DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.

 

Complaint Case No : CC/194/2019

Date of Institution : 08.11.2019

Date of Decision : 29.06.2020

Madan Lal Garg aged 57 years son of Chiranji Lal Garg, Subhash Street, Near Shama Public School, Tapa Mandi District Barnala-148101 (Punjab). 

               …Complainant

Versus

1. Branch Manager, Star Health & Allied Insurance Co. Ltd., Branch Office: SCO-70, 2nd Floor, Opposite Tata Indicom, New Leela Bhawan, Patiala -147001.

2. Managing Director, Star Health & Allied Insurance Co. Ltd. 1, New Tank Street, Valluvar Kottan High Road, Nunganbakkam, Chennai-600034.    

                …Opposite Parties

Complaint Under Section 12 of Consumer Protection Act, 1986.

Present: Sh. N.K. Garg counsel for complainant.

Sh. Rohit Jain and Sh. Lokeshwar Sewak counsel for opposite parties. 

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

(ORDER BY KULJIT SINGH, PRESIDENT):

The complainant namely Madan Lal Garg has filed the present complaint under Consumer Protection Act, 1986 (in short the Act) against Branch Manager Star Health & Allied Insurance Company, Patiala and another. (hereinafter referred as opposite parties).  

2. The facts leading to the present complaint are that the complainant had purchased one Health Policy scheme 2A+1C Policy No. P/211115/01/2020/001185 and paid the premium amount of Rs. 26,781/- through cheque No. 260024 dated 28.6.2019 issued out of his account No. 65006958952 with State Bank of India Branch Barnala. It is further alleged that the policy covered his family including his wife and child and the same was effective from 29.6.2019 to 28.6.2020. It is alleged that all of a sudden the complainant suffered from heart attack and was moved to Delhi for treatment and a request was made for cashless treatment that was declined by opposite parties vide their letter dated 5.8.2019. The complainant underwent Angiography at Maharaja Aggarsain Hospital New Delhi and spent Rs. 15,300/-. Then he was admitted to Fortis Escorts Heart Institute and Research Centre New Delhi, where he underwent operation and remained in the hospital from 3.8.2019 to 14.8.2019. He had to pay bill of Rs. 4,82,710/-. It is further alleged that the complainant lodged the claim with the opposite parties and opposite parties requisite certain documents vide their letter dated 5.8.2019 and the same were supplied to them. The opposite parties have been dilly-dallying the matter and have failed to pay the claim in spite of many efforts made by the complainant. Hence, the present complaint is filed seeking the following reliefs.- 

i) To pay the original claim of Rs. 15,300/- +Rs. 4,82,710 = Rs. 4,98,010/- alongwith interest @ 12% per annum from 14.8.2019 to 13.10.2019 (two months) i.e. Rs. 9,960/-.

ii) To pay Rs. 50,000/-  as compensation and Rs. 10,000/- as litigation expenses.   

iii) Any other relief which this Forum deems fit and proper. 

3. Upon notice of this complaint the opposite parties appeared and filed joint written version taking preliminary objections on the grounds of locus-standi, maintainability, clean hands and jurisdiction as the complainant has obtained the policy from the opposite parties at Patiala District. On merits, it is admitted to the extent that cashless request was made by the complainant towards the admission in Escorts Heart Institute And Research and the same was declined vide letter dated 5.8.2019 subject to tally. It is further submitted that the complainant neither intimated the claim towards the admission towards the alleged hospitalization in Maharaja Aggarsain Hospital and not submitted claim documents for reimbursement. The complainant failed to submit the requisite documents sought by the opposite parties. It is denied that the complainant was admitted in Fortis Escorts Heart Institute and Research Centre,  New Delhi and underwent operation and remained admitted in hospital from 3.8.2019 to 14.8.2019 and spent Rs. 4,82,710/-. It is further admitted that the complainant lodged the claim with the opposite parties and they requisite certain documents vide letter dated 5.8.2019. It is further wrong and denied that the complainant supplied all the documents to the opposite parties. It is further submitted that the policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy. The complainant submitted Pre Authorization request for cashless treatment for treatment of Unstable Angina and the same denied vide letter dated 5.8.2019 stating that the further evaluation required to ascertain the exact onset. Hence, the complainant was requested to submit documents towards reimbursement of medical expenses vide letter dated 5.8.2019. Thereafter, the opposite parties sent letter dated 13.8.2019 requesting the complainant to submit certain  claim documents towards reimbursement of medical expenses but even after repeated reminders dated 28.8.2019, 12.9.2019 and 26.9.2019 he has not submitted the claim record towards reimbursement of medical expenses. However, it is admitted that complainant has issued a legal notice which was replied vide reply dated 11.10.2019. But he has not submitted the necessary documents to process the claim without which the claim could not be processed. So, there is no deficiency in service and unfair trade practice on the part of the opposite parties. Further, the complainant purchased the policy from Patiala so this Forum has no jurisdiction to try and decide the present complaint. Lastly, they prayed for the dismissal of the present complaint with costs.

4. In support of his complaint, the complainant tendered into evidence affidavit of Madan Lal Garg Ex.C-1, copy of policy Ex.C-2, copy of denial letter dated 5.8.2019 Ex.C-3, copy of medical record of Maharaja Aggarsain Hospital Ex.C-4, copy of discharge summary Ex.C-5, copy of final bill cum receipt Ex.C-6, copy of legal notice Ex.C-7, copy of postal receipts Ex.C-8 and Ex.C-9, copy of acknowledgment Ex.C-10, copy of statement of account Ex.C-11 and closed the  evidence.   

5. To rebut the case of the complainant, the opposite parties  tendered into evidence affidavit of Rajiv Jain Ex.OP-1.2/1, copy of policy schedule Ex.OP-1.2/2, copy of terms and conditions Ex.OP-1.2/3, copy of proposal form Ex.OP-1.2/4, copy of pre authorization request Ex.OP-1.2/5, copy of query letter dated 4.8.2019 Ex.OP-1.2/6, copies of denial letters dated 5.8.2019 Ex.OP-1.2/7 and Ex.OP-1.2/8, copy of discharge summary Ex.OP-1.2/9, copy of reimbursement of medical claim Ex.OP-1.2/10, copy of first reminder dated 28.8.2019 Ex.OP-1.2/11, copy of second reminder dated 12.9.2019 Ex.OP-1.2/12, copy of rejection letter dated 26.9.2019 Ex.OP-1.2/13, copy of letter dated 11.10.2019 Ex.OP-1.2/14, copy of power of attorney Ex.OP-1.2/15 and closed the evidence. 

6. We have heard the learned counsel for the parties and have gone through the record. Written arguments also filed by opposite parties.

7. The main preliminary objection of the opposite parties is that the insurance policy was obtained by the complainant from the office of the opposite parties at Patiala District Patiala so this Forum has no jurisdiction to try and decide the present complaint. But from copy of policy alongwith proposal form Ex.C-2 it is proved on the file that the payment has been made from State Bank of India, Barnala through Account Number 65006958952 which is within the jurisdiction of this Forum, so in our view this Forum has the jurisdiction to adjudicate upon and decide the present complaint. 

8. It is admitted by the opposite parties that complainant purchased the Health Insurance Policy Ex.C-2 from the opposite parties by paying premium amount of Rs. 26,781/- valid from 29.6.2019 to 28.6.2020. It is admitted by the opposite parties that complainant suffered heart attack and he moved to Delhi for treatment and cashless treatment request was declined by the opposite parties vide letter dated 5.8.2019 Ex.C-3. However, in this letter Ex.C-3 it is mentioned that insured may however submit the documents with the opposite parties seeking reimbursement of the expenses incurred relating to the treatment of the above disease. 

9. The main objection on merits of the opposite parties in the present complaint is that as the complainant have not submitted the documents demanded by the opposite parties vide letter Ex.OP-1.2/8 and reminders Ex.OP-1.2/10 to Ex.OP-1.2/12 without which the opposite parties cannot process of the claim of the complainant so they rejected the claim of  the complainant vide letter dated 26.9.2019 Ex.OP-1.2/13. To rebut this objection the complainant failed to file any document or receipt that he submitted the requisite documents to the opposite parties. He neither filed copy of any postal receipt or by hand receipt on the file to prove that he submitted the requisite documents with the opposite parties. Even in the reply of legal notice dated 11.10.2019 Ex.OP-1.2/14 the same objection has been taken by the opposite parties so cannot say that it is an afterthought of the opposite parties. So, in our view the complainant must submit the demanded documents with the opposite parties to get processed his claim or in case he submitted the same with the opposite parties they he must file some proof of the same. However, in the interest of justice we again gives a chance to the complainant to submit the required documents with the opposite parties to settle his claim. 

10. In view of the above discussion present complaint is disposed of. Accordingly, the complainant is directed to submit the documents with the opposite parties as demanded by them to settle his claim as early as possible. Further, on receipt of requisite documents the opposite parties are  directed to settle the claim of the complainant within 30 days from the date of the receipt of requisite documents. In case the complainant will not satisfy with the outcome of the settlement of the claim by the opposite parties, then he is at liberty to file a fresh complaint before this Forum on the same cause of action. Compliance of the this order be made within the period of 30 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.

ANNOUNCED IN THE OPEN FORUM:

        29th Day of June 2020

 

 

            (Kuljit Singh)

            President

              

(Tejinder Singh Bhangu)

Member