DISTRICT CONSUMER DISPUTES REDRESSAL FORUM HOSHIARPUR

(3RD FLOOR, DISTRICT ADMINISTRATIVE COMPLEX, HOSHIARPUR)

 

                            C.C. No.  221/01.10.2014

                                            Decided on :  20.01.2015

 

Bimla Devi aged 59 years W/o Sh. Rajinder Kumar R/O Ward No.1, H.No. 148, Mahajan Mohalla Dasuya, Tehsil Dasuya, District Hoshiarpur.

 

                                    Complainant                        vs.

 

1.The New India Assurance Company Limited Branch Office G.T. Road Dasuya through its Branch Manager.

2.The Branch Head, New India Assurance Bldg. 87, MG Road, (Head office) Fort Mumbai 400001.

 

                                    Opposite parties

 

 

 Complaint u/s 12 of the Consumer Protection Act, 1986.

 

Quorum:    Sh. Ashok Kumar,President.

              Mrs.Vandna Chowdhary, Member.

              Mrs. Sushma Handoo,Member. 

 

Present:      Sh.B.B.Handa , counsel for the complainant.

             Sh.Brij Thakur , counsel for the OPs. 

 

 

ORDER 

PER ASHOK KUMAR, PRESIDENT

1.          The complainant has filed the present complaint  under Section 12 of the Consumer Protection Act,1986 against The New India Assurance Company Limited through its Branch Manager and another (hereinafter referred to as OP, for short) praying for a direction to the OP to pay the amount of Rs. 35,218/- alongwith  Rs. 10,000/- as compensation and litigation expenses.

2.         Briefly stated, the case of the complainant is that he was insured with the OP. The complainant was holder of policy with the OP for the past many years. It is averred that the complainant developed problem in her mouth and she was treated for the problem in Khosla Hospital, Shaheed Udham Singh Nagar, Opposite Television Studio, Jalandhar by Dr. Ramesh Chand Khosla who had performed the necessary surgery . She  remained admitted there  from  15-08-2013 till 17-08-2013. She spent Rs. 31,500/- as indoor patient including the surgery and other hospital charges as shown in bill/receipt No. 28 dated 17-08-2013. She also spent Rs. 3418/- as cost of medicines  purchased vide different bills. Besides above, Rs. 300/- were spent on HPC Tests vide Bill No. 18443 dated 15-08-2013. In this way, the total amount of Rs. 35,218/- was spent by the complainant . Thereafter, the complainant submitted her claim to the OP alongwith original documents on 10-09-2013 but the OP instead of settling the claim and making the payment issued letter dated                  06-11-2013 asking some irrelevant documents just to harass her  as she had  already submitted all the documents with the  claim to the OP.  However, the complainant contacted the doctor and requested to provide the documents once again which were demanded by the OP vide their letter dated 06-11-2013. Thus, the complainant supplied all the documents again as required vide their covering letter on 03.12.2013 alongwith documents i.e. (i) Email Letter dated November 12/2013 (ii) Certificate  by doctor against receipt No. 28 dated 17-08-2013, (iii) Certificate by doctor against discharge slip. But in spite of that  the OP who was intentionally not interested in settling the matter kept on sitting over the same and when complainant's son Harsh Sharma enquired from the OP, they advised him to visit their officer and got received from him a letter on 11-04-2014 ( wrongly written as 11.4.2013) which was shown to be purportedly issued on 30-12-2013 but never sent to the complainant. Thereafter, OP sent a letter on 15-04-2014 declining the claim of the complainant as “No Claim" which is illegal, unjust and against the facts on record. It is further averred that the complainant had submitted on            03-12-2013 the certificate of the doctor that receipt No. 28 of 17-08-2013 was issued by him which was already submitted at the time of filing the claim with the OP.  The act of not accepting the genuine claim amounts to  deficiency of service on the part of the OP.  So, the complainant is entitled to the relief claimed as stated at the outset of this order.

3.         On notice,   OPs filed  joint contested written statement  taking routine  preliminary objections.  On merits, it is denied that complainant remained admitted as Indoor patient in Khosla Hospital, Jalandhar from 15-08-2013 till 17-08-2013 as alleged. It is replied that whole story is false and fraud is being played with the OP to get the claim. It is further denied that complainant spent an amount of Rs. 35,218/- on her  treatment.  It is replied that Raksha TPA Pvt. Ltd., SCO 181 Sector 7-C Chandigarh issued letter dated 06-11-2013 to the complainant but it is denied that complainant has submitted all the documents required for the settlement of the claim  as per the said letter . It is further replied that prior to the letter dated 06-11-2013, letter dated 17-10-2013 was written to the complainant vide which he was asked to supply original pre-numbered preprinted duly signed and stamped receipt against final bill of the hospital as only bill for Rs. 31,500/- was supplied and to provide original detailed discharge summary duly signed and stamped by hospital. When the above said documents were not supplied then letter dated 06-11-2013 was written to the complainant. When no reply was received to the said letter then final reminder vide letter dated 16-11-2013 was issued to the complainant by the TPA. It is denied that the letter dated                     30-12-2013 was not sent to the complainant as alleged . It is further replied that when the required documents were not supplied by the complainant, the  claim was repudiated vide letter dated 30-12-2013. As the complainant has not supplied the documents as per the above said letters required for the settlement of the claim hence, there is no deficiency in service on the part of the OP. Therefore, the complaint is liable to be dismissed with costs.

4.         Both the parties wanted to lead evidence  to prove their respective pleadings and proper opportunity was given to them. The complainant tendered in evidence affidavit Ex. C-1, prescription dt.16.7.2013 Mark C2, admission chart dated 17.8.2013 Mark C3,  medical prescription dated 22.8.2013 Mark C4, bills Mark C5 to Mark C9, retail invoice Mark C10, bill Mark C11, bill dated 17.8.2013  Mark C12, laboratory profile Mark C13, receipt dated 15.8.2013 Mark C14,  report dated 21.8.2013 Mark C15, medicine bill Mark C16, reminder Mark C17, claim query Mark C18, email dated 12.11.2013 Mark C19,  certificate dated 25.12.2013 Mark C20 & Mark C21, letter dated 15.4.2013 Mark C22, repudiation letter dated 30.12.2013 Mark C23  and closed the evidence.

5.         In order to rebut the evidence of the complainant , the OP tendered in evidence affidavit of Ram Kishan Ex.OP1, insurance policy Mark OP2, letter dated 17.10.2013 Mark OP3, letter dated 6.11.2013 Mark OP4, letter dated 16.11.2013 Mark OP5, letter dated 30.12.2013 Mark OP6  and closed the evidence. 

6.         We have heard  learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

7.         Learned counsel for the complainant has vehemently argued that the genuine claim of the complainant has been repudiated though the complainant had submitted all the required documents with the claim and even thereafter in compliance of email letter dated 12.11.2013 of Raksha TPA. So, the complainant  is entitled to the relief claimed. 

8.         Learned counsel for the OP has however repelled the aforesaid contentions of the learned counsel for the complainant on the ground  that as the complainant has failed to supply the documents as demanded vide letters dated 17.10.2013, 6.11.2013 and 16.11.2013 so, her  claim was rightly repudiated  vide letter dated 30.12.2013.  It is also contended that on the prescription slips and discharge summary, only patient name Bimla Devi is mentioned so without parentage and address, it is not proved that these documents belong to Bimla Devi complainant.

9.         We have anxiously considered  the rival contentions in the light of evidence on record. 

10.         Admittedly, complainant  was insured with the OP as is also evident from Mediclaim policy Mark OP-2. It is also admitted that she filed the claim with the OP.  Controversy veers around whether or not  she actually undergone surgery and received treatment from Khosla Hospital ? Suspicion was raised by the OP qua discharge summary             Mark C-3 and   receipt against final bill of the hospital Mark C-12  on the ground that proper original detailed discharge summary and pre-numbered and pre printed receipt against final bill of hospital was not allegedly supplied. In reply vide letter Mark C-18 to email letter dated 12.11.2013 Mark C-19 of Raksha TPA  in this connection, complainant had sent certificates Mark C-21 by concerned doctor to prove receipt no.28 dated 17.8.2013 and discharge summary Mark C-20. A bare perusal of the aforesaid certificates would show that the concerned doctor certified that those documents issued by him to the complainant are original ones. In the repudiation letter Mark OP-6, no fault was found by the OP in respect of discharge summary . However, original receipt against final payment was not accepted and reply of the complainant Mark C-18 in this respect  was said to be not a proper reply, completely ignoring certificate of the doctor concerned qua receipt Mark C-21. No just and proper reason even after certificate of the doctor that the receipt issued by him to the complainant already was original is forthcoming from the side of the OP .    Therefore, the stand of the OP to repudiate the claim of the complainant on account of this cannot be countenanced by any stretch of imagination.  The contention of learned counsel for the OP that in the absence of parentage and address, the complainant cannot be connected with those documents is baseless for want of any pleadings in this respect and rather the same is found to be another excuse for not to pay the genuine claim of the complainant founded on discharge summary Mark C-3, receipt against final bill Mark C-12 and other bills Mark C-5 to C-9, Mark C-11 and  C-14. The conduct of the OP as proved above on the basis of evidence on file  clearly proves deficiency of service on the part of OPs . Therefore, in our   considered opinion, complainant is found not only entitled to the claim amount of Rs.35,218/- but also appropriate amount of compensation for harassment and mental agony and  costs for avoidable litigation to which the complainant has been unnecessarily put by the OPs.     

11.         In view of our above observations and findings, the  complaint filed by complainant is partly accepted with a direction to the OPs to pay to the complainant the claim amount of Rs.35,218/- with interest @ 9% per annum from 30.12.2013, the date of repudiation of her claim  till realization and further to pay Rs.7,000/- as litigation expenses  within a period of 30 days from the receipt of copy of this order.  Copy of the order be sent to the parties free of cost. File be consigned to the record room. 

Announced. 

    20.01.2015

 

  (Mrs.Vandna Chowdhary)    (Mrs. Sushma Handoo)     (Ashok Kumar )

                         Member                                Member               President 

SS