Complaint No: 24 of 2023.
Date of Institution: 24.01.2023.
Date of order: 31.10.2023
1. Chander Gupta Mahajan Son of Bawa Ditta C/o M/s Bawa Ditta Chander Gupta, G.T. Road, Mandi, Gurdaspur Tehsil and District Gurdaspur.
2. Komal Mahajan W/o Chander Gupta Mahajan Son of Bawa Ditta C/o M/s Bawa Ditta Chander Gupta, G.T. Road, Mandi, Gurdaspur Tehsil and District Gurdaspur.
…...........Complainant.
VERSUS
1. TATA AIG General Insurance Company Limited, 2nd Floor, R.K. Complex, Dalhousie Road, Pathankot Tehsil and District Pathankot.-145001.
2. TATA AIG General Insurance Company Limited, registered office Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 40001
….Opposite parties.
Complaint U/s 35 of the Consumer Protection Act.
Present: For the complainants: Sh.Sanjeev Mahajan, Advocate.
For the opposite parties: Sh.Sandeep Ohri, Advocate.
Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Chander Gupta Mahajan & Komal Mahajan, Complainants (here-in-after referred to as complainants) has filed this complaint under section 35 of the Consumer Protection Act (here-in-after referred to as 'Act') against TATA AIG Gen. Ins. Co. Ltd. Etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that on 17.08.2021 complainants got a Health insurance policy titled as Group Medicare vide Policy No.0238452957 from TATA AIG General Insurance Company Limited, which was valid from 07.08.2021 to 16.08.2022 from the OP. No.1 through Canara Bank Gurdaspur. It is further pleaded that the above said Policy was taken by the complainants under Group Medicare Insurance being account holder in Canara Bank Gurdaspur vide membership ID No.0238452957/109161015397128/01 of complainant No.1 and ID No.0238452957/109161015397128/02 of complainant No.2. It is further pleaded that the complainants have been taking the above said policy for last four years under the Group Medicare Insurance being account holder in Canara Bank Gurdaspur. It is further pleaded that this policy has been issued to those persons who are having Bank account with Canara Bank Grasper and complainants got the above said policy being account holder of Canara Bank Gurdaspur. It is further pleaded that this Health Insurance Policy covered the Health of complainants under this policy. It is further submitted that the OP No. 1 also issued identity card to the complainants bearing member ID No. 0238452957/109161015397128/01 of complainant No.1 and ID No. 0238452957/109161015397128/02 of complainant No.2 for this policy. It is further pleaded that on 26.10.2021 both the complainants suddenly got struck with thrombocytopenia, psychosis problem. It is further pleaded that complainants approached the Babbar Heart Care Centre & General Hospital Govt. College Road Gurdaspur for their treatment as it is included in the prescribed hospital of the OP’s No. 1 and 2. It is further pleaded that the condition of complainants were critical so they immediately admitted in the Babbar Heart Care Centre & General Hospital Gurdaspur on 26.10.2021 for their treatment and were discharged on 31.10.2021. It is further pleaded that complainant No. 1 spent Rs.54,803/- on his treatment at Babbar Heart Care Centre & General Hospital and complainant No. 2 spent Rs.37,939/- on her treatment at Babbar Heart Care Centre & General Hospital. It is further pleaded that after coming from Babbar Heart Care Centre & General Hospital the complainants lodged their claims to the OP’s No. 1 and 2 in respect to their treatment in Babbar Heart Care Centre & General Hospital Gurdaspur and submitted all the necessary documents. It is further pleaded that the OP’s No. 1 and 2 never responded about the claim of the complainants. It is further pleaded that for the above treatment complainants have to pay Rs.92,742/- on their treatment to Babbar Heart Care Centre & General Hospital. It is further pleaded that besides this, complainants have also spent Rs.50,000/- on their treatment, tests and medicines. It is further pleaded that after coming back to home the complainants made so many requests to the OP’s about their claim but of no use. It is further pleaded that complainants have already paid above mentioned bills. It is further alleged that the complainants have been visiting various Hospitals for their health checkup and spending huge amount on their treatment but the OP’s have not paid a single penny to the complainants in respect to their claim. It is further pleaded that till date not settling the claim of the complainants by the OP’s without any reason creates deficiency in service and unfair trade practice on the part of the opposite parties. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainants has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in service on the part of the opposite parties.
On this backdrop of facts, the complainants has alleged deficiency and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to release the insurance claim amounting to Rs.92,742/- along with interest at the rate of 18% Per Annum from the date of treatment of insured till its actual realization. It is further pleaded that opposite parties may also be directed to pay compensation of Rs.1,00,000/- to the complainants on account of mental and physical harassment suffered by the complainants from the hands of the opposite parties and litigation expenses as assessed by this Ld. Commission, in the interest of justice.
3. Upon notice, the opposite parties appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the complainants have no cause of action to file the present complaint and two complainants filed the joint complaint. It is further pleaded that both have separate cause of action and both have separate claim numbers and as such the joint claim by the two complainants is not maintainable and is liable to be dismissed. It is further pleaded that the complaint of the complainants is pre-mature and absolutely there are no grounds to file this complaint, on these grounds the complaint is liable to be dismissed with costs. It is further pleaded that the policy of insurance is a contract binding both the parties and neither party can traverse beyond its scope and ambit the terms are binding on both the parties. It is further pleaded that answering OP’s shall have no obligation to make any payment under the policy Section 5 clause 5, i, unless the OP’s have received all claim related documents in time and the OP’s have been provided with the documentation and information. It is further pleaded that the complainant is duty bound to produce the all-necessary documents for claim assessment to the insurer. It is pleaded that the policy was issued in favour Chander Gupta and Komal Mahajan vide Policy No. 0238452957/00045967 subject to certain terms and conditions. It is further pleaded that facts of the matter is that the complainant and Ms. Komal Mahajan were admitted to Babbar Hospital Care Center for alleged treatment of Dengue Fever to Mr. Chander Gupta and alleged treatment of Thrombocytopenia, psychosis from 25.10.2021 to 31.10.2021 and 26.10.2021 to 31.10.2021 respectively. It is further pleaded that claim was registered by both the complainants on 30.11.2021 for reimbursement of expenses to the tune of Rs.14,440/- and 54,963/- respectively. Following query letters dated (for treatment of Ms. Komal Mahajan) 04.12.2021, 08.12.2021, 05.01.2022 and 17.01.2022 for submission of following documents:-
- Cancelled cheque copy / Bank passbook statement of payee
- Blood bank stickers
- Related prescriptions and investigation reports for the enclosed bills done during hospitalization.
- Detailed discharge summary in original presenting complaints, H/o and duration of presenting complaints, past illnesses, H/o and duration of past illnesses; treatment course given in hospital.
It is further pleaded that however, in absence of any revert from her, the claim was finally repudiated vide letter dated 31.01.2022 for violation of policy condition mentioned in Section 5 clause 5 which states as under:-
“We shall be under no obligation to make any payment under this policy unless we have received all premium payments in full in time and we have been provided with all the documentation and information....”
It is further pleaded that it may be noted that in similar circumstances, a claim was reported for alleged treatment of Mr. Chander Gupta for alleged treatment of thrombocytopenia, psychosis from 26.10.2021 to 31.10.2021. It is further pleaded that after receipt of the intimation of claim, letter dated 07.12.2021, 05.01.2022, 11.01.2022 and 21.01.2022 were sent to the complainant requesting for submission of following documents:-
- Attested copies of indoor case papers of hospitalization including admission notes and daily progress notes.
- Original cash paid receipt of final bill.
- Original consolidated final bill with breakup details on hospital letterhead.
- Original detailed discharge summary on hospital letterhead.
- Prescriptions and investigation reports for the enclosed bills.
It is further pleaded that however, in absence of any revert from the complainant, the claim was finally repudiated vide letter dated 03.02.2022 for violation of policy condition mentioned in section 5 clause 5 as detailed above. It is further pleaded that there is no deficiency in services on the part of the Opposite Parties and the claim has been repudiated due to own fault and conduct on the part of both the complainants who failed to provide the relevant documents. It is further pleaded that even otherwise if this Ld. Commission comes to the conclusion that if there is any liability on the insurance company in that the case the same is as per the terms and conditions of the insurance company and in no case more than the coverage.
On merits, the opposite parties have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in services on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
4. Learned counsel for the complainant has tendered into evidence affidavit of Ms. Komal Mahajan, (Complainant No. 2) as Ex.CW-1/A alongwith other documents as Ex.C-1 to Ex.C-52.
5. Learned counsel for the opposite parties has tendered into evidence affidavit of Sh. Amit Chawla, (AVP Legal Authorized Signatory of TATA AIG Gen. Ins. Co. Ltd.) as Ex.OPW-1, 2/A alongwith other documents as Ex.OP-1, 2/1 to Ex.OP-1, 2/8.
6. Rejoinder filed by the complainant.
7. Written arguments not filed by both the parties.
8. Ld counsel for the complainants has argued that both the complainants have purchased a Health insurance policy titled as Group Medicare from opposite parties, valid from 07.08.2021 to 16.08.2022 through Canara Bank Gurdaspur. It is further argued that on 26.10.2021 both the complainants suddenly suffered from illness i.e thrombocytopenia, psychosis problem and both the complainants approached the Babbar Heart Care Centre & General Hospital Govt. College Road Gurdaspur for their treatment as it is included in the prescribed hospital of the OP’s. It is argued that complainants remained admitted in the Babbar Heart Care Centre & General Hospital Gurdaspur from 26.10.2021 for their treatment and were discharged on 31.10.2021 and complainant No.1 had spent Rs.54,803/- on his treatment , where as complainant No.2 had spent Rs.37,939/- on her treatment and after coming from Babbar Heart Care Centre & General Hospital the complainants lodged their claims to the OP’s in respect to their treatment in Babbar Heart Care Centre & General Hospital Gurdaspur and submitted all the necessary documents. It is further argued that inspite of the fact the all the relevant documents were supplied by the complainants but still the claim lodged by the complainants was repudiated by the opposite parties which amounts to deficiency in service and business mal practice. Counsel for complainant has placed reliance upon judgment of Hon'ble Supreme Court of India reported in 2022 LiveLaw (SC) 506 wherein it was held by the Hon'ble Supreme Court of India as under:-
"Insurance - Insurance companies refusing claim on flimsy grounds and/or technical grounds - While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. (Para 4.1)".
9. Ld counsel for the opposite party has argued that it is admitted fact that both the complainants were admitted at Babbar Hospital Care Center for treatment of Dengue Fever to Mr. Chander Gupta and treatment of Thrombocytopenia, psychosis from 25.10.2021 to 31.10.2021 and 26.10.2021 to 31.10.2021 respectively and claim was registered by both the complainants on 30.11.2021 for reimbursement of expenses to the tune of Rs.14,440/- and 54,963/- respectively and query letters dated (for treatment of Ms. Komal Mahajan) 04.12.2021, 08.12.2021, 05.01.2022 and 17.01.2022 for submission of following documents i.e Cancelled cheque copy / Bank passbook statement of payee , Blood bank stickers , Related prescriptions and investigation reports for the enclosed bills done during hospitalization and Detailed discharge summary in original presenting complaints, H/o and duration of presenting complaints, past illnesses, H/o and duration of past illnesses; treatment course given in hospital and since the complainant No.2 failed to supply the documents mentioned as such the claim was repudiated vide letter dated 31.01.2022 for violation of policy condition mentioned in Section 5 clause 5 and similarly the claim lodged by Mr. Chander Gupta for treatment of thrombocytopenia, psychosis from 26.10.2021 to 31.10.2021. documents were demanded i.e Attested copies of indoor case papers of hospitalization including admission notes and daily progress notes, Original cash paid receipt of final bill, Original consolidated final bill with breakup details on hospital letterhead, Original detailed discharge summary on hospital letterhead and Prescriptions and investigation reports for the enclosed bills. It is further argued that the claim was finally repudiated vide letter dated 03.02.2022 for violation of policy condition mentioned in section 5 clause 5 as detailed above and there is no deficiency in services on the part of the Opposite Parties and the claim has been repudiated due to own fault and conduct on the part of both the complainants who failed to provide the relevant documents and as such the complaint is liable to be dismissed.
10. We have heard both the counsels for the parties and gone through the record.
11. It is admitted fact that on 17.08.2021 complainants purchased a Health insurance policy titled as Group Medicare vide Policy No. 0238452957 from TATA AIG General Insurance Company Limited, which was valid from 07.08.2021 to 16.08.2022 from the OP No.1 through Canara Bank Gurdaspur. It is further admitted fact that the above said Policy was taken by the complainants under Group Medicare Insurance being account holder in Canara Bank Gurdaspur vide membership ID No.0238452957/109161015397128/01 of complainant No.1 and ID No.0238452957/109161015397128/02 of complainant No.2. It is further admitted fact that policy has been issued to those persons who were having Bank account with Canara Bank Grasper and complainants got the above said policy being account holder of Canara Bank Gurdaspur. It is further admitted fact that this Health Insurance Policy covered the Health of complainants under the policy. It is further admitted fact that the OP No.1 also issued identity card to the complainants bearing member ID No.0238452957/109161015397128/01 of complainant No.1 and ID No.0238452957/109161015397128/02 of complainant No.2 for this policy. It is further admitted fact that claim lodged by both the complainants in respect of treatment under taken at hospital has been repudiated vide letter dated 27.09.2022 Ex.OP 1,2/4. The only dispute for adjudication before this commission is whether the repudiation of the claims by the opposite parties for want of documents amounts to deficiency in service and whether one compliant is maintainable by both the complainants in respect of medical claims of both the complainants. To prove their case the complainants have placed on record all the treatment record and medical bills and discharge slip in respect of the treatment under gone by the complainants, whereas on the other hand opposite parties have placed on record letters by way of which documents i.e in respect of complainant No.2 Cancelled cheque copy / Bank passbook statement of payee, Blood bank stickers, Related prescriptions and investigation reports for the enclosed bills done during hospitalization and Detailed discharge summary in original presenting complaints, H/o and duration of presenting complaints, past illnesses, H/o and duration of past illnesses and treatment course given in hospital were demanded and it is the plea of the opposite party that since the complainant No.2 failed to supply the documents mentioned as such the claim was repudiated vide letter dated 31.01.2022 for violation of policy condition mentioned in Section 5 clause 5 and similarly the claim lodged by Mr. Chander Gupta for treatment of thrombocytopenia, psychosis from 26.10.2021 to 31.10.2021. documents were demanded i.e Attested copies of indoor case papers of hospitalization including admission notes and daily progress notes, Original cash paid receipt of final bill, Original consolidated final bill with breakup details on hospital letterhead, Original detailed discharge summary on hospital letterhead and Prescriptions and investigation reports for the enclosed bills. We have also gone through the email Ex.C51 which has been sent to the opposite parties by way of which it has been explained by the complainants that all the relevant documents were supplied to the opposite parties and surveyor also discussed in this regard with the complainants. There are many e mails sent by the complainants but the same have not been replied by the opposite parties. We are of the view medical insurance is purchased by the complainants for under going treatment in case of some medical emergency but the claim settlement is made so complex that a normal citizen is unable to deal with it. We are of the view that what so ever documents were available with the complianants were supplied by them and if some more documents were required regarding admission and treatment of the complainants, in that case it is duty of the opposite parties to collect the same from the concerned hospital through their team of investigators and surveyors who are paid by the insurance companies. More over it is not the plea of the opposite parties that the claim lodged by the complainants are not genuine and when the claim is not disputed and in that case, the claim cannot be repudiated on the ground of non supply of documents. Even opposite parties have not been able to explain as to what is necessity of the documents regarding settlement of the claim.
12. We have placed reliance upon judgment of Hon'ble Supreme Court of India reported in 2022 LiveLaw (SC) 506 wherein it was held by the Hon'ble Supreme Court of India as under:-
"Insurance - Insurance companies refusing claim on flimsy grounds and/or technical grounds - While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. (Para 4.1)".
13. As for question of filing one complainant is concerned we are of the view that when both the complainants are insured vide one policy then why the complainants can not maintain single compliant. More over the filing of single compliant has avoided multiplicity of litigation. As for amount involved is concerned, it is plea of the counsel for the opposite parties that claim in respect of Komal Mahajan was raised for Rs.14,440/- and Chander Gupta Mahajan for Rs.54,963/- but when the complainants have clarified this disputed fact vide email Ex C50, the same was not replied by the opposite parties. More over opposite parties have not placed on record any evidence that claim raised in respect of Komal Mahajan was Rs.14,440/- and not Rs.37,939/-. From the above discussion and evidence on record we are of the view that act of the opposite parties of having repudiated the claim of the complainants on flimsy grounds amounts deficiency in service and business mal practice.
14. Accordingly present compliant is partly allowed and opposite parties are directed to pay amount of Rs.54,963/- in respect of claim lodged by complainant No.1 and Rs.37,939/- in respect of claim lodged by complainant No.2 alongwith interest @ 9% P.A. from the date of receipt of copy of this order till realization of the amount. Opposite parties are further directed to pay Rs.2,000/- to the complainants for mental tension, harassment, inconvenience and cost of litigation. Entire exercise shall be completed within 30 days from the receipt of copy of this order.
15. Copy of the order be communicated to the parties free of charges. File be consigned.
(Lalit Mohan Dogra)
President.
Announced: (B.S.Matharu)
Oct. 31, 2023 Member.
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