Delhi

East Delhi

CC/395/2019

MUSADDI LAL - Complainant(s)

Versus

THE NAINITAL BANK - Opp.Party(s)

31 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. No.395/2019

 

	MUSADDI LAL GARG, R/O A-1/203, NEW KONDLI, DELHI - 110096	….Complainant
Versus
	THE NAINITAL BANK LTD. NEW KONDLI, BRANCH NEW KONDLI, EAST DELHI - 110096	……OP
	GENINS INDIA INSURANCE TPA LTD. D-34, GROUND FLOOR, SECTOR-2, NOIDA - 201301	……OP
	NATIONAL INSURANCE CO. LTD. 5/222, CANAL ROAD, TIKONIA, HALDWANI-DISTRICT, NAINITAL-263139	……OP

 

Date of Institution	:	20.12.2019
Judgment Reserved on	:	17.03.2023
Judgment Passed on	:	31.03.2023

               

QUORUM:

 

Sh. S.S. Malhotra	(President)
Ms. Rashmi Bansal	(Member)
Sh. Ravi Kumar	(Member)

Order By: Shri S.S. Malhotra (President)

 

 

JUDGEMENT

 

1. By this Order the Commission would dispose off the complaint of the Complainant with respect to deficiency in service by OP1 in not forwarding the amount of the premium within time to the OP3, against OP2 in not granting cashless facility at the hospital and against OP3 with respect to not disbursing the amount of the treatment against the medical policy.   
2. Brief facts as stated by the complainant in the complaint are that he has paid Rs.9,293/- to the OP1, who is an agent of OP3 for the purpose of renewal of the Mediclaim Policy with effect from 29.10.2018 to 28.10.2019 vide receipt No. 461800811810009887 dated 13.11.2018, and scroll No.8821181106001337 dated 20.09.2018.  However, the Insurance Company did not release the policy inspite of the repeated reminders and it was finally issued by the Insurance Company only on 20.05.2019 but meanwhile the complainant developed certain ailments and was admitted in Paras Hospital, Gurugram who after examining him advised admission and as such he was admitted there on 23.04.2019.  He raised a cashless claim but OP2 demanded the policy and since the policy was not released by the OP3 the same could not be submitted and as such complainant could not get cashless facility.  After the discharge from the Hospital he submitted bill for reimbursement to OP2 but TPA raised so many objections and one of the objections was that original documents be submitted and in absence thereof, the affidavit be submitted.  Complainant accordingly submitted the affidavit with OP2 and after all such formalities only part payment was released by the OP3 and remaining amount of the Rs.3,07,470/- was not issued for which he has filed the present complaint claiming the said amount of Rs.3,07,470/- along with interest @ market rate and compensation of Rs.2,00,000/- . 
3. All OPs were served and OP1 took the copy of the complaint from the Commission on 13.04.2022 and did not file the reply within limitation and only filed the same on 07.11.2022 and the Commission observed that reply of the OP is beyond the statutory period and as such the reply was not taken on record for the purpose of defence of OP.  However, it is a matter of record that OP1 meanwhile has filed an application for its deletion which would be disposed off simultaneously now. 
4. OP2  has taken the preliminary objection that he is the IRDA approved licensed 3^rd Party and from the very definition it is clear that there is no privity of contract in between complainant and OP2 and as such complainant is not the consumer of OP2, and even otherwise the present claim is not maintainable against OP2 as it only functions for very limited purpose in nature i.e. after receiving the claim of the insured, he scrutinizes all the relevant documents and then sends the same to OP3, the Insurance Company for necessary consideration of the claim along with bills, hence is not responsible for accepting or repudiating the claim of any of the complainant.  Therefore, claim of the complainant against OP2 is without any cause of action and be dismissed.  On merit the contents of complaint are denied and contents of preliminary objections are reiterated. 
5. OP3 has filed its reply taking preliminary objections that present complaint is not maintainable before this Commission as it involves complicated questions of law, there is no deficiency on the part of OP3, all the policies are contract between the insurer and insured and both the parties are bound by the terms and conditions of the contract and one of the conditions is that complainant has to supply the original medical bills which is an essential ingredient of processing the claim and since complainant has not submitted the same in entirety and therefore the bills which were submitted in original were reimbursed and balance amount was not reimbursed and the same is only on account of not submission of the document in original by the complainant.     
6. On merit complainant is an insured of the OP3, he got the policy, the premium was received are the facts which have not been disputed.  It is further stated by OP3 that complaint of the complainant against OP3 be dismissed being without any cause of action as this is the complainant who had not furnished the original documents. 
7. Complainant has filed his evidence by way of affidavit and has exhibited the  original bill of Paras  Hospital dated 23.04.2019 along with copy of prescriptions as Annexure C-4, Request for TPA to OP2 is exhibited as Annexure C-5, Receipt of the estimated expenditure is exhibited as Annexure C-2, the denial of the claim initially by OP3 for a period of more than 7 months on account of non-pursuing the policy on time by OP3 as Annexure C-9A and 9B, Denial/Issuance of commission of all the bills in original as exhibit C-11 i.e. bill for Rs.355430/- dated 22.07.2019 for Rs.15670/- dated 01.08.2019, for Rs.4370/- and Rs.10606/- dated 28.06.2019 totalling Rs.3,66,076/- and as C-11, it is further stated in the evidence that OP has paid Rs.40935/- and Rs.11671/- on 30.08.2019 and 25.11.2019 and balance amount of Rs.3,07,470/- has not been paid and other relevant documents. 
8. OP2 has filed evidence of Sh. Sudhir Kumar, Deputy Manager, and opportunity of OP3 to file evidence was closed vide order dated 09.01.2023. Both the parties the complainant as well as OP2 and OP3 filed their written arguments.
9. The Commission has perused the record. 
10. In nutshell the case of the complainant is that he paid the insurance claim to OP1 for onward submission to OP3 which OP1 had been receiving for about 7 years in terms of some internal agreement between OP1 and OP3 but either OP1 did not submit the premium to OP3 or OP3 did not issue the policy in time and the policy was only issued on May, 2019 but meanwhile the complainant required hospitalization and when he submitted the bill for cashless OP2 did not process his claim for want of original papers and only after writing so many emails and letters OP2 issued the policy in May, 2019 alongwith the continuity benefits but it caused mental harassment to the complainant.  Not only this when the complainant submitted the bills after discharge the OP3 reimbursed only partial  amount and did not reimburse the whole amount  for the reason that OP2 has not done its activity of submitting the bills and the affidavit to OP3.  The OP1’s reply is not on record, OP2 has filed its reply as well as evidence, and although the  reply of OP3 is on record but it has not filed its evidence.  The issue therefore is either the OP3 was deficient in providing the services to the complainant in not reimbursing the bill, or whether OP2 was deficient in discharging his duties for not collecting the original documents of the complainant from  the  hospital or whether OP1 was negligent in not getting the policy of the complainant issued within time.  In the entire written statement filed by OP2 or OP3 it has no where been alleged by the OP2 and OP3 that the  claim of the complainant is not genuine.  The complainant submits that he furnished the bill to the  OP2 in original and OP2 in return submitted that some bills are not original and complainant had  to submit some affidavit which were submitted to the OP2 but despite that OP2 did not reimburse the amount.  The Commission is considering the contention of each OP one by one.  As far as OP1 is concerned its reply cannot be read for the purpose of its defence, therefore it stands admitted that despite having received the payment from  the complainant in October itself, the same was not forwarded to the insurance company/OP3 in time and as such OP1 is deficient in providing services to the complainant w.r.t. getting the policy of the complainant within time and  apart from that there is no deficiency on the part of OP1.  OP1 is accordingly directed to pay a compensation of Rs.7000/- to the complainant.  Consequently, application of the OP1 for its discharge that it is not a necessary party in the proceedings is dismissed. 
11. As far as OP2 and  OP3 are concerned irrespective of the fact that OP2 has no direct privity of contract with complainant but it is the OP2 who has to collect the bill from the complainant, has to consider the same, has to comply with all the formalities while acting as a mediator in between the hospital on one side and the insurance company on the other hand w.r.t. checking genuineness of the claim, genuineness of the ailment, the genuineness of the  documents and the bill issued and it is only after his opinion, OP3 acts and finally it is  said as to whether the  claim is to be given or to be rejected.  Therefore, OP2 who is  collecting  the documents from the complainant has a duty towards the complainant to fulfil all the deficiencies if any w.r.t. the collecting of documents, or w.r.t. taking the opinion of the  doctors/hospital which it has not done.  Therefore, there is privity of contract indirectly in between OP2 and the complainant.  Therefore, liability of OP2 with OP3 is joint and several. 
12. As far as OP3 is concerned, apart from the  objections that complainant has  not provided the original documents/bills to the OP2, there is no other objection.  The  complainant has submitted all the original bills to OP2, OP2 has enquired from the  complainant and  has  stated that for certain bills which were not in original,  complainant has to submit an affidavit.  As per complaint the affidavit has been submitted by complainant to OP2 and there is no denial either by OP2 or by OP3 that complainant has  not submitted the affidavit.  Therefore, the OP2 and OP3 are liable for not providing the insurance claim to the complainant despite the fact that all the formalities have been completed by  the complainant.  Therefore, OP2 and OP3 are liable to pay jointly and severally to the  complainant. 
13. The Commission accordingly hereby orders as follows:

- OP1 is deficient in providing the necessary services w.r.t. not issuing the policy in time to the complainant and it directed to pay Rs.7000/- as compensation to the complainant. 

- OP2 and OP3 are deficient in providing the necessary services to the complainant in not reimbursing the claim timely and are directed to pay Rs.3,07,470/- with interest @ 9% p.a from the date of filing the complaint till the date of realization jointly and severally. 

- OP2 and OP3 also to pay compensation of Rs.25,000/- to the complainant jointly and severally including litigation charges. 

This order be complied with within 30 days from the date of receipt of the order.

Copy of the order be supplied / sent to the parties free of cost as per rules.

File be consigned to Record Room.

Announced on 31.03.2023.