DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 276 of 19.7.2016
Decided on: 15.11.2017
Paramjeet Kaur wife of Surinder Singh, resident of vill. Sainsarwal, Tehsil and District Patiala.
…………...Complainant
Versus
1. TATA AIG General Insurance Company Limited, A-501, 5th Floor, Building Number 4, Infinity IT Park, Dindoshi, Malad East, Mumbai – 400097, through its Authorized Signatory.
2. TATA AIG General Insurance Company Limited,(now TATA AIA Insurance Company Limited), SCO 134, Chhoti Baradari, Patiala through its Branch Manager/Authorized Signatory.
3. Axis Bank Ltd., Near Narain Continental, Chhoti Baradari, Patiala through its branch Manager.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.L.S.Sandhu,Advocate,counsel for complainant.
Opposite parties No.1&3 ex-parte.
Sh.Narinder Singh,Advocate, counsel
for opposite party no.2
ORDER
SMT.NEENA SANDHU, PRESIDENT
Smt.Paramjeet Kaur complainant has filed this complaint under Section 12 of the Consumer Protection Act,1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.) praying for the following reliefs:-
- To pay Rs.31,816/-the expenses spent on the treatment + Rs.5,000/- as transportation charges alongwith interest @14% till realization
- To pay Rs.10,000/- as compensation for causing mental agony and physical harassment
- To pay Rs.5500/- as counsel fee alongwith Rs.5000/-as litigation expenses and
- To grant any other relief,which this Forum may deem fit.
2. In brief, the case of the complainant is that she obtained a cashless Medi Prime policy bearing No.0200615866 for the period from 15.5.2015 to 14.5.2016, for the sum assured of Rs.3,00,000/- and paid Rs.4739/- as premium to OPs no.1&2 through OP no.3. On 10.5.2016, she suffered from pain in her abdomen and got admitted in Sadbhawna Medical & Heart Institute, Patiala from where he discharged on 12.5.2016. She requested OPs no.1&2 through Sadbhawna hospital for cashless treatment, but the the OPs no.1&2 refused to do so and she was forced to pay Rs.31,816/- to the said hospital as expenses incurred on her treatment.An amount of Rs.5000/-was also spent on transportation. She also got sent a legal notice dated 30.5.2016 upon the OPs but to no effect. It is stated that the OPs violated terms and conditions of the insurance policy and are liable to indemnify for the same .He requested the OPs many times to pay expenses incurred by her on her treatment but they refused to pay the same. The act and conduct of the OPs amounted to deficiency in service which caused mental agony and physical harassment to her. Hence this complaint.
3. On being put to notice, Op No.2 appeared and filed its written version while OPs no.1&3 failed to come present and were accordingly proceeded against ex-parte.
4. In the written version filed by OP no.2 preliminary objections have been taken, that the complaint is barred by limitation and is not maintainable in the present form, that the complainant has not come to the Forum with clean hands; that the complainant has no locus standi or cause of action to file the present complaint and is liable to be dismissed. On merits , it is it is admitted that Medi Prime Policy bearing No.0200615866 was issued in the name of the complainant. It is denied that the policy was a cashless policy. It is stated that the insurance policy is a contract in itself and the parties are bound by the terms and conditions of the policy for settlement of any claim there under. It is stated in the preliminary objections that the complainant was admitted in Sadbhavna Medical and Heart Institute on 11.5.2016 with complaint of acute bleeding. A request was raised by the hospital with TPA towards cashless treatment of the complainant for hysterectomy which was denied on the same day under clause 3.C.1 and 3.C.2 and was rejected with the following note:-
“Please note that the denial of authorization for cashless access does not imply the denial of treatment and does not in any way prevent you from seeing medical attention or hospitalization and lodging your claim for reimbursement, which will be processed on merit”
It is stated that letter to the hospital was sent during preauthorization of the claim. She never submitted any documents for reimbursement of the claim. There is no deficiency of service on the part of the OP. After denying all other averments made in the complaint it was prayed to dismiss the complaint.
5. The complainant filed rejoinder to the written version filed by OP no.2 stating therein that Section 3.C.1 and Section 3.C.2 are not part and parcel of the policy. It is further stated that the OPs, except the policy, have never supplied any terms and conditions regarding exclusion to the complainant, therefore, these are not binding upon the complainant. It is admitted that she admitted in Sadbhavna Medical and Heart Institute on 10.5.2016 and discharged on 12.5.2016 and a request was raised with TPA towards cashless treatment, which was rejected. It is denied if the complainant never submitted any document for reimbursement of the claim.After denying all other pleadings of written version, it was prayed that the complaint may kindly be accepted.
6. On being called to do so, the ld.counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C17 and closed the evidence.
The ld. counsel for OP no.2 tendered in evidence affidavit of Mohd.Azhar Wasi, Head North Zone Claim, Ex.OPA alongwith documents Exs.OP1 to OP4 and closed the evidence.
7. We have heard the ld.counsel for the parties , gone through the written arguments filed by the ld. counsel for the complainant and have also gone through the record of the case, carefully.
8. The ld. counsel for the complainant has submitted that the OPs did not supply the terms and conditions to the complainant, as such these are not biding upon her. The ld. counsel for OP no.2, has contended that the terms and conditions were supplied to the complainant alongwith policy schedule.
9. In the letter,Ex.C1,it is clearly written that the policy wording (please refer for complete list of benefits and exclusion) were including in the welcome kit. Had the complainant not received the terms and conditions of the policy , he could have asked the insurance company to provide the same after receipt of the said letter. No such document has been placed on record by the complainant to show that she had made any complaint to the insurance company about the non receipt of the terms and conditions of the policy. Even otherwise it is not the case of the complainant that he has not received the welcome kit. Since the terms and conditions were the part of the welcome kit, therefore, it cannot be said the same have not been sent by the insurance company to the complainant.
10. The ld. counsel for the complainant has further contended that after declining the request for cashless facility by the insurance company, on its advice, she lodged the claim, with it for reimbursement of the amount, incurred by her on her treatment and also submitted the requisite document with it. However, the insurance company, did not pay any amount. The ld. counsel for OP no.2 has submitted that the complainant had taken the insurance policy in question for the period from 15.5.2015 to 14.5.2016. On 10.5.2016 she suffered pain in her abdomen and was admitted in the hospital for the operation of hysterectomy and was discharged on 12.5.2016.The request made by the complainant for cashless facility was declined as per term No 3.31 of the insurance policy because she was operated upon before the expiry of the waiting period. Since the complainant has not submitted the requisite documents with it, for settlement of the claim, therefore, she cannot blame the insurance company for the non settlement of the claim. It may be stated here that no document has been placed on record by the complainant, to prove that she had furnished the necessary documents with the insurance company for reimbursement of the amount which she incurred on her treatment . In the absence of any documentary proof, it cannot be ascertained that as to whether the complainant had furnished the necessary documents with the insurance company for the reimbursement of mediclaim. As such the insurance company i.e. 1&2 cannot held guilt for non reimbursement of the mediclaim amount to the complainant. So far as the complaint filed against OP no.3 is concerned , same is liable to be dismissed as neither specific allegation has been leveled nor proved against it.
11. In view of the aforesaid discussion , we dismiss the complaint against OP no.3 and dispose of the same against Ops No.1&2. The complainant is directed to submit the claim form alongwith necessary documents with the insurance company for reimbursement of the medical expenses incurred by her on her treatment within 15 days from the date of the receipt of the certified copy of this order. Thereafter OPs No.1&2 shall reimburse the amount as per the terms and conditions of the policy within 45 days from the receipt of the claim form and necessary documents from the complainant. The parties are left to bear their own costs. Certified copy of this order be sent to the parties free of costs under the Rules. Thereafter file be indexed and consigned to the Record Room.
ANNOUNCED
DATED:15.11.2017
NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
