Haryana

Yamunanagar

CC/211/2012

Pankaj Kumar Mittal S/o Fateh Chand - Complainant(s)

Versus

The Oriental Assurance Company Ltd. - Opp.Party(s)

S.S.Panjeta

07 Dec 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                          Complaint No… 211  of 2012.

                                                                                          Date of institution: 29.2.2012.

                                                                                          Date of decision: 7.12.2015

Pankaj Kumar Mittal son of Fateh Chand, aged 46 years, resident of 1242, Thatheran Street, Jagadhri.  

                                                                                                           …Complainant.

                                    Versus

 

1. The Oriental Assurance Company Limited, Opposite Hindu Girls College, Ist Floor, Court Road, Jagadhri, through its Branch Manager.
2. M/s Vipul Medcorp TPA Private Limited, SCO No. 98, First Floor, Industrial Area, Phase-2, Chandigarh-160002.

                                                                                                               …Respondents 

 

BEFORE:         SH. ASHOK KUMAR GARG, PRESIDENT.

                        SH. S.C.SHARMA, MEMBER.

 

Present:  Sh. S.S.Panjeta, Advocate, counsel for complainant.  

                Sh. Amit Bansal, Advocate, counsel for OPs.               

 

ORDER

1.                    Complainant Pankaj Kumar Mittal filed the present complaint under section 12 of the Consumer Protection Act praying therein that respondents (hereinafter referred as OPs) be directed to pay a sum of Rs. 28892/- in respect of individual mediclaim policy alongwith interest from the date of lodging of claim till realization and further to pay Rs. 50,000/- as compensation for mental agony, harassment and economic loss alongwith Rs. 2200/- as cost of proceedings.

2.                     Brief facts of the present case, as alleged by the complainant,  are that  he obtained an individual mediclaim policy  bearing No. 261701/48/2012/1127 which was valid w.e.f. 1.1.2011 to 31.12.2011 for the sum insured of Rs. 1,20,000/- covering the health risk of his wife Neetu Mittal, son Master Yash Mittal and Ms. Priyanka, daughter. The wife of complainant became ill and she got admitted in Aggarwal Hospital, Yamuna Nagar where she was treated for stone problem and operation was conducted. The wife of complainant got admitted from 6.2.2011 to 8.2.2011 and he spent a sum of Rs. 28892/- on her treatment which includes hospitalization, medicines etc. An intimation was also given to the OP regarding the admission of his wife in the Hospital. The complainant submitted all the bills and other record to the OP No.1 company for the grant of claim amount to the tune of Rs. 28992/- and completed all the formalities but the claim of the complainant was not settled. The complainant several times visited the office of OPs and requested for settlement of his claim vide letter dated 4.4.2011, 4.6.2011, 30.9.2011 and 16.11.2011 but inspite of these letters the OPs did not give any reply nor the claim of the complainant was settled. The complainant several times contacted the OPs and requested for payment of Rs. 28892/- on account of claim amount covered under the policy but the complainant put off the matter on one pretext or the other. Hence, this complaint.

3.                     Upon notice, OPs appeared and filed its written statement by taking some preliminary objections such as  complaint is not maintainable, complainant has suppressed the material facts and on merit it has been stated that after receiving the intimation from the complainant it was properly and immediately entertained by the opposite party, moreover the complainant was requested to send the presenting complaints with duration prior to surgery, original investigation reports including ultrasonography report  vide letter dated 14.3.2011 and 30.3.2011 but the complainant failed to supply the relevant and necessary document which were very much necessary to settle the claim of the complainant, having waited sufficient long time, opposite party was no other option but to close the claim file as the complainant is not interested in pursuing his claim and accordingly on 22.6.2011 the claim file of the complainant was closed with the remarks “ query reply not received” the intimation regarding the fate of the claim was duly given to the complainant vide letter dated 22.6.2011. It has also made clear in the letter dated 22.6.2011 that the complainant can represent his case within 15 days of rejection of his claim by the Opposite party, but the complainant failed to give any representation regarding his claim and also failed to supply the relevant and necessary documents to the OPs, hence, there is no deficiency in service on the part of OPs and the complaint is without merit and is liable to be dismissed.

4.                     To prove the case, counsel for complainant tendered into evidence affidavit of complainant as Annexure CW/A and documents such as Photo copy of insurance policy as Annexure C-1, Photo copy of insurance cover note as Annexure C-2, Photo copy of discharge card of Aggarwal Hospital as Annexure C-3, Photo copies of prescription slip alongwith medicine bills as Annexure C-4  to C-7, Photo copy of Ultrasound Abdomen Report as Annexure C-8, Photo copy of ultrasound report as Annexure C-9, Photocopies of prescription slip alongwith hospital bills and medicine bills as Annexure C-10 to C-17, photo copy of claim form as Annexure C-18, Carbon copy of detail wise list of claim as Annexure C-19, Photo copy of letter dated 5.2.2011 as Annexure C-20, Photo copy of letter issued by Sr. Branch Manager regarding status of claim case as Annexure C-21, Photo copy of letter dated 30.3.2011, 4.4.2011, 4.6.2011, 30.9.2011, 16.11.2011, 6.1.2012  and 20.1.2012 regarding correspondence of mediclaim as Annexure C-22 to C-28 and closed the evidence on behalf of complainant. 

5.                     On the other hand, counsel for the OPs tendered into evidence letter dated 14.3.2011 as Annexure R.1 and closed the evidence on behalf of OPs. 

6.                     We have heard the counsels of both the parties and have gone through the pleadings as well as documents placed on the file carefully and minutely. The counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas the counsel for OPs reiterated the averments made in the reply and prayed for dismissal of complaint.

7.                     We have perused the letter issued by Vipul Medcorp TPA Private Ltd. on 14.3.2011 (Annexure R-1) in which it has been mentioned that “ kindly sent presenting complaint with duration prior to surgery original investigation reports including ultrasonography report and all previous policy copies and second repudiation letter dated 22.6.2011 Annexure R-1/A in which it has been mentioned that we regret to inform you that your claim fails to meet the following criteria and is considered non admissible:-

                        “quarry reply not received”

Except these two letters OPs insurance company has not filed any other document even did not bother to file insurance policy with its terms and conditions or any affidavit on behalf of the OPs Insurance Company to support the version mentioned in their written statement.

8.                     On the other hand, counsel for the complainant hotly argued that he had already submitted all the documents including discharge card of Aggarwal Hospital, Yamuna Nagar, Ultrasound abdomen report and all the medical bills alongwith claim form photo copy of which is also attached with this case file as Annexure C-3 to C-18. Learned counsel for the complainant draw our attention towards the Annexure C-1 Insurance policy for the period from 1.1.2011 to 31.12.2011 in which number of previous insurance policy bearing No. 261701/48/2010/1485 is mentioned and stated that on the previous year also he was having insurance policy covering the health insurance of his family from the same insurance company i.e. OP Insurance Company. Learned counsel for the complainant further draw our attention towards various letters written to the OPs Insurance Company on dated 4.4.2011 Annexure C-23, dated 4.6.2011 Annexure C-24, dated 30.9.20121 Annexure C-25, dated 16.11.2011 Annexure C-26 and dated 6.1.2012 Annexure C-27 in which he has repeated the request so many times to pay the claim amount and lastly prayed that despite of all these OPs Insurance Company failed to make the payment of his genuine claim. So, there is a deficiency in service on the part of OPs.

9.                     After going through the above noted arguments advanced by both the parties, we are of the considered view that there is a deficiency in service on the part of OPs as the Ops failed to point out any specific document which was asked to submit from the complainant whereas complainant had already submitted all the documents with the OPs which is evident from photo copies filed with this complaint. Further the quarry raised by the OPs insurance company in respect of all previous insurance policy seems to be not genuine as the OPs insurance company itself mentioned the number of previous insurance policy in the present insurance policy and have all records with it from the date when the complainant obtained first insurance policy from the OPs insurance company. Moreover, as the insurance company failed to file any affidavit in support of its plea taken in the written statement as well as failed to file any insurance policy with terms and conditions. Hence, we are of the considered view that OPs insurance company his illegally repudiated the genuine claim of the complainant, which is a gross negligence and deficiency in service on the part of OPs Insurance Company. Hence the complainant is entitled for relief.

10.                   Resultantly, we partly allow the complaint of complainant and direct the OPs Insurance Company to pay a sum of Rs. 28892/- to the complainant alongwith interest at the rate of 7% per annum from the date of filing of complaint till its realization and further to pay a sum of Rs. 2000/- as litigation expenses. Order be complied within 30 days after preparation of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced: 7.12.2015.

                                                                                                (ASHOK KUMAR GARG)

                                                                                                PRESIDENT

 

 

 

                                                                                                (S.C.SHARMA)

                                                                                                MEMBER