Haryana

Yamunanagar

CC 1229/2010

Usha Rani W/d Madan Lal - Complainant(s)

Versus

The BRanch Manager,The Oriental Insurance Company Ltd. - Opp.Party(s)

Chander Mehta

31 Mar 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                         Complaint No.1229  of 2010.

                                                                                         Date of institution: 24.12.2010.

                                                                                         Date of decision: 31.03.2016

Smt. Usha Rani aged about 73 years widow of late Sh. Madan Lal Gupta, R/o House No. 436-R, Model Town, Yamuna Nagar.    

 

 

                                                                                                           …Complainant.

                                    Versus

 

1. The Branch Manager, The Oriental Insurance Company ltd. Opposite Madhu Hotel, Jagadhri Road, Yamuna Nagar-135001.
2. The Regional Manager, The Oriental Insurance Company Ltd. Regional Office, LIC Building 2^nd Floor, Jagadhri Road, Ambala Cantt. 133001.
3. The Oriental Insurance Company Ltd. Regd. & H. O. Oriental House, Asaf Ali Road, New Delhi-10002.
4. The Branch Manager Vipul Medcorp TPA Private Limited, SCO No. 98, First Floor, Industrial Area, Phase-2, Chandigarh-160002.

     

 

                                                                                                               …Respondents 

 

BEFORE:         SH. ASHOK KUMAR GARG, PRESIDENT.

                        SH. S.C.SHARMA, MEMBER.

 

Present:  Sh. Chander Mehta, Advocate, counsel for complainant.  

                Sh. Amit Bansal, Advocate, counsel for OPs.            

             

 

ORDER

 

1.                     Complainant Usha Rani filed the present complaint under section 12 of the Consumer Protection Act,1986.

2.                     Brief facts of the present case, as alleged by the complainant, are that  the complainant is a senior citizen of India aged about 75 years old and purchased a mediclaim policy bearing No. 261700/48/2008/440 (Annexure C-1) valid from 30.06.2007 to 29.06.2008 for a sum of Rs. 3,00,000/- from respondent No.1 (hereinafter referred as OP). The complainant was operated and remained admitted in  Gaba Hospital Yamuna Nagar from 19.03.2008 to 30.03.2008 and after discharged, all the bills of hospital, laboratory and chemist shop were submitted to OP No.1 in April 2008 for claim. It has been further stated that complainant has been enjoying mediclaim policy continuously for the last more than 3 years but during all these three years she never claimed any mediclaim being very honest of mediclaim holder. Since April 2008, the complainant had been visiting the company office and also keep pulse through telephone but the Op No.1 always assured the complainant that her cheque is in the pipe line but it is a matter of very serious concern that complainant was informed after two years that her claim has been declined. It was a matter of utter surprise and shocking that in the month of April 2010, the complainant received a letter dated 5.4.2010 from the OP No.4 i.e. TPA (Annexure C-4) in which complainant was asked to submit documents to unable the company to look into the claim pertaining to the complainant claim papers filed on 29.03.2010. The complainant lodged her claim during the month of April 2008 but the OP No.4 i.e. TPA is again asking for more than documents after a gap of 2 years. It has been further mentioned that when her claim was not settled by the OPs then the complainant approached the Assistant Secretary office of the Insurance Ombudsman Chandigarh through her son Dr. Arun Gupta who is one of the leading practitioner of Yamuna Nagar City being Child Specialist vide letter dated 22.05.2010 (Annexure-5) and also wrote letters dated 14.7.2010 (Annexure-6), letter dated 11.08.2010 (Annexure-8) and letter dated 23.11.2010 (Annexure-9) to the Ombudsman but all in vain. Tilll date, no claim has been paid by the OPs insurance company. Lastly prayed for acceptance of the complaint praying therein that the Ops be directed on account of deficiency in service to pay Rs. 1,00,000/- on account of mental agony and Rs. 1,00,000/- on account of mental torture and Rs. 2,00,000/- on account of expenses borne by her son Dr. Arun Gupta who visited 10 times to the office of Op No.2 and 4 and Rs. 1,00,000/- on account of expenses for great negligence and Rs. 21150/- on account of bill of Gaba Hospital and Rs. 75000/- on account of mediclaim bills already submitted to OP No.1 and Rs. 11,000/- as litigation expenses. Hence, this complaint.

3.                     Upon notice, OPs appeared and filed its written statement by taking some preliminary objections such as  complaint is not maintainable, there is no deficiency or negligence in service on the part of OPs. The complainant has not approached the Hon’ble Forum with clean hands and has suppressed the material facts, whereas true facts are that as the complainant had not supplied the relevant documents required from her vide letter dated 05.04.2010 (Annexure C-4/R-1, R-2, R-3). So, the claim of the complainant has been rightly repudiated vide letter dated 03.09.2010 (Annexure R-5) as the complainant failed to submit the “original numbered receipt against payment made to Gaba Hospital.” Lastly, it has been stated that the present complaint has been filed just to put the undue pressure and to gain unlawfully from the OPs Insurance Company and on merit all the allegations were denied and reiterated the stand taken in the preliminary objections, however, it has been admitted that complainant was having a mediclaim insurance policy bearing No. 261700/48/2008/440 (Annexure-1) valid from 30.06.2007 to 29.06.2008 for a sum of Rs. 3,00,000/-. Lastly prayed for dismissal of complaint being a deficiency in service on the part of OPs.  

4.                     To prove the case, counsel for complainant tendered into evidence affidavit of complainant as Annexure CX and documents such as Photo copy of Insurance policy as Annexure C-1 and C-2, Photo copy of querry letter issued by Ombudsman to the complainant’s son dated 20.05.2010 as Annexure C-3, photo copy of querry letter issued by TPA dated 05.04.2010 as Annexure C-4, Photo copy of complaint made to the Ombudsman as Annexure C-5, C-6 and C-7, Photo copy of      e-mails made to the Ombudsman dated 11.8.2010 and 23.11.2010 as Annexure C-8 and C-9, Photo copy of certificate of Gaba Hospital dated 7.3.2010 as Annexure C-10 alongwith computer generated bill on letter pad of Gaba Hospital, Photo copy of miscellaneous bills of Chemist Annexure C-1 to C-23, Photo copy of letter dated 17.03.2010 issued by Divisional Manager, OIC to the TPA as Annexure C-24, Photo copy of miscellaneous letters as Annexure C-25 and C-26, Photo copy of application dated 8.4.2008 for registering the claim as Annexure C-27, Photo copy of quarry letters/reminder issued by the TPA as Annexure C-28, Courtier receipt dated 14.7.2010 as Annexure C-29, Photo copy of complaint to the TPA in Performa II as Annexure C-30 and 31 and closed the evidence on behalf of complainant.

 5.                    On the other hand, counsel for the OPs tendered into evidence affidavit of Sh. R.S.Kalra, Divisional Manager OIC as Annexure RX and documents such as Photo copy of letter dated 5.4.2010 as Annexure R-1, Photo copy of 1^st reminder as Annexure R-2, Photo copy of 2^nd reminder as Annexure R-3, Photo copy of 3^rd reminder as Annexure R-4 and Photo copy of repudiation letter as annexure R-5 and closed the evidence on behalf of OPs.   

6.                     We have heard the counsels of both the parties and have gone through the pleadings as well as documents placed on the file carefully and minutely. The counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas the counsel for OPs reiterated the averments made in the reply and prayed for dismissal of complaint.

7.                     It is admitted fact that complainant Smt. Usha Rani was having mediclaim insurance policy bearing No. 261700/48/2008/440 (Annexure-1) valid from 30.06.2007 to 29.06.2008 for a sum of Rs. 3,00,000/- issued by OP No.1 Insurance Company.  Further, it is also admitted fact that complainant is getting claim free insurance mediclaim policy from the last 3 years continuously without any break from the OPs. It is also not disputed that complainant remained admitted in Gaba Hospital from 19.3.2008 to 30.3.2008 and was operated on 20.3.2008.

8.                     The only version of the complainant is that after discharge from the hospital on 30.3.2008, a claim was lodged and all the documents including bills were submitted with the office of OP No.1 in the month of April 2008 but despite so many requests genuine claim of the complainant has not been paid by the OPs. Even a complaint was also made with the Insurance Ombudsman, Chandigarh which is evident from copy of complaint (Annexure C-3 and C-5) and E-mails sent on 11.8.2010 (Annexure C-8) and 23.11.2010 ( Annexure C-9) but all in vain which constitute deficiency in service on the part of OPs and counsel for the complainant referred the case law titled as Sandeep Kumar Chourasia Versus Divisional Manager, The New India Insurance Company Ltd. and Another, 2013 CJ page 485 (SC) wherein it has been held that Mediclaim cannot be rejected by going against opinion of Medical Board. Further referred the case law titled as M/s Tanawala Synthetic Textile Ltd. vs. Oriental Insurance Co. Ltd. 1996(2) CLT page 496, wherein it has been held that Consumer Protection Act 1986, Section 2(1)(i)(o) and (g)- Insurance Claim-Deficiency in service- Delay of more than three years in settling claim- amounts to deficiency in service.  Learned counsel for the complainant further referred the case law titled as Col. Bhim Singh Versus Regional Manager, National Insurance Co. Ltd. & Another, 1(1992) CPJ Page 205 (NC) wherein it has been held that Deficiency in service- Complainant misusing his mare with opposite party for Rs. 2 lakhs- Mare died during the existence of the policy- Complainant filed claim with the opposite party, who took 30 months to settle the claim- Claimed interest for inordinate delay, travelling boarding and lodging expenses and punitive damages- Whether there was deficiency in service on the part of Opposite party- Insurance Company? Yes.

9.                     On the other hand, counsel for the OPs argued at length that when the complainant failed to submit the “original numbered receipt against payment made to Gaba Hospital” despite so many letters and reminders (Annexure R-1 to R-4) then the claim of the complainant was rightly repudiated vide repudiation letter dated 3.9.2010 Annexure R-4 and R-5. Further learned counsel for the OPs argued that even the letter (Annexure C-27) on which endorsement has been made by the Divisional Manager, OIC on 16.3.2010, is a manipulated letter which might have been procured from the official of the Insurance Company, whereas the complainant has totally failed to file any documentary evidence on which she lodged the claim with the TPA after discharged from the Hospital on 30.3.2008. All the correspondence and E-mails even the complaint made to the Ombudsman is after the date of this endorsement made on 16.3.2010 (Annexure C-27). Meaning thereby that no document has been filed by the complainant that she ever made any complaint or quarry between April 2008 to 16.3.2010 with the OPs insurance company. Further, learned counsel for the OPs argued that complainant has totally failed to mention or disclose in her complaint that she remained/admitted in the Gaba Hospital due to what reason i.e. not a single iota of word has been disclosed/mentioned in her complaint that she was suffering from which disease and remained admitted and operated for that. No prescription slips or admission chart even the discharge summary has been filed with this complaint, from which it became clear that the complainant was suffering from that disease. It has also been further argued that no cogent evidence/documentary evidence has been filed by the complainant that the complainant had spent huge money on her treatment as has been stated in her complaint.

10.                   Further learned counsel for the OPs argued that the complaint of the complainant is hopelessly time barred because as per the version of the complainant herself, she was discharged from Gaba Hospital on 30.3.2008 and submitted all the bills/documents in the month of April 2008 whereas the present complaint has been filed on 12.12.2010 i.e. after a period of more than 2 years 8 months and referred the section 24(a) of the Consumer Protection Act which is reproduced here as under:

24-A Limitation period, The District Forum, The State Commission,  National Commission shall not admit a complaint unless it is filed within a period of 2 years from the date on which the cause of action arisen.

11.                   Further referred the case law titled as Sou Sindhu Kailash Gawade Versus Gurudatta Construction, 2013(2) CPR page 420 (NC) and Pappu Managaratanam Versus Sai Sha Finance and Chits & Another, 2015(1) CPJ page 105 (NC) and Smt. Bimla Rani vs. ESI Hospital and others 2013(2) CPR page 739 (NC) and M/s Tolani Shipping Co. Ltd. through its authorized Signatory Seeta Venkatraman Versus Sterling Holiday Resort (I) Ltd. 2013(3) CPR page 397 (NC). And lastly prayed for dismissal of complaint.  

12.                   We have perused the quarry letter (Annexure R-1) and reminders and repudiation letter (Annexure R-4 and R-5) vide which the claim of the complainant has been repudiated on the ground that the complainant failed to submit the original bills bearing serial number, bill of Gaba Hospial, despite so many letters and reminders (Annexure R-1 to R-3) but on the other hand, we have also perused the certificate alongwith bill issued by Gaba Hospital on 7.3.2010 (Annexure C-10) in which Dr. Gurmeet Singh Gaba and Dr. B.S.Gaba of Gaba Hospital has disclosed the serial number of that Bill as 5935 dated 30.3.2008 and it has further been certified that a sum of Rs. 21,150/- was received from Smt. Usha Rani, who was admitted in the hospital on 19.3.2008 and discharged on 30.3.2008 and in the bill, details of the amount charged in various head has also been disclosed.  When the serial number of that bill has been clearly disclosed by the doctors of the Gaba Hospital in their certificate (Annexure C-10) then the demand of bills bearing serial number (Annexure R-1) seems not genuine for which the claim of the complainant can be repudiated. The OPs Insurance Company can verify the genuineness of the bills issued by Gaba Hospital by deputing any investigator, but no investigator has been deputed by the Ops Insurance Company in this case. Even, the Ops Insurance Company failed to file any affidavit of the concerned doctor/ officials who scrutinized the claim papers of the complainant and repudiated the claim. Further, it is not the case of the OPs that the complainant never remained admitted and operated in Gaba Hospital from 19.3.2008 to 30.3.2008 and all the bills and treatment papers have been falsely procured. Further, it is also not the case of the OPs insurance company that disease for which the complainant remained in Hospital from 19.3.2008 to 30.3.2008 was not covered under the insurance policy or the complainant was having pre existing disease and the insurance policy in question was obtained by not disclosing the true facts regarding her health whereas it is not disputed that the complainant was obtaining mediclaim insurance policy from the OPs Insurance Company for the last 3-4 years without any claim.

13.                   Although the complainant has failed to file any documentary evidence that she had written any letters to the OPs between April 2008 to March 2010 i.e. upto  the letter dated 17.3.2010 on which Divisional Manager of the OPs insurance Company have made endorsement which is reproduced here as under:-

The above claim papers are found lying in the papers bunch and had been handed over to me by my department. From the papers it seems to be claim of mediclaim. The above initials are of Sh. P.N. Bodh, DM but has no date. Therefore, it is clear that documents were given and due to oversight date and documents had been misplaced. Thus, we may, be allowed to send the papers to TPA and registered the claim. We may also be allowed to delay condone”

                                                                                    Sd/-

                                                                                    16.3.2010.

14.                   From the above noted endorsement, it is clear that claim papers which were submitted to OP No.1, were sent to the TPA on 16.03.2010 by the OP No.1 Insurance Company. Even,  then the OP No.4 TPA cannot repudiate the claim of the complainant without any cogent reason. More particularly without mentioning the specific condition of insurance policy which was violated by the complainant. In the present case, the OPs insurance company did not bother to file any insurance policy with its terms and conditions and further has not filed any affidavit or any documentary evidence to controvert the endorsement made by the Divisional Manager allegedly obtained in collusion with the complainant. When the Senior Officer of Divisional Manager Rank has made endorsement on the letter himself and has admitted that papers were lying in the office then it cannot be said that any fault lies with the complainant.

15.                   Now question remains what amount of compensation, the complainant is entitled? To decide this question we have minutely examined the complaint as well as bills filed by the complainant. From the perusal of these bills, it is evident that an amount of Rs. 21150/- has been paid to the Gaba Hospital which is evident from bill Annexure C-10. Further, some bills of chemist (Annexure C-11 to C-23) have also been filed for amounting to Rs. 5233/- with this complaint i.e. total amount of Rs. 21150 + 5233 = 26383/- has been spent by the complainant. Except these bills no other documentary evidence has been filed by the complainant from which we can presume that the complainant had spent huge amount on her treatment as mentioned in her complaint. Moreover, From the figure mentioned in respect of  claimed amount it seems that complainant wants to get undue advantage whereas it is well settled law that Consumer Fora are not meant for earning profit by way of huge compensation and the same view has been held by the Hon’ble Delhi State Consumer Disputes Redressal Commission, New Delhi in case titled as Bses Rajdhani Power Ltd. Versus Anuradha Anand (Dr) 2015(2) CLT Page 178 wherein it has been held that Suitable compensation- Consumer Foras are not meant to enrich the complainants by awarding huge compensation- Foras are meant to solve the complaints of the complainants with suitable compensation.

16.                   In the circumstances noted above, we are of the considered view that the arguments advanced by counsel for the OPs is not tenable as the OPs Insurance company has failed to convince this Forum that there was any violation of the terms and conditions of the insurance policy and the claim of the complainant has been rightly repudiated. Further the arguments that the complaint is hopelessly time barred is also not tenable as the claim of the complainant has been repudiated on 3.9.2010 and present complaint has been filed on 24.12.2010 i.e within the period of two (2) years. So, the complainant is entitled to get relief.  

17.                   Resultantly, we partly allow the complaint of complainant and direct the Ops to         release an amount of Rs. 26383/- to the complainant alongwith interest at the rate of 9% per annum from the date of filing of complaint i.e. 24.12.2010 till its actual realization and further to pay a sum of Rs. 5000/- as compensation for mental agony and harassment as well as Rs. 2000/- as litigation expenses. Order be complied within 30 days after preparation of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced: 31.03.2016.

                                                                                                (ASHOK KUMAR GARG)

                                                                                                PRESIDENT

 

 

 

                                                                                                (S.C.SHARMA)

                                                                                                MEMBER