Sunil Kumar complainant has filed this complaint U/s 12 of the Consumer Protection Act of 1986 against the opposite parties for the release of insured amount as he is holder of Health Insurance Policy No.233106/48/2014/295 of PNB Oriental Royal Mediclaim and having MA-ID 5010233112 and has paid the regular installments from his account No.1250000101153520 and the said policy gives the benefit to refund medical treatment and hospital expenses during the validity period of this policy. It was pleaded that complainant became ill and was treated in Govind Ballanh Pant Hospital New Delhi on Jan. 2015 where he had to undergo open heart surgery and spent Rs.2,00000/- and after this he again had to get treatment at S.G.L. Super Speciality Charitable Hospital, Jallandhar, Punjab in July, 2015 where he had spent Rs.80,000/- on his treatment. It was further pleaded that complainant lodged the claim with the Insurance Company i.e. opposite party No.1 which had not been settled, cleared/paid till date. Complainant also prayed that appropriate action may kindly be taken against the Insurance Company, hence this complaint.

2.       Notice of the complaint was issued to opposite parties. Opposite party no.1 had appeared through their counsel and filed the written reply by taking the preliminary objections that complaint filed by the complainant against the replying opposite is hopelessly premature as till date he had not filed the requisite documents with the Medi Assist Insurance TPA Pvt. Ltd. (Third Party Claim Settling Authority) for settlement the claim of reimbursement. It was stated that there was gap in policy from 01.09.2014 to 31.08.2015 and the policy in question was first year policy and due this reason request of the complainant for cashless hospitalization was denied. It was further stated that Insurance Company is still ready to settle the claim under the terms and conditions of the policy but due non supplying the requisite documents by the complainant the said TPA is not in a position to settle the claim and as such the claim of the complainant is still under process for want of requisite documents. That complainant is estopped to file the instant complaint as there is no deficiency in service on the part of the opposite party No.1 i.e. Insurance Company as defined in section 2 (i) (g) of the Consumer Protection Act, 1986 under the heading ‘Deficiency’. That the present complaint had not been drafted under the provisions of the Consumer Protection Act and as such the same is liable to be dismissed on this ground. On merits, it was admitted that complainant had got medi claim policy from the Insurance Company in the year of 2013 but it was denied that the complainant was regular policy holder of the Insurance Company since 2013. It was further denied that complainant ever paid the premium for the period from 01.09.2014 to 31.08.2015 and complaint of the complainant was silent about the period of the treatment as in which date he was got admitted in the hospital and in which date he was discharged from the hospital and due the said reason opposite party No.1 is not in a position to give the detailed and proper reply of the complaint and the question of treatment of open heart surgery of the complainant and expenses on the treatment is denied for want of knowledge and the complainant be put to strict proof about the same. It was also denied that any legal notice was ever served upon the opposite party No.1 i.e. Insurance Company by the complainant. It was stated that the complaint filed by the complainant against the replying opposite party is false, frivolous, vexatious and in fructuous as there was no deficiency in service on the part of opposite party No.1. All other averments made in the complaint have been denied and last prayed for dismissal of the complaint with exemplary costs along with any other relief to which the opposite party No.1 is found entitled under the law.        

3.      Opposite party No.3 also appeared through Sh.Sham Singh Sr. Manager but he had failed to appear for filing of reply to the main complaint. Notice issued to opposite party no.2 had not been received back and on 02.03.2017 opposite parties no.2 & 3 were proceeded against exparte.

4.       Complainant had tendered into evidence his own affidavit Ex.C1 along with documents Ex.C2 to Ex.C54 and closed his evidence.

5.       Counsel for the opposite party No.1 had tendered into evidence affidavit of Sh.Karam Singh D.M. Oriental Insurance Company Ex.OP-1 along with documents Ex.OP-2 to Ex.OP-5 and closed the evidence on behalf of opposite party No.1.

6.       Written arguments filed by opposite party No.1 but not filed by the complainant.

7.       We have carefully examined all the documents/evidence produced on record for its contained statutory merit and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for some of the documents that have been somehow ignored to be produced by the contesting litigants. We observe that the prime dispute prompted firstly at the OP insurer’s assertive allegation (vide their written statement duly deposed through Affidavit Ex.OP1/1) that there has been a period gap of discontinuation in the applicable policy w e from 01.09.2014 to 31.08.2015 and as such the policy in question has been in its first year. Further, the OP insurers have put forth their other allegation(s) that the complainant has failed to prove the payment of premium for this period of the policy-gap and ’have also not provided the date of hospitalization/ discharge etc in his reimbursement claim that has been still lying deferred with them as Pre-mature, awaiting settlement.

8.       However, we find that the OP insurers have simply based its ‘claim-deferment’ (amounting to repudiation) on the bald statements (sans any cogent evidence) and that gets duly rebutted autobiographically by virtue of:

i) Insurance policy (Ex.C15/ Ex.OP1/3) with its period of insurance duly incorporated over the same as: 01.09.2014 to 31.08.2015;

ii) The OP3 Savings Bank’s Pass Book (Ex.C7) duly incorporating the insurance premium debit entry (with narration: To DD for Oriental Ins. Co.) dated 23.08.2014 for Rs.5780/- duly charged to the SB A/c of Sunil Kumar complainant;

iii) Discharge Summary (Ex.C9) duly issued by the Govind Ballabh Pant Hospital, New Delhi; duly exhibiting the Date of Admission as: 03.12.2014, of the Operation (procedure/surgery etc) as: 08.12.2014 and of Discharge as: 17.12.2014;

Finally, we find that the OP insurers’ queries/objections etc stand duly clarified by the complainant and as such the delay/deferment at their end clearly amounts to deficiency in service on their part and that holds them up against an adverse statutory award with a firm directive to settle the claim expeditiously. We observe that the OP insurers have failed to prove/place on record that the complainant has wrongly filed his hospitalization claim against a non-existent insurance policy with its premium not paid at the time of its purchase. Further, we also find that the insurers have un-necessarily deferred/delayed the settlement of a valid claim on arbitrary and flimsy grounds and that rakes them up for any adverse statutory award under the Act.

9.       We, finally find that the OP insurers’ act of withholding of ‘settlement’ of present insurance claim on the above count(s) have caused further ‘delay’ in communicating its denial/deferment to the complainant amounting to ‘deficiency in service’ coupled with adoption of ‘unfair trade practice’ and that certainly holds the OP insurers liable to an adverse statutory ‘award’ under the applicable statute.      

10.     In the light of the all above, we find that the OP insurers have indeed infringed the consumer rights of the present complainant and thus ORDER them to settle and pay him the impugned insurance claim in full but in terms of the terms of the applicable insurance policy besides to pay him Rs.5000/- as compensation and Rs.3000/- as cost within 30 days of the receipt of the copy of these orders otherwise the aggregate awarded amount shall attract interest @ 9% PA from the date of orders till actual payment.

11.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to records. 

                           (Naveen Puri)

                                                                                             President.

ANNOUNCED:                                                            (Jagdeep Kaur)

AUG. 25, 2017.                                                                          Member               

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