DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA (PUNJAB)
CC No. 440 of 23-09-2010 Decided on : 31-01-2011
Krishan Kumar Goyal S/o Sh. Kishori Lal R/o 191, Phase-1, Bathinda. .......Complainant Versus
The New India Assurance Co. Ltd., through its Divisional Manager, Mall Road, Bathinda. Senior Divisional Manager, New India Assurance Co. Ltd., 2nd Floor, Hemkund Chamber 89, Nehru Place, New Delhi. Raksha TPA Pvt. Ltd., 15/5, Mathura Road, Faridabad 121003.
.... Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM Ms. Vikramjit Kaur Soni, President Dr. Phulinder Preet, Member Sh. Amarjeet Paul, Member
For the Complainant : Sh. Krishan Lal, complainant in person. For the Opposite parties : Sh. J.D. Nayyar counsel for the opposite party Nos. 1 & 2. Sh. Vijay Kumar, A.R. of opposite party No. 3.
O R D E R
VIKRAMJIT KAUR SONI, PRESIDENT
This complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 as amended upto date (here-in-after referred to as 'Act'). The complainant is a retired Manager of Punjab National Bank, Bathinda. He had purchased a Medi Claim Insurance from New India Assurance Company Ltd., through Punjab National Bank, Head Office New Delhi, and a policy No. 311800/34/08/87/000001010 and enrollment No. 2013 (PNB) was issued to him after receiving the amount from the Bank collected from the retired employee. As per instructions, the complainant sent a claim of Rs. 3418/- of Chemotherapy done at Acharaya Tulshi Centre, Cancer and Research Institute, Bikaner on 29-12-2009, alongwith original bills, receipts and X-ray films etc., on 28-01-2010, on account of chemotherapy of his wife Pushpa Devi being cancer patient. The opposite parties neither paid any claim to the complainant nor intimated the fate of his claim. Hence, this complaint seeking directions to the opposite parties to pay his claim of Rs. 3418/- with interest alongwith compensation and cost. The opposite party Nos. 1 & 2 in their joint written version pleaded that claim of the complainant was not paid due to lack of exact information and documents which the complainant failed to provide. In the claim submitted by the complainant, he has no where mentioned that on the claim form that the claim was for post hospitalization expenses. The complainant has lodged his first claim on 6th December, 2009 for treatment of his wife for Rs. 25,539/- and that claim was duly settled to the satisfaction of the complainant. If this fact had been disclosed earlier, the present claim would have been cleared as post hospitalization claim long time back. The claim of the complainant's wife has been reviewed and the opposite party No. 2 has already paid the admissible claim amount of Rs. 3418/- subject to submission of revised claim form and prescriptions on the last date of hearing. The opposite party No. 3 in its separate written reply submitted that opposite party No. 3 is ready to pay the admissible claim amount of Rs. 3418/- subject to submission of revised claim form and prescriptions. However, the opposite party No. 3 prayed that the complainant is not entitled to any other relief. Parties have led their evidence in support of their respective pleadings. Arguments heard and written submissions submitted by the parties perused. The complainant had filed the claim of his wife on account of chemotherapy alongwith bills, receipts and X-ray films etc., to the tune of Rs. 3418/- with opposite party No. 3 on 28-01-2010. The opposite party neither replied nor paid the claim to the complainant. The opposite party Nos. 1 & 2 have submitted that they have not paid the claim of the complainant due to lack of exact information and documents which the complainant has not provided to them. In his Claim Form the complainant has not filled the information regarding the post hospitalization expenses. Neither the complainant has attached required prescriptions/case summary nor presented fresh admission and supporting documents. The opposite party No. 3 has submitted that the claim of the complainant was not paid due to lack of exact information and documents which the complainant has not provided to it and in the Claim Form submitted by the complainant, he had nowhere mentioned that claim is for post hospitalization expenses. The complainant has also not submitted the required prescriptions/case summary. The case was presented as a first admission and supporting documents was mere investigation. Due to lack of the said information and documents, the claim of the complainant was treated as OPD case and as per the terms and conditions of the policy, the claim was repudiated. The complainant has lodged his first claim on 6th December, 2009 for treatment of his wife for Rs. 25,399/- and the claim was duly settled to the entire satisfaction of the complainant. The present claim would have been cleared as pre-post hospitalization claim long time back if this fact had been disclosed earlier. The opposite party No. 3 had reviewed the claim of the complainant and his ready to pay admissible claim amount of Rs. 3418/- subject to submission of revised claim form and prescriptions. During the pendency of the complaint on 26-11-2010, the opposite party tendered a cheque No. 335326 dated 23-11-2010 amounting to Rs. 3418/- drawn on Axis Bank towards full and final settlement of the claim of the complainant. The complainant received the said cheque and recorded his statement separately as under :- “Stated that I receive the above said cheque under protest as I also claim the costs and compensation.” The clause No. 2.3 of the Insurance Policy Ex. C-5 of the opposite parties reads as under :- “2.3 Expenses on Hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments i.e. Dialysis, Chemotherapy Radio-therapy, Eye Surgery, Dental Surgery, Lithotrips (Kidney stone removal) Tonsillectomy, D & /c taken in the Hospitalization/Nursing Home and the insured is discharged on the same day, the treatment will be considered to be taken under Hospitalization Benefit.” The complainant prayed that despite his repeated requests to the opposite party, they did not pay the claim in violation of their own aforesaid clause and his claim has been paid by the opposite parties after filing the complaint before this Forum. The opposite parties have unnecessarily harassed him and not paid the claim which was submitted by him with the opposite parties on 28-01-2010. The claim has been received during pendency on 23-11-2010, approximately after 10 months of filing his claim. As per the rules of the Insurance policy, the claim is to be settled/repudiated within 90 days/3 months. In the present case, the opposite parties took the time of 10 months to process and pay the claim of the complainant. Hence, there is delay on the part of the opposite parties. The complainant being a retired person has suffered a lot in the hands of the opposite parties. If the claim would have been paid in time, he would not have knocked the door of this Forum. Hence, this complaint is accepted with Rs. 3,000/- as compensation and cost. Since the claim amount has already been paid to the complainant, the opposite parties are directed to pay Rs. 3,000/- jointly and severally to the complainant being compensation and cost to the complainant, within 30 days from the date of receipt of copy of this order.
A copy of this order be sent to the parties concerned free of cost and the file be consigned to record.
Pronounced 31-01-2011 (Vikramjit Kaur Soni) President
(Dr. Phulinder Preet) Member
(Amarjeet Paul) Member
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