DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA (PUNJAB)<br /> <br /> CC No. 130 of 02.05.2008<br /> Decided on : 21-07-2008<br /> <br /> Bhupinder Singh S/o Sh. Raghbir Singh C/o Jagat Cloth House, Main Bazar, Goniana, District Bathinda.<br /> ... Complainant<br /> Versus<br /> <br /> 1.The New India Assurance Co. Ltd., Divisional Office, The Mall, Bathinda through its Divisional Manager.<br /> 2.Alankit Heath Care Limited, 205-208, Anarkali Complex, Jhandewalan Extension, New Delhi 110 055 through its Managing Director<br /> <br /> ...Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer Protection<br /> Act, 1986.<br /> <br /> QUORUM :<br /> Sh. Lakhbir Singh, President<br /> Dr. Phulinder Preet, Member<br /> <br /> For the Complainant : Sh. Rohit Romana, Advocate.<br /> For the Opposite parties : Sh. J.D Nayyar, Advocate, counsel for opposite party No. 1.<br /> Opposite party No. 2 exparte<br /> <br /> O R D E R<br /> <br /> LAKHBIR SINGH, PRESIDENT<br /> 1. Complainant had purchased a Hospitalisation and Domiciliary Hospitalisation Benefit Policy i.e. Individual Mediclaim bearing No. 360600/48/06/20/70000081 of Rs. 1,35,000/- with Domiciliary Hospitalisation limit of Rs. 25,250/- for the period from 20.10.06 to 19.10.07 from opposite party No. 1. Opposite party No. 1 had sent first page of the policy. Terms and conditions or other ancillary papers have not been supplied so far. In the first week of September, 2007 he was suffering from high fever. He got himself checked up from local hospital on 9.9.07. When he did not recover, he got himself checked up from Dr. Rupinder Sidhu of Malwa Superspeciality Hospital, Bathinda who got him admitted on 15.9.07. He diagnosed that he was suffering from acute Liver disease and Amoeblusis . Treatment was given to him upto 20.9.07 as indoor patient. Thereafter he got medicines as per advice of Dr. Sidhu. He had gone to Dayanand Medical College & Hospital, Ludhiana (Here-in-after referred to as 'DMC Ludhiana') for check up and treatment on 25.9.07. After examination he was admitted. Clinical tests were conducted. He was treated as indoor patient upto 28.9.07. Thereafter he was advised follow-up treatment as outdoor patient after every week. In this manner, he got treatment from the Doctors of DMC, Ludhiana upto 25.11.07. Claim was lodged with the opposite parties for Rs. 51,113/-. All the original documents including record of Doctors, discharge summary of DMC Ludhiana, bills of medicines etc. were submitted. Letter dated 18.1.08 was received by him from opposite party No. 2 requiring him to submit proper discharge summary of the hospitals, post hospitalisation prescription from 1.10.07 and certificate from physician about past history of Liver disease and Amoeblusis. Reply dated 1.2.08 was given by him. Letter dated 14.3.08 was sent by opposite party No. 2 intimating that claim of Rs. 20,307/- only has been finalised and the remaining claim of Rs.30,806/- has been disallowed on the ground that no prescription slips of the medicines regarding which bills have been submitted have been produced. Cheque of Rs. 20,307/- was sent alongwith letter. In this manner, claim has been repudiated. He alleges that this repudiation is against law and facts as he remained under treatment of the doctors from 9.9.07 till 25.11.07. Medicines the bills of which have been submitted were prescribed by the concerned Doctor during the treatment and he has consumed them for recovery from illness. At the time of taking the policy, he was not apprised that he should get the prescription slips from the Doctor for each medicine. He assails the repudiation as illegal, null and void, against law and facts. Accordingly, he has preferred this complaint under Section 12 of the Consumer Protection Act, 1986 (Here-in-after referred to as 'Act') seeking direction from this Forum to the opposite parties to pay him the balance claim amount of Rs. 30,806/- alongwith interest @18% P.A. from November, 2007 till payment; Rs. 50,000/- on account of mental tension and agony and loss of physical health besides Rs. 5,000/- as cost of the complaint.<br /> 2. Opposite party No. 1 filed its version taking legal objections that complaint is not maintainable in the present form; complainant has no cause of action to file it; this forum has got no jurisdiction to entertain and try the complaint; complaint is false and frivolous; complainant is not consumer and he is estopped from filing the complaint by his act and conduct. On merits, it admits that medi-claim policy was purchased by the complainant. Inter-alia their plea is that complete policy alongwith requisite papers including terms and conditions, card and book-let were supplied to him. Claim was payable as per terms and conditions, rules and regulations of the policy by opposite party No. 2 which is third party agency for making the payment of the claim. Claim was submitted for Rs. 51,113/-. Certain documents were furnished by the complainant. Letter dated 18.1.08 was written by opposite party No. 2 to the complainant asking him to submit the discharge summaries of the hospitals, post hospitalisation prescription from 1.10.07 and certificate from physician about past history of Liver disease and Amoeblusis. Letter dated 1.2.08 in the shape of reply was sent by the complainant. Since prescription slips of the doctors concerning the medicines regarding which bills have been furnished were not submitted complete claim could not be allowed. Complainant was entitled to the claim of the medicines which were prescribed by the Doctors. Rs. 20,307/- were payable on the basis of the bills and the prescriptions. Accordingly cheque was sent towards full and final settlement. Rs. 30,806/- have been disallowed. It denies that the repudiation of the claim to this extent is illegal, null and void and against facts. Other averments are not admitted.<br /> 3. Registered A.D. post notice was issued to opposite party No. 2 on 14.5.08. Neither registered cover nor A.D. was received back till 19.6.08 i.e. within 30 days. Accordingly, opposite party No. 2 was deemed to have been duly served. No one came on its behalf. Accordingly, it has been proceeded against exparte.<br /> 4. In support of his averments contained in the complaint, complainant has produced in evidence photocopy of Insurance policy schedule (Ex. C-1), photocopy of discharge summary (Ex. C-2), photocopy of letter dated 1.2.08 (Ex. C-3), photocopies of letters (Ex. C-4 & Ex. C-5), photocopies of letters dated 21.1.08 & 28.1.08 (Ex. C-6 & Ex.C-7), photocopy of another letter (Ex. C-8), photocopies of claim bills detail (Ex. C-9 to Ex. C-12), photocopy of form (Ex. C-13), photocopy of list of bills (Ex. C-14), photocopy of lab test report (Ex. C-15), photocopy of discharge summary (Ex. C-16 to Ex. C-18), photocopy of prescription of Dr. R S Sidhu (Ex. C-19), photocopies of retail Invoices (Ex. C-20 to Ex. C-23), photocopies of cash memos (Ex. C-24 to Ex. C-26), his another affidavit (Ex. C-27), photocopies of cash memos and receipts (Ex. C-28 to Ex. C-66) and photocopies of lab reports (Ex. C-67 to Ex. C-81). <br /> 5. In rebuttal, on behalf of opposite party No. 1 affidavit of Sh. P K Jain, Senior Divisional Manager (Ex. R-1), photocopy of despatch register – one page (Ex. R-2) and photocopy of letter dated 14.7.08 (Ex. R-3) have been tendered in evidence.<br /> 6. We have heard learned counsel for the parties. Besides this, we have gone through the record.<br /> 7. Mr. Romana, learned counsel for the complainant vehementally argued that copy of the terms and conditions and other ancillary papers were not supplied to the complainant alongwith first page of the policy due to which he was not aware that prescription slips through which medicines were prescribed by the doctors were required. He further argued that complainant had purchased all the medicines the bills of which have been furnished to the opposite parties on the basis of prescriptions of the Doctors and as such the repudiation of the claim to the tune of Rs. 30,806/- vide letter dated 14.3.08 is not justified. For this, he drew our attention to the documents Ex. C-1 to Ex. C-81 including affidavit Ex. C-27 of the complainant.<br /> 8. Mr. Nayyar, learned counsel for opposite party No. 1 countered the arguments of the learned counsel for the complainant by submitting that complete policy alongwith its terms and conditions, book-let and card were supplied to the complainant and he was well aware that in case of illness, prescription slips issued by the Doctor regarding medicines are required. Claim has been rightly disallowed to the extent of Rs. 30,806/-.<br /> 9. We have considered the respective arguments and we feel ourselves inclined to agree with the learned counsel for opposite party No. 1. Onus to prove the deficiency in service lies heavily on the complainant. To prove that terms and conditions and other ancillary papers were not supplied, there is bald affidavit of the complainant which is Ex. C-27. It stands amply rebutted with the affidavit of Sh. P K Jain Sr. Divisional Manager of opposite party No. 1 who has categorically stated that complete policy alongwith all the requisite papers including policy terms and conditions, card and book-let were supplied to the complainant. Not to speak of this, opposite party No. 1 has produced copy of the despatch register and copy of the letter dated 14.7.08 issued by Airman Courier Service copies of which are Ex. R-2 & Ex. R-3 respectively. All the official acts performed by the public servants in the discharge of their public duties are presumed to be correct. A perusal of Ex. R-2 reveals that document was remitted to the complainant. Entry to that effect has been made in the despatch register at Sr. No. 6522. Letter of the courier services further corroborates that courier was given to it by New India Assurance Co. Ltd., for delivery to the complainant and as per their general practice courier is delivered on the next date. Even otherwise the plea of the complainant that terms and conditions and other ancillary papers were not supplied to him does not sound to reason. Copy of the policy schedule is Ex. C-1. Policy was valid from 20.10.06 to 19.10.07. This complaint was presented by the complainant on 2.5.08. There is nothing before us to conclude that before this date, he knocked the door of opposite party No. 1 with the complaint that copy of the terms and conditions and other ancillary papers were not supplied to him. His this eleventh hour averment appears an after thought. Incase of illness complainant was required to get the prescription slips of the medicines from the concerned Doctors. Thereafter he was to purchase those medicines and receive the bills. Admittedly complainant has produced the prescription slips worth Rs. 20,307/- and the bills of the medicines. Accordingly claim has been allowed and amount has been paid to this extent. Learned counsel for the complainant could not show us any rule and regulation that bill of each and every medicine purchased by the insured is payable by the opposite parties. Hence, we conclude that repudiation of the claim of Rs. 30,806/- is justified. No deficiency in service on the part of the opposite parties is proved.<br /> 10. In view of our foregoing discussion, complaint is dismissed. Parties are left to bear their own cost.<br /> Copy of this order be sent to the parties concerned and file be also consigned. <br /> Pronounced :<br /> 21-07-2008 (Lakhbir Singh )<br /> President<br /> <br /> <br /> (Dr.Phulinder Preet) <br /> Member<br /> 'iki' <br />