BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.403 of 2016
Date of Instt. 19.09.2016
Date of Decision: 16.04.2019
Rakesh Kumar son of Shri Bhagat Ram R/o H. No.254, Harnam Dass Pura, Jalandhar.
..........Complainant
Versus
1. The Cholamandlam MS General Insurance Company Limited, 2nd Floor, Dare House, 2 NSC Bose Road, Chennai 600001 through its MD/Office Head/Director/Authorized Representative.
2. The Cholamandlam MS General Insurance Company Limited, B-92-2481/21, Second Floor Civil Lines Old, GT Road, Jalandhar, Punjab 144001 through office head.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. Manuj Aggarwal, Adv Counsel for the Complainant.
Sh. A. K. Gandhi, Adv Counsel for the OPs No.1 & 2.
Order
Karnail Singh (President)
1. This complaint has been filed by the complainant, wherein alleged that he is the holder of the family health policy bearing No.2856/00150566/000/01 of OPs and the same was valid for 11.06.2015 to 10.06.2016. In the said policy complainant, his wife Pushpa Rani and his daughter Narmada are covered. Originally the complainant took a policy on 11.06.2014, thereafter the same was renewed. The daughter of the complainant namely Narmada was not well and due to the said reason, she was admitted to the Sigma Hospital, Child & Maternity Center, Jalandhar on 08.05.2016. The primary diagnose was of Enteric Fever of Narmada. She was discharged from the said hospital on 11.05.2015. The name of the treating doctor is Dr. Ashwin Malhotra.
2. That the complainant, as per the terms of the policy submitted the claim of her daughter medical treatment before OPs along with all documents and OPs without any justification declined the claim of the complainant on the alleged ground that“the submitted documents are manipulated and fabricated without genuine hospitalization” through repudiation letter dated 29.06.2016. The alleged ground taken by the OPs is false and concocted one. The claim application submitted by the complainant was duly stamped and signed by the treating doctor and the hospital authorities also issued discharge slip to the complainant. The claim of the complainant is genuine and OPs intentionally without any reason, right or authority refused to release the genuine claim of the complainant, which caused mental harassment to the complainant and after frustration, the complainant served a legal notice to the OP, but all in vain and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay an amount of Rs.15,548/- to the complainant along with interest @18% per annum from the date of payment qua the claim of medical reimbursement of Narmada daughter of the complainant and further OPs be directed to pay compensation of Rs.50,000/- and OPs be also directed to pay litigation expenses of Rs.11,000/-.
3. Notice of the complaint was given to the OPs and accordingly, both the OPs served and appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the instant complaint is false, vexatious and has been filed with a malafide intention just to harass the OPs. It is further averred that the complaint is not maintainable against the OPs and the same is liable to be dismissed. The OPs have rightly denied the claim of the complainant as the claim of the complainant is not genuine one, the documents submitted by the complainant was found manipulated and fabricated by the OPs during investigation. So, the present complaint is liable to be dismissed in the light of the terms and conditions of the insurance policy. It is further averred that the complainant has not come before the Forum with clean hands rather the complainant submitted forged and fabricated documents and further the official of the hospital refused to verify the documents and as such, the complaint of the complainant is liable to be dismissed. It is further averred that the complainant is not a consumer within the definition of Section 2(d) of the Consumer Protection Act and further averred that the complaint contains intricate and complicated questions of facts and law and voluminous evidence is required by the Forum to reach at just and final conclusion and thus, the complaint should be dismissed. On merits, it is admitted that the insurance policy was obtained for himself as well as his wife and one daughter and it is also admitted that the complainant submitted an insurance claim of his daughter, but the same has been rightly repudiated by the OP. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
4. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA along with some documents Ex.C-1 to Ex.C-25 and closed the evidence.
5. Similarly, counsel for the OPs No.1 & 2 tendered into evidence affidavit Ex.OP/A along with some documents Ex.OP-1 to Ex.OP-32 and closed the evidence.
6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
7. Before imparting with the main issue in dispute, first of all we like to take a legal issue raised by the OP in its reply in preliminary objections Para No.5 that the complainant is not a consumer within the definition of Section 2(d) of the Consumer Protection Act.
8. We have deeply considered the above objection of the OP and find that the complainant alleged that he got insurance policy for himself as well as for his wife Pushpa Rani and his daughter Narmada, it is pertinent to make it clear here that the insurance policy in original or its copy has not been placed on the file by either of the party i.e. neither complainant nor the OP, no doubt the OP has brought on the file copies of insurance policy, which is Ex.OP-3 and Ex.OP-9, but these insurance policies are stand in the name of Darshan Singh, not in the name of the complainant or his daughter Narmada. We can only make it clear from the copy of the insurance policy whether the insured person is only complainant Rakesh Kumar or other family member are covered under his name or in alternative whether all the family members are individually insured, but this fact is not make it clear for want of copy of insurance policy.
9. Though in the absence of insurance policy, if we gone through the contents of the complaint, wherein the complainant himself alleged that he got insurance policy for himself as well as for his family and daughter, it means all the members of the family are insured persons not the member are insured through head of the family i.e. complainant, so if Narmada is also insured and covered under the said insurance policy, then she herself is a consumer and the instant complaint has to be filed by the Narmada, who got treatment from the hospital and all the treatment bills are stand in the name of Narmada, but the complainant Rakesh Kumar filed the instant complaint without explaining the reason under which capacity filed the instant complaint whether as a representative or legal heir. So, in the absence of these type of clarification, the instant complaint is not maintainable because the complainant is not a consumer rather his daughter Narmada is a consumer. However, we like to make it clear that if the Narmada is a minor as narrated in the document her age 10 years, then the complainant can file the instant complaint in the name of Narmada through LR i.e. Complainant Rakesh Kumar, but the instant complaint filed directly by Rakesh Kumar as consumer, which is not covered under the law, therefore, the instant complaint of the complainant being not maintainable, is dismissed with no order of cost. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.
10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
16.04.2019 Member President
