| ORDER | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.349 of 02-06-2014 Decided on 13-01-2016 Kuldeep Jindal aged about 38 years S/o Dev Raj Jindal R/o H.No.136, Mohan Nagar, Ward No.12, Gidderbaha, Tehsil Gidderbaha, District Sri Muktsar Sahib now R/o Street No.3, H.No.30331, Paras Ram Nagar, Bathinda. ........Complainant Versus Royal Sundaram Alliance Insurance Company Limited, Corporate Claims Department, Sundaram Towers, 45 & 46, Whites Road, Chennai-600014, through its M.D/Chairman. .......Opposite party Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.M.P Singh Pahwa, President. Smt.Sukhwinder Kaur, Member. Sh.Jarnail Singh, Member. Present:- For the Complainant: Sh.M.K Dhamija, counsel for complainant. For Opposite party: Sh.Rakesh Mangla, counsel for opposite party. ORDER M. P. Singh Pahwa, President The complainant Kuldeep Jindal (here-in-after referred to as complainant) has filed complaint U/s 12 of Consumer Protection Act, 1986 against opposite party Royal Sundaram Alliance Insurance Company Limited (here-in-after referred to as opposite party). Briefly stated, the case of the complainant is that he purchased one medical insurance policy namely 'Health Shield Insurance Policy' from opposite party and paid it requisite premium from time to time. Opposite party issued policy in his favour for a sum of Rs.1 lac for the period from 12.12.2011 to 11.12.2012. As per this policy, Mamta Jindal wife and Diksha Jindal daughter of complainant are covered as insured persons. It is alleged that the daughter of the complainant namely Diksha Jindal fell ill and got admitted in Sanjivini New Born & Child Care Hospital, Bathinda on 14.9.2012 and remained admitted upto 23.9.2012. Approximately, an amount of Rs.50,000/- was spent on her treatment including Rs.27,300/- charged by hospital and Rs.22,000/- for medicines and other misc. expenses. The complainant lodged claim vide claim No.HRA-68851 and completed all the requisite formalities to honour his claim, but his claim was repudiated vide letter dated 24.12.2012 on the ground of fraud alleging that if any claim is in any respect fraudulent or if any fraudulent means or devices are used by the insured person or anyone acting on their behalf to obtain any benefit under this policy, all the benefits will be forfeited. It is further alleged that the repudiation letter is totally illegal, null and void and not binding upon the right of the complainant. The claim has been illegally repudiated on the flimsy ground. The claim is not fabricated in any manner and it is genuine one. The complainant submitted all the bills alongwith medical certificate and claim cannot be said to be forged claim. On this backdrop of facts, the complainant has alleged deficiency in service on the part of opposite party and has claimed compensation to the tune of Rs.50,000/- in addition to Rs.5500/- as cost of litigation and prayed for reimbursement of claim amount. Hence, this complaint. Upon notice, opposite party appeared through its counsel and contested the complaint by filing its written version. In written version, opposite party has raised the legal objections that the complaint is frivolous and not tenable at law and deserves to be dismissed with costs. All the averments and contentions of the complainant unless specifically admitted in the written version are specifically denied. This Forum has no territorial jurisdiction to entertain this complaint as the complainant took the policy from Chennai office of opposite party and claim was made in Chennai office and was denied by Chennai office. As such, the complaint is not maintainable before this Forum merely because the complainant took treatment at Bathinda. It is pleaded that the complainant has first time taken one 'Health Shield Standard Policy' valid from 12.12.2011 to 11.12.2012 in his favour. The policy was issued subject to its terms and conditions. He made claim under the policy stating that his daughter Diksha Rani was admitted to M/s Sanjivini Hospital from 14.9.2012 to 23.9.2012 for the treatment of ailment of Viral Hepatitis. Opposite party investigated this matter after appointing independent investigator M/s Mack Insurance Auxiliary Services Limited. The investigation revealed various discrepancies in the claim of the complainant as he was trying to make fabricated and fraudulent claim. The independent investigator concluded by stating that the claim was fraudulent as even though the daughter of complainant was treated for acute viral hepatitis yet the type of hepatitis with which her daughter was suffering was not detected, which was just impossible as the treatment could not have been done without detecting the same. The opposite party revealed the relevant excerpt of the investigation report, which is reproduced as under:-
“Insured-Diksha Jindal Hospital-M/s Sanjivini Hospital Diagnosis-Acute Viral Hepatitis Findings and Verifications:- In the chemist bill book the bills were issued only for baby Diksha and rest of the bills were empty as no name has been written on them. The lab bills were also similarly issued only to baby Diksha and rest of the bills were empty as no name has been written on them. The hospital bill book was not shown to investigator. The hospital authorities told investigator of opposite party that they issue the bill only on the letter head of the hospital. In the treatment record it is clearly mentioned that the injection Pipzo 1.5 gm Iv 6 hourly and injection Amicacin, 500mg, IV BD is to be given, which is an adult dose and such a heavy dose can never be given to a child of 1.6 yrs old (10.8 Kg). This means either an adult was treated or the papers were fabricated. The chemist bills were also issued by the treating doctor. The prescription slips and chemist bills bear the same handwriting. Conclusion-Hardcore Fraud. Conclusion-The case seems to be fraudulent and papers are fabricated.”
As per opposite party, the claim has been denied being with ulterior motive of making wrongful loss to the complainant after relying upon the below mentioned clause for repudiating the claim:- “If any claim is in any respect fraudulent, or if any fraudulent means or devices are used by the Insured/Insured Person or anyone acting on their behalf to obtain any benefit under this policy, all benefit under this policy shall be forfeited, the company may choose to void the policy and reclaim all benefits paid to the Insured/Insured Person.” It is further asserted that opposite party thoroughly investigated to ascertain the veracity of the claim made by the complainant and found that it is fraudulent. Opposite party observed from the detailed investigation that the complainant has tried to manipulate the medical documents, which tantamount to making fraudulent claim by using fraudulent means. Therefore, his claim is inadmissible as per terms and conditions of the policy and fraud vitiates the contract of insurance. On merits also, opposite party controverted all the material averments and reiterated its version as taken in the legal objections and detailed above. In the end, opposite party prayed for dismissal of complaint. Parties were afforded opportunities to produce evidence. In support of his version, the complainant tendered into evidence photocopy of policy, (Ex.C1); photocopies of letter, (Ex.C2 and Ex.C3); his own affidavit dated 31.5.2014, (Ex.C4); photocopies of discharge summary, (Ex.C5 to Ex.C8); photocopies of cash memos, (Ex.C9 to Ex.C25, Ex.C27 to Ex.C76) and affidavit of Dr.Sunil Garg dated 27.8.2014, (Ex.C26). In order to rebut the claim of complainant, opposite party tendered into evidence affidavit of G.Vinay Prakash dated 3.9.2014, (Ex.OP1/1); photocopy of policy schedule, (Ex.OP1/2); photocopy of key features of policy, (Ex.OP1/3); photocopy of terms and conditions of policy, (Ex.OP1/4); photocopy of claim form, (Ex.OP1/5); photocopies of treatment chart, (Ex.OP1/6 to Ex.OP1/13); photocopies of prescription slips, (Ex.OP1/14 to Ex.OP1/23); photocopy of letter, (Ex.OP1/24); photocopy of health card, (Ex.OP1/25); photocopy of letter, (Ex.OP1/26) and submitted written arguments. We have heard learned counsel for the parties and gone through the file as well as written arguments submitted by opposite party. Learned counsel for complainant has submitted that the material facts are not in dispute. It is not disputed that the complainant obtained medical insurance policy, which covered his daughter Diksha Jindal also. The complainant has alleged that his daughter Diksha Jindal suffered from illness and she remained admitted in the hospital from 14.9.2012 to 23.9.2012. The complainant submitted claim alongwith supporting documents with opposite party. His claim was repudiated mainly on the basis of investigator report, but investigation report is not formally tendered into evidence, although, there is reference of same in the affidavit of G.Vinay Prakash, (Ex.OP1/1), copy of investigation report is produced on record by opposite party alongwith written arguments as Annexure-A. This report is not admissible in evidence being not tendered into evidence. Even otherwise, this report is not based on factual position. In this report, it is mentioned that in chemist bill book, the bills were issued only for baby Diksha and rest of bills were empty. No detail of the empty bills is collected, even photocopies of these empty bills are not collected. Moreover the complainant has got produced number of bills issued to other persons. Hospital bill books were not shown to investigator. Dr.Sunil Garg, treating doctor has furnished affidavit and cleared entire position. It is also mentioned that in treatment record, injections mentioned for patient were actually meant for adult dose and such a heavy dose can never be given to a child of 1.6 yrs old. This means either an adult was treated or the papers were fabricated. There is nothing to prove this fact by medical evidence. Moreover there is nothing to show that investigator was medical expert. Even otherwise, this fact could have been easily enquired from treating doctor. No step was taken to seek clarification from treating doctor. In these circumstances, the report of investigator cannot be accepted and it is liable to be disbelieved. There is no ground to repudiate the claim of the complainant. Opposite party unnecessarily delayed to settle the claim of the complainant. Therefore, complainant is entitled to compensation also. On the other hand, learned counsel for opposite party has reiterated his stand as taken in written version and detailed above. It is further submitted by learned counsel for opposite party that the complainant has failed to prove his case. The matter was got investigated. The conclusions of the investigator were detailed in the written version. Copy of report of investigator is also produced on record as Annexure-A alongwith written arguments. The proceedings in the Forum are summary in nature, as such, the report can be looked into, even if not formally tendered into evidence. It is further submitted by learned counsel for opposite party that the investigator found number of discrepancies qua treatment and purchase of medicines. These discrepancies fall under the fraud. As such, there is no illegality in repudiation the claim of the complainant. It is further submitted by learned counsel for opposite party that this Forum has no territorial jurisdiction to decide this complaint as office of opposite party is at Chennai and policy is issued from Chennai and claim was repudiated from Chennai. Therefore, this Forum has no territorial jurisdiction. The complaint is liable to be dismissed on this score also. We have given careful consideration to these submissions. Before coming to controversy on merits, it is to be decided whether this Forum has territorial jurisdiction to decide this complaint or not. Of-course, policy was issued from Chennai and claim was repudiated from Chennai, but the complainant has taken treatment from Bathinda. It is 'Health Shield Insurance Policy'. The complaint can be filed at any place where even part of cause-of-action accrued. The matter relates to reimbursement of claim regarding treatment, which was taken for daughter of complainant at Bathinda hospital. Therefore, this Forum has territorial jurisdiction to decide this complaint. The material facts are not in controversy. It is not disputed that the complainant purchased one 'Health Shield Insurance Policy' of opposite party and submitted his claim qua treatment of his daughter Diksha Jindal. The claim has been repudiated mainly on the basis of investigator report, copy of report was not tendered into evidence. However, observations of the investigator resulting repudiation of claim is revealed in the written version. As per opposite party, in the chemist bill book, the bills were issued only for baby Diksha and rest of the bills were empty. Investigator has not collected the photocopies of empty bills. There is also nothing to corroborate this finding of investigator. Moreover the complainant has examined the chemist, who has produced bills issued to other persons during that period. It is also finding of the investigator that the lab bills were similarly issued only to baby Diksha and rest of the bills were empty. Again at the cost of repetition, investigator has not collected the photocopies of empty bills or any other particulars of empty bills to corroborate this finding. It is mentioned that the hospital bill book was not shown to investigator and hospital authorities told him that they issue the bill only on the letter head of the hospital. The investigator could have verified this fact from treating doctor Dr.Sunil Garg. Moreover the complainant tendered affidavit of Dr.Sunil Garg, (Ex.C26) wherein he has explained the position. It is also mentioned that the injections mentioned for patient are to be given to an adult and such a heavy dose can never be given to a child. It is concluded that either an adult was treated or the papers were fabricated. The investigator could have verified this fact from the treating doctor. Moreover there is nothing to show that the investigator is an specialist in the field of medicine. Therefore, in these circumstances, it cannot be concluded that the report of investigator is based on factual position and is not sufficient to repudiate the claim of the complainant. As such, this report is not acceptable and it is rejected. As the report of investigator is not accepted, as such opposite party is required to examine the matter afresh and decide the claim of the complainant after ignoring this report. For the reasons recorded above, the complaint is partly accepted with Rs.3000/- as cost and compensation against opposite party. Opposite party is directed to settle the claim of the complainant afresh. It is made clear that opposite party is at liberty to seek any information/clarification from the complainant or concerned doctor, which is necessary for the settlement of the claim. The compliance of this order as whole be made within 60 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Pronounced in open Forum:- 13-01-2016 (M.P Singh Pahwa) President (Sukhwinder Kaur) Member (Jarnail Singh) Member
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