Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No.144/06.06.2017
Mrs. Krishna w/o Late Sh. Yadram
R/o 251-A, Near Balmiki Mandir, VPO Mubarakpur Dabas,
Delhi …Complainant
Versus
OP1- Dedicated Health Care Service TPA India Pvt. Ltd. (DHS)
At 8-B, Tej Building, 2nd Floor, Bahadur Shah Jafar Marg,
ITO, Near Times of India Building, New Delhi-110002 .
OP2- The Branch Manager
Bank of Baroda, House No. 171, Near Bimal Hospital,
Nangloi, Delhi-110041
OP3-United India Insurance Company Limited
At TP Hub RO, 1, Kanchan Junga Building-18, Floor No.8,
Barakhamba Road, Delhi-110001 ...Opposite Party
Date of filing: 06.06.2017
Coram: Date of Order: 11.06.2024
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
ORDER [ex-parte]
Inder Jeet Singh , President
1.1. (Introduction to dispute ) –Complainant’s husband Sh. Yad Ram/insured was working in Bank of Baroda, there was insurance policy, however, he was hospitalized and during treatment he was expired. The medical bills of Rs.1,42,260/- was deposited by the complainant. However, when claimed was lodged with all documents to OPs, it was not reimbursed. That is why the complaint.
2.1. (Case of complainant) –Succinctly, complainant’s husband Sh. Yad Ram was working in Bank of Baroda and he was lastly posted at Nangloi Branch. He was suffering from pneumonia and he was admitted in Maharaja Agrasen Hospital, Punjab Bagh, Delhi on 25.07.2016 but during treatment he died on 27.07.2016. The complainant deposited amount of medical bills of Rs. 1,42,260/- in the said hospital. The complainant approached Bank of Baroda/OP2 with all original record of medical bills for reimbursement of medical claim; however, no response was received from OP2. Then complainant filed application before insurance company/OP3 for the claim amount but she was asked original payment bills. The original payment bills were submitted to OP2/ Bank and complainant contacted the said bank and asked about original payment bills and other documents. The OP2 apprised complainant that all original payment bills have already been sent to the Headquarter of OP3 and under such situation, how the complainant could furnish original bills again. The OPs have not provided services and to settle the claim, which caused harassment, mental agony, stress and monitory losses to the complainant. The complainant sent legal notice dated 24.03.2017 to the OPs but there is no answer to the notice or to settle the claim. There is deficiency of services. The complainant is a consumer under the Consumer Protection Act 1986. The complainant claims bills amount of Rs.1,42,260/- appropriate compensation in lieu of mental agony, pain, suffering and financial losses besides litigation charges of Rs. 50,000/- and other reliefs.
2.2. The complaint is accompanied with the record of medical bills of Rs. 1,42,260/- and advance receipts, legal notice dated 24.03.2017 with postal receipt and track report, of its service upon OP1 & OP2, identity card of insured-Yad Ram with EC No. 38577, e-card issued by United India Insurance Co. Ltd. in favour of Bank of Baroda in the name of Yad Ram and bearing name of OP1, claim form, letter dated 10.02.2017 by OP1 to Yad Ram (since deceased), death certificate and copy of identity proof of complainant.
2.3. It is relevant to mention that initially OP1 & OP2 were impleaded, however, then an application was filed to implead Insurer/OP3, the application was allowed on 01.08.2017 and thence notices were sent to all the OPs.
The OP1 & OP2 failed to appear, therefore, they were proceeded ex-parte on 16.10.2016. The OP3 had also appeared but it failed to furnish the written statement, consequently by order dated 29.01.2018, right to file written statement was closed and case was put to complainant’s evidence.
3. (Evidence)- In order to establish the complaint, the complainant led her own exclusive evidence by filing affidavit coupled with the documentary record filed with the complaint.
4.1 (Final hearing)- The parties were given opportunity to file the written arguments. The complainant filed her written arguments (being replica of her case/complaint), but there were no written argument on behalf of any of the OPs.
4.2. Moreover, both the sides were given opportunity to make oral submissions, however, none of the parties made appearance for oral submissions, therefore, the material on record will be considered to decide the consumer dispute.
5.1 (Findings) - The contentions of both the sides are considered, keeping in view the material on record, inclusive of documentary record filed and proved, besides statutory provisions of law.
5.2 The case of complainant has already been introduced in paragraph 2 above besides the documentary record. Although, the OPs failed to appear and challenge the complaint but still the complainant has to prove the case. Therefore, by considering the stock of all material, the following conclusions are drawn:-
(i) The letter dated 10.02.2017 issued by OP1 in the name of Sh. Yad Ram mentions all details, the name of insurance company is United India Insurance Co. Ltd. (i.e. OP3) and clients name is Bank of Baroda (i.e. OP2). The e-card (at page no. 28 of the paper book) reflects in its front side the names of United India Insurance Co. Ltd., Bank of Baroda and Yad Ram, with details of policy no. 500100/48/15//41/00000437 having validity from 01.10.2015 to 30.09.2016. The back side of e-card mentions the name of OP1/TPA, a facilitator to process the claim on behalf of Insurer/OP3 and Bank/OP2.
(ii) The medical record and documents are also proved by the complainant, showing Sh. Yad Ram was admitted in the hospital on 25.07.2016 and he was discharged on 28.07.2016. The patient Yad Ram was hospitalized during the tenure of insurance policy. The death certificate has also been proved that he expired on 27.07.2016.
(iii) The total medical expenses bill is of Rs.1,42,260/- and it stand established. However, OP1’s letter dated 10.02.2017 is in respect of seeking original payment receipt and those record was furnished by the complainant with OP2/bank, which remained unchallenged and un-rebutted
(iv) Since the complainant had original papers and the same were furnished with the OP2 bank, there was an inter-se arrangements between the OPs and that is why the e-card mentions names of all the OPs and complainant cannot be declined the valid claim when OP2 bank had received the original document and the same ought to have been forwarded to the insurer as assured to the complainant.
(v) The circumstances culled out make out a case of valid claim, however, for want of settlement of this medical claim, it amounts to deficiency of services besides harassment and mental agony to the complainant.
5.3 In view of the discussion and conclusion in sub-paragraph above, the complaint has been proved and the claim of complainant is made out for medical bills of Rs.1,42,260/- against OP2 & OP3. However, the OP1 is TPA/facilitator, therefore, no case is made out against OP1 and complaint is liable to be dismissed against OP1.
5.4 The Insured claims compensation (without mentioning the amount) in lieu of sufferings, harassment and mental agony from OPs besides cost of Rs. 50,000/-as the litigation and other appropriate relief because of denial of claim. Since, it is already held, that the insured is entitled for reimbursement of Rs.1,42,260/- and by considering the inconvenience, difficulties, trauma faced by them, the complainant also deserves reasonable compensation to be consonance to the situation involved. Thus, compensation of Rs.15,000/- is determined in favour of complainant and against the OP2/Bank & OP3/insurer besides costs of Rs.10,000/- is also allowed in favour of complainant and against OP.
5.5 The complainant claims other relief too. It may be considered from the point of view of interest. It is also a fact that the complainant has parted with money, while spending the amount on treatment from her pocket despite insurance cover. Therefore, simple interest at the rate of 5%pa from the date of complaint till realisation of amount in favour of complainant and against OP2 & OP2 will serve both ends of justice, according interest is determined at the rate of 5%pa..
6.1 Accordingly, the complaint is allowed in favour of the complainant and against the OP2 & OP3 to pay/reimburse, jointly and/or severally medical bills of Rs.1,42,260/-along-with interest at the rate of 5%pa from the date of complaint till realization of the amount, apart from compensation of Rs.15,000/- and cost of Rs. 10,000/-. The OP2 & OP3 will pay the amount within 45 days from date of this order, failing which they will be liable to pay enhanced interest at the rate of 7% on the amount Rs.1,42,260/-.The OP2 & OP3 may deposit the amount within time in the Registry of this Commission by way of valid instrument in the name of the complainant.
6.2 The complaint against OP1 is dismissed.
7. Announced on this 11th day of July 2024 [ज्येष्ठ 21, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.
[ijs-77]
