Punjab

Rupnagar

CC/22/78

Mohinder Singh - Complainant(s)

Versus

The new India assurance co. ltd - Opp.Party(s)

Abhishek Bhardwaj

09 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, ROOPNAGAR

 

Consumer Complaint No. 78 of 2022

Date of Institution:          : 23.05.2022

Date of Decision            :  09.06.2023

 

Mohinder Singh s/o Kartar Singh, r/o Sunder Nagar Colony, Morinda , District Ropar, Punjab Mob. 9779457693

 

….. Complainant

Versus

 

1.       The New India Assurance Co. Ltd., through its Authorized  Officer/Person, New India Assurance Building 87, M.G Road, Fort Mumbai, Maharashtra 400001.

2.       Medi Assist India TPA Pvt. Ltd,, through its Authorized Officer/Person,  1^st Floor, North Wing, Plot No. 7, Excom House, Saki Vihar Road, Saki Naka, Andher (E ), Mumbai , Maharashtra 4000072.

3.       Life Insurance Corporation of India, Branch Morinda through its Branch Manager, Plot No. 81-82, City Centre, Prem Nagar, Morinda District Ropar, Punjab 140101.

 

                                                                               …..Opposite parties

 

(Complaint under the provision of Consumer Protection Act)

 

QUORUM:

 

SH.KULJIT SINGH, PRESIDENT

SH.RANVIR KAUR, MEMBER

 

COUNSEL FOR THE PARTIES

 

For complainant                       :         Sh.Abhishek Bhardwaj, Advocate

For OP no.1                             :         Sh. Amit Gupta, Advocate

For OP no.2                             :         Ex-parte

For OP no.3                             :         Sh. Ankur Verma, Advocate

                            

Per : KULJIT SINGH, PRESIDENT

 

1.                Brief facts of the case are that the  complainant is a LIC Club Member Agent having code no. 00208332. OPs no.1 and 2  leading business in the Insurance policies  and also selling the policies jointly and severally known to provide services in the following categories i.e. Health Insurance Policies, Insurance  Policies and General Policies.  LIC of India is a policyholder of Medi-claim Insurance  of OPs no.1 and 2, who provides the benefit of Group Mediclaim Insurance Scheme of OPs no.1 and 2 to its each and every LIC Club Member Agents as Beneficiaries.  The Health Care of Beneficiary  and his family is covered for a sum insured of Rs.5,00,000/-  in the medi claim policy of OPs no.1 and 2, in which the beneficiary (complainant) can take the benefit of up to Rs.5,00,000/- from the policy of OPs no.1 and 2 for his health related problems.  On 03.09.2020, the complainant felt serious ill i.e. Heart related problem and he had taken treatment at Government Hospital Morinda and further referred to Cheema Medical Complex Mohali on 06.09.2020 for treatment of Artery Blockage, where he was inserted with 2 stents in his heart.  As per policy he is covered in the  medi claim insurance scheme and paid Rs.1,90,000/-  vide cheque no. 050971 on 07.09.2020 for the stents which was inserted in the heart of the complainant and after two days he was discharged from the  hospital i.e. on 09.09.2020. The total amount of Rs.2,16,758/- had been spent on the treatment of the complainant.  The complainant submitted a claim of Rs.2,16,758/-  along  with all original papers, documents, discharge summary of the hospital, bills and payment receipt of the hospital and all the entire documents relevant of the hospitalization within 30 days from the date of discharge as per the policy or procedure for reimbursement of claim of OPs no.1 and 2.  It is pertinent to mention here that  original receipt of bill i.e. Rs.1,90,000/- was misplaced by the family members of the complainant, so as per instructions of OPs no.1 and 2 the complainant has send duplicate copy of the original receipt of Rs.1,90,000/-  which was attested by Hospital Authorities. After 60 days from the submission of the claim vide claim no. 102156894 when OPs no.1 and 2 did not release the claim amount to the complainant  then complainant approached official of OPs no.1 and 2 through OP no.3 and also through official of Divisional Office of OP no.3 many times through phone calls  but OPs no.1 and 2 failed to release the amount to complainant nor settled the claim.  The complainant also served a legal notice upon OPs  but of no use. Due to act and conduct of OPs, the complainant has filed the instant complaint and prayed that the OPs be directed to release the amount of Rs.2,16,758/- with interest @ 18% , besides Rs.30,000/- as compensation and Rs.20,000/- as litigation expenses.

2.                 Upon notice, OP no.1 appeared and filed its separate written reply and contested the complaint of the complainant by averring that the complainant has obtained insurance policy no. 1203003420040000007 against which the claim no. 102156804 was raised by complainant and claim was processed for a sum of Rs.2,16,758/-  The complainant has not provided the complete set of documents and unable to provide the proper IFSC code as payment was not going through the IFSC code and as complainant has failed to reply with regard to the same so the payment of the complainant was delayed and now as correct particulars of IFSC code have been provided so payment is being made. Any deficiency  in service and unfair trade practice was denied by OP no.1 and it prayed for dismissal of the complaint.

3.                 OP no.3 appeared and filed its separate written reply and contested the complaint of the complainant by averring that  the complainant has submitted the duplicate receipt for Rs.1,90,000/-  which was attested by the Hospital Authorities. OP no. 3 has sent the requirement along with duplicate receipt for Rs.1,90,000/- vide letter dated 18.01.2022 through speed postdated 08.02.2022. The claim of the complainant has to be considered by OPs no.1 and 2 and OP no.3 merely has to transmit the documents to OPs no.1 and 2 for consideration of claim. OP no. 3 has no authority to consider or release the claim under the medi claim policy. OP no.3 denied other averments of the complainant even on merits and prayed for dismissal of the complaint.

4.                 The complainant has tendered in evidence his affidavit Ex.CW-1/A along with copies of documents Ex.C-1 to Ex.C-9 and closed the evidence. On the other hand, OP no.1 has tendered in evidence affidavit of Kamlesh Aggarwal Senior Divisional Manager as Ex.OP-A along with copies of documents Ex.OP-1 to Ex.OP-3 and closed the evidence.  OP no.3 has tendered in evidence affidavit of Sh. Rajesh Bhatia Manager (Legal) as Ex.OP-3/A  along with copies of documents Ex.OP-3/B to Ex.OP-3/O and closed the evidence.

5.                 We have heard learned counsel for the parties and have also gone through the record of the case very minutely.

6.                 It is an established fact that the is a LIC Club Member Agent having code no. 00208332. OPs no.1 and 2  leading business in the Insurance policies  and also selling the policies jointly and severally known to provide services in the following categories i.e. Health Insurance Policies, Insurance  Policies and General Policies.  LIC of India is a policyholder of Medi-claim Insurance  of OPs no.1 and 2, who provides the benefit of Group Mediclaim Insurance Scheme of OPs no.1 and 2 to its each and every LIC Club Member Agents as Beneficiaries.  The Health Care of Beneficiary  and his family is covered for a sum insured of Rs.5,00,000/-  in the medi claim policy of OPs no.1 and 2, in which the beneficiary (complainant) can take the benefit of up to Rs.5,00,000/- from the policy of OPs no.1 and 2 for his health related problems. On 03.09.2020, the complainant felt serious ill i.e. Heart related problem and he had taken treatment at Government Hospital Morinda and further referred to Cheema Medical Complex Mohali on 06.09.2020 for treatment of Artery Blockage, where he was inserted with 2 stents in his heart.  The complainant has placed on record various documents in support of his case. Ex.C-1 is copy of Reimbursement Claim Form, in this the complainant claimed the amount of Rs. 2,16,758/- . Ex.C-2  is copy of prescription slip  dated 05.09.2020 on the record prepared by Dr. Ramandeep Singh, Medical Officer on the record. On the other hand, OP no.2 placed on record blank cheques  with note Ex.OP-3 on the record in this note it has been specifically mentioned that : bank IFSC code note not valid.  Ex.OP-3/F is copy of discharge summary of the patient Mohinder Singh/Complainant on the record. In this summary, it has been specifically mentioned that date of admission of the complainant/patient as 06.09.2020 and date of discharge mentioned as 09.09.2020, it seems that the patient is indoor patient. Similarly, we have also examined the bills of the medicines as well as test reports of the patient on the record.

7.                 This fact is not disputed that the complainant had taken the treatment on 03.09.2020 and he felt seriously ill i.e. Heart related problem and had taken treatment at Government Hospital Morinda and further referred to Cheema Medical Complex Mohali on 06.09.2020 for treatment of Artery Blockage, where he was inserted with 2 stents in his heart.  As per policy he is covered in the  medi claim insurance scheme and paid Rs.1,90,000/-  vide cheque no. 050971 on 07.09.2020 for the stents which was inserted in the heart of the complainant and after two days he was discharged from the  hospital i.e. on 09.09.2020. The total amount of Rs.2,16,758/- had been spent on the treatment of the complainant. The complainant claimed for amount of Rs.2,16,758/-  as per medical claim form Ex.C-3 on the record.  The position is the instant case is very clear because OP no.1 specifically mentioned in para no. 1 of its written reply that “complainant has obtained insurance policy no. 1203003420040000007 against which the claim no. 102156804 was raised by complainant and claim was processed for a sum of Rs.2,16,758/-  The complainant has not provided the complete set of documents and unable to provide the proper IFSC code as payment was not going through the IFSC code and as complainant has failed to reply with regard to the same so the payment of the complainant was delayed and now as correct particulars of IFSC code have been provided so payment is being made.” We have also perused two cheques Ex.OP-1 and Ex.OP-2 on the record. From perusal of above said para and two cheques , it has transpired that the OP no.1 is ready to make the payment of 2,16,758/- to complainant which he has spent on his treatment but due to not provide the IFSC code payment was not going through IFSC code. From perusal of entire record of the file, it has transpired that the OP no.1 is ready to release the payment of the claim amount to complainant but complainant failed to provide the proper particulars, due to non-availability of proper documents OP no.1 failed to make the payment in the account of complainant, so it is crystal clear that OP no.1 had not intentionally made the payment to complainant and OP no.1 also admitted in para no.1 of its reply that they are ready to make the  payment to complainant but complainant failed to provide the proper particulars to them.

8.                 Keeping in view the totality of the facts and circumstances of the case, we partly allow the complaint of the complainant and complainant is directed to provide proper IFSC code to OP no.1 so that payment was paid to complainant and also directed to provide the correct particulars to OP no.1 for release of his claim amount within 15 days from receipt of copy of this order and OP no.1 is directed to release the payment of claim to complainant on receipt of particular by complainant.

9.                 The compliance of the order be made within 45 days from receipt of copy of this order.

10.              This complaint could not be decided within stipulated period due to heavy pendency of the cases. Copies of the order be supplied to the parties free of costs.

11.              File be indexed and consigned to the record room.

Dated         :09.06.2023                                      (Kuljit Singh)

                                                           President

 

                                         ( Ranvir Kaur)                                       

                                                            Member