Order by:

Smt.Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that the complainant being mother is the nominee in the policy in question has filed the present complaint. The son of the complainant namely Keshav Chhabra during his life time has purchased one mediclaim policy No..P/211222/01/2020/004577 from opposite party on 7.2.2020 valid from 08.02.2020 to 07.02.2021 and paid the requisite premium of Rs.8277/-. Unfortunately son of the complainant met with a road accident on 8.2.2020 as a result of which, he received multiple injuries and remained admitted in Amandeep Hospital, Amritsar for treatment. He got discharged from the hospital on 22.02.2020. Ultimately, he died on 01.03.2020. The post mortem on the dead body of son of the complainant was conducted in Civil Hospital, Malout by Dr.Rajinder Singh vide PMR no.RS/04/PMR/2020 dated 01.03.2020. Regarding the occurrence, FIR no.42 dated 12.2.2020 u/s 279,337,338, 427 IPC and 304A IPC added later on has been registered in PS: City Malout. Thereafter, complainant being the nominee under the policy has duly lodged the claim with opposite party and also completed all the requisite formalities, but despite that opposite party has repudiated the claim of the complainant vide letter dated 14.06.2021 on the pretext that despite the request of the opposite party, the complainant has failed to submit the chemical analysis reports of deceased. Alleged that complainant also approached to the Police authorities for the purpose of report of chemical examination, through her son in law namely Sanjeev Kumar under RTI Act, but the same could not be given to her on the pretext that the case is still under investigation and till then they are unable to issue the report of examiner. Thus there is no fault on the part of the complainant in not providing the said report. The complainant is widow lady and she is being harassed by the opposite party whereas demand of chemical report by opposite party not required to adjudicate the reasonable claim of the complainant because this is not a death claim but only a claim of medical bills. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite party may be directed to pay Rs.3,81,000/- with regard to the mediclaim of his son alongwith interest.

b)      To pay an amount of Rs.1,00,000/- as compensation on account of damages, mental tension and harassment.

c)       To pay an amount of Rs.11,000/- as counsel fee.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in summary procedure under C.P. Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has concealed material facts and documents from this Commission as well as from the opposite party, therefore, the complainant is not entitled to any relief. Further averred that son of the complainant namely Keshav Chhabra availed the ‘Star Comprehensive Insurance Policy No.P/211222/01 /2020/004577 for the period 08/02/2020 to 07/02/2021 and in this policy said Keshav Chhabra was insured for an amount of Rs.5 Lakhs. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. The complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form and no pre-existing disease was declared by the insured. Further submitted that insured preferred claims in the first day of the policy. The claim in dispute is reported in the first day of the policy and the claim registered vide no.CLI/2020/211222/0888323. The claim form regarding the medical reimbursement expenses towards the treatment of son of complainant taken by him at Amandeep, Hospital Amritsar from 09.02.2020 to 22.02.2020. Diagnosis with compound fracture of shaft of femur RT, both bone RT forearm, upper end tibia RT was submitted and cashless hospitalization from the hospital and claimed amount of Rs.4,11,398/- was submitted. On perusal of submitted record, medical team of the Opposite Party demands documents vide letter dated 09.02.2020 and on 10.02.2020, an amount of Rs.75000 provisionally was granted on an estimated amount of Rs.1,85,000/- until the complete documents will not be submitted, but later on again team of Opposite Party demanded some documents to process claim and the same was not submitted by the complainant. Further vide letter dated 21.02.2020, the cashless was withdrawn and the Pre Authorization Request for cashless treatment was rejected. So, after the rejection and withdrawal of cashless hospitalization by Opposite Party, the DLA (Deceased Life Assured) was died on 01.03.2020. Thereafter, the complainant has submitted the claim form on 12.06.2020 along with the documents like death certificate, FIR and postmortem report. Thereafter again a team was deputed by Opposite Party who gave field visit report and collected some documents like medical bills etc. from Amandeep Hospital. On perusal of the Post Mortem submitted by the complainant, it was observed that Stomach with contents Part of small & large intestine with contents have sent to viscera for chemical analysis. Hence, query was raised vide letter dated 12.01.2021 and followed by reminders dated 27.01.2021 & 11.02.2021 to submit the Chemical Analysis report. In spite of repeated reminders, the complainant had not submitted the Chemical Analysis report which is the vital and mandatory documents to process the claim. Hence, the claim was repudiated on non submission of to the necessary documents vide condition no.2 of the policy. The complainant is not the consumer of the Opposite Party and the complaint is liable to be dismissed; the complainant has no locus standi or cause of action to file the present complaint against the Opposite Party; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the policy. Hence, the Opposite Party are not liable to pay any claim; this Commission has no jurisdiction to try and decide the present complaint as neither complaint is resident of Moga, so this Commission has got no jurisdiction to try the present complaint. On merits, all other allegation made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, the complainant has tendered into evidence affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to Ex.C10.

4.       To rebut the evidence of complainant, ld. counsel for the Opposite Party has tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OPs/1 alongwith copies of documents Ex.OPs/2 to Ex.OPs/8.

5.       We have heard the ld. counsel for both the parties and also gone through the record.

6.       The son of the complainant namely Keshav Chhabra (now deceased) has availed mediclaim policy No.P/211222/01/2020/004577 from opposite party on 7.2.2020 valid from 08.02.2020 to 07.02.2021 and paid the requisite premium of Rs.8277/- and sum insured of the policy was 5 lakh. The complainant was nominee under the said policy. Unfortunately, Keshav Chhabra son of the complainant met with a road accident on 8.2.2020 and received multiple injuries and admitted in Amandeep Hospital, Amritsar on 09.02.2020 and discharged from the hospital on 22.02.2020 and ultimately died on 01.03.2020. All these facts discussed above have been admitted by both the parties.

7.       The dispute arises between both the parties, when the Opposite Party rejected the cashless claim of the son of the complainant, vide letter dated 21.02.2020. The subject of this letter was (Rejection and Withdrawal of Approval Given Earlier) which clearly shows that initially the Opposite Party approved the claim and thereafter they rejected it on the ground that “patient was injured prior to the policy inspection”. If it was so, then onus was upon the Opposite Party-Insurance Company, they have to prove it with evidence. Thereafter, vide letter dated 24.06.2020 Opposite Party demanded some documents from the complainant, which was duly submitted by the complainant to Opposite Party and vide letter dated 11.09.2020, Opposite Party alleged that the complainant get tampered the date of admission and mis-represented the facts, however, they have not produced on record any document in support of their version. Further in the letter dated 28.11.2020 Opposite Party asked the complainant to submit complete claim form alongwith discharge summary, investigation reports, hospital bills, payment receipts, prescriptions, medical bills etc. and lastly vide letter dated 17.12.2020, Opposite Party demanded chemical examination and complete post mortem report with HPE reports from the complainant. The perusal of letter dated 14.06.2021 shows that Opposite Party finally repudiated the claim of the complainant on the ground that complainant despite their request has not produced the chemical examination report to the Opposite Party. All these correspondences made by the Opposite Party shows that from the very start, the Opposite Party was not interested to give claim and finding ways to reject the claim of the complainant on one pretext or the other. As far as chemical examination report is concerned, the complainant pursued the matter and moved an application to S.S.P, through RTI, however vide letter 21.05.2022, office concerned refused to give the report. So, the complainant being senior citizen lady managed to gave all the documents demanded by Opposite Party from time to time. Moreover, the other documents demanded by the Opposite Party from the complainant are already on file. Hence, we are of the view of that the rejection of cashless claim and thereafter repudiation of the genuine claim of the complainant amounts to deficiency in service on the part of the Opposite Party.

8.       Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.3,81,000/- being the amount of medical expenses. However, vide Bill Assessment Sheet Ex.OPs/8, the Opposite Party assessed the final admissible amount to the tune of Rs.3,48,197/-. Hence we allow the same.

9.       From the above discussion, we partly allow the complaint of the complainant and direct the Opposite Party to pay an amount of Rs.3,48,197/- (Rupees Three Lakh Forty Eight Thousand One Hundred Ninety Seven only) to the complainant. Opposite Party is also directed to pay compository costs of Rs.15,000/-(Rupees Fifteen Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Party within 45 days from the date of receipt of copy of this order, failing which, the Opposite Party is further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission