/-.  Complainant had been paying premium regularly and policy expired on 13.06.2016.  Medi claim policy was further got extended by complainant from 30.06.2016 for a period of 12 years i.e. till 14.06.2028 vide renewal contract No.52677208 and the date of commencement of policy was 14.06.2016. Under said policy complainant was insured against Rs.2,30,000/- and her husband was nominee.  As per said policy medical expenses upto Rs.2,30,000/- were to be incurred by complainant in future on herself on any medical treatement which  were to be paid by OPs to complainant. Complainant had to undergo medical treatment in respect of some serious disease of her abdomen and in this regard, she remained admitted in IVY Hospital Mohali from 19.08.2016 to 27.08.2016. During her treatment, complainant incurred an amount of Rs.69,214/-.Thereafter, complainant filed her claim of Rs.69214/- with the OPs alongwith documents. The Ops had assured the complainant that needful will be done within 5-6 days from the date of application of her claim. Complainant made various visits and requests to Ops but to no effect.  She also issued legal notice dated 07.11.2016 to OPs but OPs failed to do the needful till date.  Upon said notice, complainant was called by OPs and was asked to submit her claim with them by filling a form. Accordingly, she filled the said form and submitted her claim with the OPs in the month of May 2017. Complainant was informed that her claim will be released to her within a period of 3-4 months and that the complainant will be informed accordingly by the branch.  As per IRDA Rules, Ops were required to clear the claim of complainant within 30 days, but OPs have not cleared the same.   It is prayed that Ops be directed to pay Rs.69,214/- i.e. claim amount alongwith compensation of Rs.1,00,000/- on account of harassment and mental tension. 
2. Upon notice,OPs appeared and filed joint reply by taking preliminary objections i.e.the complaint is false and has been filed to get undue benefit of the cost from OPs; Ops are unable to file reply on merits regarding alleged medical expenses as the claim file of complainant is not traceable from the record of OPs, therefore, the Ops stated that amended reply shall be filed as and when claim file of complainant is traced out. Complainant has not approachedthis Forum with clean hands; the contract of insurance between the complainant and OP is governed by its policy terms and conditions; the complaint is devoid of any material facts and has been filed to harass and gain undue advantage and unjustified money from OPs. On merits, it is submitted that complainant was issued policy bearing No.51035301 under plan in question and said plan expired on 13.06.2016. However, in June 2016, new policy reliance care of her advantage was issued in favour of complainant subject to terms and conditions. The medical expenses benefits under policy, if any, are payable subject to terms and conditions of the policy.The OPs are unable to trace the claim file of complainant.  Other averments of complaint are denied and prayed for dismissal of complaint.
3. In order to prove the complaint, the complainanthas tendered in evidence her affidavit Ex.CW1/Aalongwith documents Ex.C-1 to Ex.C-13 and closed the evidence. In rebuttal, the counsel for OPs has tendered affidavit of LalitSaini Ex.OP1 and then closed the evidence.
4. We have heard learned counsel for the parties and have also examined written arguments of both the parties and the record of the case very carefully.
5. The question for determination before the Forum is that whether this Forum has jurisdiction or not in the present case.From the record, it is transpired that OP No.2 is runningits business in the District Fatehgarh Sahib.  So this Forum has territorial jurisdiction to decide the dispute of present complaint.
6. The issuance of policy in question is admitted by both the parties.  From document Ex.C-3 to Ex.C-7, it is revealed that complainant has undergone some treatment in the Hospital from Ex.C-12 and Ex.C-13, it is proved that complainant has submitted the claim form with the Ops.  On the other hand, the Ops have submitted that they are unable to trace the claim file of the complainant.  It is crystal clear from the reply submitted which is duly supported with affidavit of authorized signatory that the OPs were unable to trace the claim file which is gross negligence on the part of OPs that they failed to trace its own record. As such, an adverse inference can be drawn against the OPs.  Moreover, the documentswhich  are duly supported with the affidavit of complainant is also believable that she submitted claim form alongwith other documents twice, but the Ops have failed to settle the dispute of the complainant. As such, we are of the considered view that there is deficiency in service as well as unfair trade practice on the part of the OPs, therefore, the OPs are liable to pay medical reimbursement claimed by complainant.
7. In view of the above facts and circumstances, the present complaint is partly allowed and the OPs are directed to pay claim amount to complainant alongwith interest @ 6% from 07.11.2016 till realization.  Further, the Ops are directed to pay Rs.5,000/- as compensation for harassment.
8. Entire compliance of above said be made within a period of 30 days from the date of receipt of certified copy of this order. 
9. Copy of this order be supplied to the parties as per permissible rules.

Pronounced: 27.05.2019                 

                                                                             (Kuljit Singh)

•                                                                       President

                                                                             (Inderjit)

                                                                              Member