Haryana

Ambala

CC/193/2022

Narinder Singh - Complainant(s)

Versus

Tata AIG General Insurance Co Ltd - Opp.Party(s)

Ashok Gupta

18 Jun 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	193 of 2022
Date of Institution	:	08.06.2022
Date of decision	:	18.06.2024

Narinder Singh S/o Sh. Ramkesh, aged about 36 years, resident of Village Khaira, P.O. Baknaur, Tehsil and Distt. Ambala

          ……. Complainant

Versus

1. Tata AIG General Insurance Company, 3rd Floor, Shanti Complex, Jagadhari Road, Opp. Civil Hospital, Ambala Cantt, through its Manager.

 

2. Claims Department, Family health Plan (TPA) Ltd. Srinilaya- Cyber Spazio, Suite # 101, 102, 109 & 110 Ground Floor, Road No.2, Banjara Hills, Hyderabad-500034, through its M.D./ Manager/ Authorized Signatory

                                                                                   ….…. Opposite Parties

Before:        Smt. Neena Sandhu, President.

                             Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Ashok Gupta, Advocate, counsel for the complainant.

                             Shri Ashwani Walia, Advocate, counsel for OP No.1.

                   OP No.2 already ex parte.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the amount of Rs.42,296/- incurred by the complainant on his treatment.
2. To pay compensation to the tune of Rs.1 lac for mental agony and harassment

            

2.           Brief facts of the case are that the complainant on 24.09.2019 got himself and his spouse namely Amandeep Kaur insured for health under the master policy No.0237868334, Certificate No.030349 issued by OP No.1. The complainant was insured for an amount of Rs.5.00 lacs. At the time of issuing the policy of Family Health Plan to the complainant, he was hale and hearty and he paid an amount of premium i.e. Rs.9931/-. The said policy was valid for the period from 24.09.2019 to 23.09.2020 and out of the total premium amount Rs.9931/- the complainant paid Rs.7605/- as demanded by the official of the OP No.1. The first policy inception was made by the OPs with floater plan. On 06.07.2020 all of sudden, the complainant felt fever and he consulted the doctor of Aggarsain Hospital, near Old Sessions Court, Ambala City, where he was got admitted and he remained admitted there for 11.01.2020. The doctor, who gave him the treatment was Pankaj Garg and he diagnosed the complainant as "UTI Sepsis Purexis". The complainant before had never any such disease and he never fell ill in his life time. During his treatment, he remained admitted in the Aggarsain Hospital, Ambala for six days, for which he paid an amount of Rs.15,000/- for hospitalization. Over and above this amount of Rs.15,000/-, the complainant also spent huge amount for medicines and as such,  total amount of  Rs.42,296/- was spent by the complainant on his treatment. The complainant intimated the OP No.1 and sent his medical claim alongwith all the bills; report and admit card, but the OPs instead of passing the claim of the complainant, on 24.1.2020 sent back the premium amount i.e. Rs.7605/- in his account. The OPs have ignored the claim filed by the complainant with malafide intention. Ultimately the complainant through his counsel served a registered legal notice dated 14.02.2022 to the correct addresses of the OPs but to no avail. Hence, the present complaint.
3.           Upon notice, OP No.1 appeared and filed written version wherein it raised preliminary objections with regard to maintainability of this complaint; no cause of action arose to the complainant against OP No.1; this Commission is not having jurisdiction to entertain this complaint etc. On merits, it has been stated that OP No.1 has not received any claim intimation in respect of the policy in question, as such, the question of payment of claim amount did not arise. The company is supposed to settle the claim within 90 days on receipt of the same, yet, the complainant has failed to register his claim.  Upon receipt of proposal form, OP No.1 manually debited the premium amount from the account of the complainant on 24.09.2019, to the tune of Rs.7605/- against Rs.9931/-. A letter to the complainant was sent on 23.12.2019, through courier intimating him about the shortfall. Rest of the averments of the complainant were denied by the OP No.1 and prayed for dismissal of the present complaint with heavy costs.
4.           Upon notice, none appeared on behalf of the OP No.2 before this Commission, therefore, it was proceeded against ex-parte vide order dated 02.08.2022.
5.           Learned counsel for the complainant tendered affidavit of the complainant as Annexure C-A alongwith documents as Annexure C-1 to C-15 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OP No.1 tendered affidavit of G.G. Padmakar Tripathi, Assistance Vice President – Legal and Legal representative of TATA AIG General Insurance Co. Ltd., having Office at Peninsula Business Park, Tower-A, 15^th Floor, G.K.Marg, Lower Parel, Mumbai-400 013, Maharashtra as Annexure R-A, alongwith documents Annexure R-1 and R-2 and closed the evidence on behalf of OP No.1.
6.           We have heard the learned counsel for the complainant and learned counsel for the OP No.1 and have carefully gone through the case file and also gone through the written arguments filed by the learned counsel for the OP No.1.
7.           Learned counsel for the complainant submitted that by not settling the genuine claim of the complainant, despite the fact that he lodged the claim submitted by completing all the formalities, the OPs are deficient in providing service and indulged into unfair trade practice.
8.           On the contrary, the learned counsel for the OP No.1 submitted that the complainant failed to make the complete premium amount to the OPs. The complainant never lodged any claim with the OP No.1 qua the said treatment. He further submitted that even the part premium amount of Rs.7605/- paid by the complainant stood admittedly refunded to the complainant. 
9.           It may be stated here that it is settled law that the date of issuance of the insurance policy is the valid date of commencement of the risk. In the present case, though against the premium of Rs.9931/- only an amount of Rs.7605/-  stood received by the OP No.1, yet, in our considered opinion, once OP No.1 have issued a valid insurance policy in question, Annexure C-5, on receipt of the said premium amount, they cannot wriggle out of any claim arising out of the said insurance policy. It is not the case of OP No.1 that it has issued the policy in question, subject to deposit of the remaining amount of premium of Rs.2326/- (Rs.9931/- (minus) Rs.7605/-). OP No.1 has also failed to establish its case that the part premium was received from the complainant under protest. OP No.1 has also failed to justify its stand, as to what stopped it from non-issuance of the policy in question, on receipt of part premium amount of Rs.7605/-.
10.           However, irrespective of the fact, what has been discussed above, the complainant has also fairly admitted that he was liable to pay an amount of Rs.9931/- as premium but has paid an amount of Rs.7605/- and it has also been admitted by him that the said amount of Rs.7605/- has been credited back in his account by the OPs, yet after filing of the claim with them. Under these circumstances, it will be in the fitness of the things, if the complainant is directed to deposit the entire premium amount of Rs.9931/-, with the OPs in order to get his claim amount, in case, it is payable.   
11.           Despite the above discussions, one more significant issue remained unproved by the complainant to the effect that he ever lodged the claim with the OPs. In our considered opinion, once the OP No.1 has taken a specific objection to the effect that the claim has never been lodged by the complainant qua the treatment in question, the complainant was required to prove the same but he failed to do so.
12.           For the reasons recorded above, this complaint stands disposed of, with the direction to the complainant to lodge the claim qua the treatment in question with the OPs, within the period of 30 days from the date of receipt of the certified copy of this order. Upon receipt of the said claim, the OPs shall settle the same in accordance with law, within the period of three months from the date of receipt of the said claim and in case the claim is payable, the OPs shall pay the same, on receipt of the premium amount of Rs.9931/-, from the complainant. However, liberty shall be remained with the complainant, to file fresh complaint, in case, any fresh cause of action accrued to him qua the policy in question. Certified copies of the order be sent to the parties concerned, as per rules.  File be annexed and consigned to the record room.

Announced:- 18.06.2024.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President