Punjab

Ludhiana

CC/14/811

Chanchal singh - Complainant(s)

Versus

Royal Sundram Alliance Ins.Co.Ltd - Opp.Party(s)

Sukhwinder Singh

11 Jul 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No. 811 of 27.11.2014

Date of Decision            :   11.07.2016 

 

Chanchal Singh aged about 62 years son of Sh.Madan Singh, resident of village Seelon Kalan, Tehsil and District Ludhiana.

….. Complainant

                                                         Versus

 

1.Royal Sundram Alliance Insurance Company Limited, B.M.Tower, (Mahindra & Mahindra), Ist Floor, B.R.S.Nagar, Ludhiana through its Area Manager.

2.Royal Sundram Alliance Insurance Company Limited, Corporate Office, Sundram Tower 45 & 46 Whites Road, Chennai.

…Opposite parties 

             (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

 

SH.G.K.DHIR, PRESIDENT                                     

MRS.          BABITA, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                      :          Sh.S.S.Cheema, Advocate

For OPs                          :          Proxy Ms.Ravinder Kaur, Advocate

 

PER G.K.DHIR, PRESIDENT

 

1.                Complaint under Section 12 of Consumer Protection Act, 1986(hereinafter in short referred to as ‘Act’) filed by complainant Sh.Chanchal Singh against Ops by claiming that he got the policy bearing No.MIB0019206000100-MR01 from OPs with validity period from 31.8.2013 to 30.8.2014 by paying Rs.10,000/- as premium. This policy was issued by the OPs after completing due formalities and physical checkup of body of the complainant. Policy was purchased for providing financial aid to the complainant in the event of any illness. In February 2014, complainant suffered heart ailment, due to which, he had to undergo surgery by incurring expenses of Rs.2,20,900/- on his treatment. Complainant remained admitted in S.P.S.Apollo Hospital, Sherpur Chowk, Ludhiana for the period from 17.2.2014 to 19.2.2014. At the time of issue of policy, OPs assured the complainant to bear the expenses of ailment/treatment to the extent of Rs.1 lac. Complainant approached OPs and presented the necessary documents regarding his ailment for submitting prayer to reimburse to extent of Rs.1 lac as per the terms and conditions of the policy, but that request was not entertained by the concerned officials of OPs. Complainant visited the office of OP1 on various occasions for requesting the concerned officials to pay the insured amount, but to no effect. Thereafter, complainant through counsel Sh.S.S.Cheema, Advocate got served a legal notice dated 2.9.2014 on OPs and thereafter, filed this complaint by pleading deficiency in service on the part of OPs. Compensation of Rs.25,000/- along with amount of Rs.1 lac on account of medical claim sought.

2.                In the joint written statement filed by OPs, it is admitted that the complainant got the Mediclaim Group Health Insurance Policy with validity period from 31.8.2013 to 30.8.2014. It is claimed that the case of the complainant is governed by the terms and conditions of the policy. Complainant has never submitted the claim for his admission at S.P.S.Apollo Hospital for the period from 17.2.2014 to 19.2.2014. So, complaint of the complainant alleged to be pre-mature. Until and unless the claim lodged, OPs could not have presumed that the complainant remained admitted in the hospital for the alleged heart ailment. As per the terms and conditions of the policy, claim should have been lodged within 30 days after getting discharge from the hospital, but no claim lodged by the complainant. So, there is no deficiency in service on the part of OPs. Allegations regarding repudiation of claim denied by terming them as false and baseless. Complaint alleged to be brought for vexatious litigation. Besides, it is claimed that the complainant has not approached this Forum with clean hands. Each and every other averment of the complaint denied by claiming that as per the terms and conditions of the policy, in case, intimation of claim submitted after 90 days from the date of discharge from the hospital, then claim shall not be entertained. Besides, it is averred that claim beyond 180 days period from the date of expiry of policy is not maintainable.

3.                Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.P1 to Ex.P3 and Mark-A and Mark-B and thereafter, closed the evidence.

4.                On the other hand, counsel for the OPs tendered in evidence affidavit Ex.RA of Sh.Aneesh Bhaskaran, Senior Legal Executive of OPs along with document Ex.R1 and thereafter, closed the evidence.

5.                          Written arguments not submitted by any of the parties. Oral arguments alone addressed by the counsel for the parties and those were heard. Records gone through minutely. 

6.                Admittedly, policy in question was purchased by the complainant. However, it is the case of the Ops that the complainant has not lodged any claim regarding his admission in S.P.S.Apollo Hospital, Sherpur Chowk, Ludhiana for the period from 17.2.2014 to 19.2.2014 and as such, the complaint is pre-mature. Besides, it is contended that the claim form duly completed should have been submitted along with documents within 30 days from the date of discharge from the hospital, but the same has not been submitted and as such, complaint not maintainable, particularly when the claim sought with respect to the admission of the complainant in S.P.S.Apollo Hospital, Ludhiana during period from 17.2.2014 to 19.2.2014, but alleged legal notice Ex.P1 got served on 2.9.2014 i.e. after 6 ½ months of discharge from the hospital. These contention of counsel for OPs has no force, particularly when contents of letter Ex.R1 submitted by OPs itself establishes that certificate of insurance, terms and conditions of insurance qua the policy in question for the period from 31.8.2013 to 30.8.2014, sent by OPs to the complainant on 12.5.2015. Letter Ex.R1 is of date 12.5.2015. Through this letter Ex.R1, thanks were conveyed to the complainant for choosing the health insurance plan. Through Ex.R1, documents consisting of certificate of insurance, terms and conditions, guide to the policy and service etc., were forwarded to the complainant. The present complaint filed on 27.11.2014 and as such, virtually the terms and conditions of the policy along with certificate of insurance conveyed to the complainant through letter Ex.R1 of date 12.5.2015, after filing of this complaint. In view of sending of terms and conditions and certificate of insurance to the complainant by the OPs after filing of this complaint, certainly the complainant would not have known of the terms and conditions of the policy, until the date of filing of complaint. Being so, if complainant has not lodged any claim in writing, then it was due to fault of OPs in not sending the certificate of insurance and terms and conditions of the policy at earliest. Ops cannot get benefit of their own wrong in such circumstances.

7.                Certainly, procedure for lodging the claim is there and as such, complainant must lodge the claim in writing along with documents within 30 days from the date of receipt of copy of this order, so that his insurance claim may be processed by the OPs within the specified period. As the policy documents were not sent to the complainant before filing of this complaint and as such, he suffered lot of mental harassment. Complainant has to get the legal notice Ex.P1 served through counsel before receipt of the policy documents and as such, certainly complainant entitled for the litigation expenses. In view of fault of OPs in not sending the policy documents before filing of this complaint, OPs now estopped from claiming that claim of the complainant not entertainable as per the terms and conditions of the policy, particularly when those terms and conditions never conveyed to the complainant until filing of the complaint. So, directions need be issued to the Ops to consider the claim of the complainant.

8.                As a sequel of the above discussion, complaint partly allowed in terms that complainant will lodge the claim in writing along with documents with OPs within 30 days from the date of receipt of copy of this order. After receipt of this claim and documents, OPs will process the same and adjudicate/settle the same within 60 days from the receipt of those documents. After such adjudication, the payment( if any) will be made by the OPs to the complainant within 30 days from the date of final order( to be passed by OPs). Compensation for mental harassment of Rs.5000/- and litigation expenses of Rs.3000/- more allowed in favour of complainant and against OPs. These amounts of compensation and litigation expenses be paid by OPs within 30 days from the date of receipt of copy of order. Copies of order be supplied to the parties free of costs as per rules.

9.                File be indexed and consigned to record room.

 

                   (Babita)                                        (G.K. Dhir)

          Member                                          President

Announced in Open Forum

Dated:11.07.2016

Gurpreet Sharma.