DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA(PUNJAB)<br /> CC. No.18 of 21-1-2009.<br /> Decided on: 3-9-2009.<br /> <br /> Raj Kumar son of Sh. Lal Chand, aged about 59 years, resident of House No. 1614, Street No. 3, Nai Basti, Bathinda.<br /> ........Complainant.<br /> Versus<br /> <br /> 1. The New India Assurance Company Limited, through its Branch Manager, Red Cross Complex, The Mall, Bathinda.<br /> 2. Alankit Health Care Limited, Alankit House-E/21, Jhande walan Extension, New Delhi-110055, through its Chairman/Managing Director/Manager.<br /> .....Opposite Parties.<br /> Complaint under section 12 of <br /> the Consumer Protection Act,1986.<br /> <br /> Present:- <br /> For the complainant : Sh. N.P. Singh, counsel for the complainant.<br /> For the opposite parties : Sh. Vinod Garg counsel for the opposite party No.1.<br /> Opposite party No.2 is already exparte.<br /> <br /> QUORUM<br /> Sh. George, President.<br /> Sh. Amrajeet Paul, Member.<br /> ORDER<br /> <br /> GEORGE,PRESIDENT:-<br /> <br /> 1. The present complaint has been filed by the complainant under Section 12 of the Consumer Protection Act,1986 (here-in-after referred to as 'Act') with allegations against the opposite parties that he purchased a Hospitalization and Domiciliary Hospitalization Benefit Policy No. 360601/34/07/20/00000013 w.e.f. dt. 29.04.2007 to 28.04.2008 for his family from opposite party No.1. on 30.12.2007 he suddenly suffered acute Dyspnoea attack (bronchial asthma) with pneumothorax on right side and lungs problem. He was admitted in S.Mittal Nursing Home, Opposite Canara Bank, The Mall, Bathinda on 30.12.2007under the treatment of Dr. R.K.Mittal, M.D., Chest & Asthma Specialist and he informed the opposite party No.1 on the same day for insurance claim. He was treated as patient by Dr. R.K.Mittal and he remained in the hospital till dt. 7-1-2008 and during the period, he spent a sum of Rs. 13148/- for which he submitted his claim with the opposite party No.1 along with original prescription slips, medical bills and payment receipts when he was discharged from the hospital. However, in spite of his repeated requests for his claim it was not hounoured and opposite party No.1 verbally told that his medical claim has been rejected. The act of the opposite party in rejecting the medical claim is illegal, unjustified, arbitrary, malafide and against the principle of natural justice which amounts to deficiency in services and unfair trade practice. Therefore, he has filed the present complaint seeking direction to the opposite parties for payment of Rs.13148/- alongwith interest of 18% as medical claim and payment of compensation to the tune of Rs.25,000/- due to mental agony, harassment and inconvenience and litigation expenses Rs. 5,000/-. <br /> <br /> 2. Opposite party No.1 contested the allegations raising objections that the complaint is false, frivolous and liable to be dismissed; it involves intricate question of law and fact which can only be decided by the Civil Court; Complainant concealed the material facts; the complaint is bad for non joinder of necessary parties; the complainant did not supply the documents required by TPA i.e. certificate from treating physician supported by prescriptions and investigation which were asked by TPA vide letters dt. 28.2.2008, 13.3.2008 and 29.3.2008 and only after that, the claim was closed as claim vide letter dt. 25.4.2008 by TPA. It has been averred that the complainant failed to supply the required documents to TPA and due to non receipt of the documents, the claim file was sent to the complainant vide letter dt. 25.4.2008. However, if the Hon'ble Forum come to the conclusion that the complainant is entitled to any relief, only in that case, it is submitted that the complainant may be directed to submit the certificate/documents required by TPA.<br /> <br /> 3. During the proceedings of the complainant, an application was moved by complainant for impleading TPA i.e. M/S Alankit Health Care, New Delhi as opposite party No.2. Application was allowed. Opposite party No. 2 did not appear to contest the complaint and therefore on 22.6.2009, opposite party No.2 proceeded against as exparte.<br /> <br /> 4. To prove the respective assertions, both the parties have led their evidence. The complainant brought on record in evidence, his own affidavits dt. 21.1.2009 and 20.4.2009 Ex.C-1 and Ex.C-8 and he also brought on record, photo copy of insurance policy Ex.C-2; photo copy of discharge certificate dt. 7.1.2008 Ex.C-3; photo copies of bills Ex.C-4 and C-6; photo copy of receipt dt. 8.1.2008 Ex.C-7; photo copies of letters dt. 19.5.2008 and 9.7.2008 written by opposite party No.1 to opposite party No.2 were sent through registered post Ex.C-9 and C- 10, respectively.<br /> <br /> 5. To controvert the evidence of the complainant, opposite party No.1 brought on the record in evidence, affidavit of Sh. P.K.Jain, Senior Divisional Manager, dt. 28.4.2009 Ex.R-1; copy of policy Ex.R-2; photo copy of claim form Ex.R-3; letters of complainant dt.1.1.2008 Ex.R-4 and copies of letters dt. 28.2.2008, 13.3.2008, 29.3.2008 and 5.4.2008 Ex.R-5, to Ex.R-8, respectively.<br /> <br /> 6. We have heard the learned counsel appearing on behalf of both the parties and have perused the entire record of the case carefully. <br /> <br /> 7. Complainant and his family purchased a Hospitalization and Domiciliary Hospitalization Benefit Policy from opposite party No.1for a period 29.04.2007 to 28.04.2008. The complainant, after he was discharged from the hospital of Dr. S.Mittal on dt. 7.1.2008 and he submitted his medical claim to opposite party No.1 as per claim form Ex.R-3 along with all the relevant documents for settlement of his claim. These documents were sent to opposite party No.1 and opposite party No.2. Opposite party No. 2 vide letters Ex.R-5, Ex.R-6 and Ex.R-7 are addressed to the complainant and copies of these letters are also enclosed to opposite party No.1; further demanded from the complainant, the certificate from the treating physician clearly mentioning the duration of Bronchial Asthma supported by prescription and investigation. Surpassingly, all these letters were never reached to the complainant nor opposite party No. 1.These letters Ex.R-5 to Ex.R-7do not show whether they were sent by registered or ordinary post. Opposite party No.2 has rejected the claim of the complainant vide letter dt.25.4.2008 Ex.R-8 on the ground that information sought vide letters dt. 28.2.2008, 13.3.2008 and 29.3.2008 has not been received by them so they are left with no option but to close the case as the claim could have not been kept open for an indefinite period; hence his claim has been filed as “NO CLAIM”. Even this letter was never reached the complainant. The copy of this letter was handed to the complainant when he asked the opposite parties for clearance of his claim. It appears from this letter that it does not show as to whether it was sent by registered or ordinary post. Letter Ex.C-9 reveals that even opposite party No. 2 did not receive letter dt.25.4.2008 allegedly issued by opposite party No.1 whereby the claim of the complainant was rejected. Opposite party No.1 requested opposite party No.2 vide letter dt. 15.5.2008 and requested opposite party No.2, to reopen the claim file letter dt. 15.5.2009 and sent to the opposite party No.1 and sent original the complainant. Despite letter dt.19.5.2008 Ex.C-9 written by opposite party No.1 to opposite party No.2. Opposite party No.2 did not take it seriously to settle his claim. Another dt. 9.7.08 Ex.C-10 letter was sent by opposite party No.1 to opposite party No.2 by registered post, wherein opposite party No.1 has written to opposite party No.2 i.e. “This has ref. To our letter dated 19.5.2008 (Copy enclosed) and personal telephonic discussions the undersigned had with you twice. About one and half months have passed but we have not heard anything in this regard from your side which is very regretful. Insured is visiting our office again and again for settling his claim, but we have no answer of his questions as you are not giving any reply which is very bad stage of affairs. Please take it seriously and settle the claim immediately and inform us per fax. Please treat the matter as MOST URGENT & doing the at the earliest”<br /> <br /> 8. The contents of letters Ex.C-9 and Ex.C-10 fully support the stand taken by complainant that he has never received letters Ex.R-5 to Ex.R-8 from opposite party No.2 and that opposite party No.2 has not seriously taken to reply the letters written by opposite party No.1 i.e. Ex.C-9 and Ex.C-10.<br /> <br /> 9. That from the facts and the circumstances discussed here-in-above, it is strongly emerged that opposite party No.2 despite receiving all the documents required for settlement of the claim of the complainant, shown to have been issued letters Ex.R-5 to Ex.R-7 to complainant as well as opposite party No.1 but these letters never reached either the complainant or opposite party No.1. Even the letter of repudiation of claim dt.25.4.2008 Ex.R-8 never reached the complainant nor the office of opposite party No.1. This is a strong circumstance to give the irresistible conclusion that opposite party No.2 never dispatched letter Ex.R-5 to Ex.R-7 either to the complainant or to opposite party No.1 and factiously taking the shelter of these three letters Ex.R-5 to R-7. The claim of the complainant was repudiated vide letter dt. 25.4.2008 Ex.R-8 and even this letter was never dispatched nor reached either to the complainant or opposite party No.1. The conduct of opposite party No.2 appears to be totally inadequate and this amounts to be serious deficiency in service which is not result of daily routine but over passing the claim of a consumer by adopting unfair trade practice to defeat the legitimate claim of the complainant. <br /> <br /> 10. We, therefore, constrained to issue the following directions:-<br /> i. Opposite Party No.1&2 shall immediately pay the claim of the complainant to the tune of Rs. 13,148/- alongwith interest @ 9 % P.A., w.e.f. 01.04.2008 (the date calculated on expiry of three months period from the date of intimation i.e. 01.01.2008, a period required for processing the case in an effective manner in normal courses till final payment).<br /> ii. Opposite Party No. 2 shall pay compensation to the tune of Rs.25,000/- to the complainant on account of mental tension, agony, harassment and inconvenience, the complainant has under gone. <br /> iii. Opposite Party No.1&2 shall liable to pay cost of the litigation to the tune of Rs.5,000/- in equal proportions. <br /> <br /> 11. The compliance of this order be made within 45 days from the date of receipt of copy of this order.<br /> <br /> 12. The copy of this order be sent to the parties concerned free of cost and file be indexed and consigned.<br /> <br /> Pronounced (GEORGE)<br /> 3-9-2009 PRESIDENT<br /> <br /> <br /> (AMARJEET PAUL)<br /> MEMBER<br /> <br />