Punjab

Faridkot

CC/17/199

Amit Bansal - Complainant(s)

Versus

The Oriental Insurance Co. Ltd. - Opp.Party(s)

Peush Jain

08 Jan 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     199

Date of Institution: 19.06.2017

Date of Decision :   8.01.2019

 

1. Amit Bansal son of Ashok Bansal son of Manohar Lal.
2. Charu Bansal wife of Amit Bansal son of Ashok Bansal,

Both residents of # 47, Adarsh Nagar, Old Cantt Road, Faridkot.                                           

 

                                                                           .........Complainant

Versus

1. The Oriental Insurance Company A-25/27 Asif Ali Road, New Delhi 110002.
2. M/s Medi Assist India 4/1 IBC Knowledge Park, Tower “D”, 4^th Floor, Bannerghatta Road, Bangalore 560029.
3. Punjab National Bank, Main Bazar Branch, Old Jail Road, Faridkot through its Branch Manager (PB).
4. Delhi Heart Institute & Multispecialty Hospital, Goniana Road, Bathinda.
5. The Oriental Insurance Company Kotkapura through its Branch Manager.

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt. Param Pal Kaur, Member.

 

Present:  Sh Peush Jain, Ld Counsel for Complainant,

               Sh Vinod Monga, Ld Counsel for OPs-1, 2 & 5,

     Sh Yash Pal Bansal, Ld Counsel for OP-3,

     Sh Jasvir Singh, Representative on behalf of OP-4.

ORDER

(Ajit Aggarwal, President)

                                             Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make payment of insurance claim  with interest and for further directing OPs to pay Rs.1,00,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.33,000/-.

2                                   Briefly stated, the case of the complainant is that complainant no.1 purchased a mediclaim insurance policy bearing no.233200/48/2016/3208 from OP-1 valid from 29.01.2016 to 28.01.2017 for a sum of Rs. 5,00,000/- and complainant his wife complainant no. 2 and their daughter Viritka was insured under the said policy cover. It is submitted that during the subsistence of said insurance policy, on 23.01.2017, complainant and his wife met with an accident while travelling in a car bearing no. PB-04T-8100 being driven by brother of complainant and they were admitted in the hospital of OP-4 for treatment of accidental injuries. As per policy, they were entitled for cashless treatment and for this purpose, they submitted all the policy related documents to OP-4, but did not discharge complainants without clearing the bill for expenses on treatment of complainant and his wife on the ground that OP-2 has not made payment of treatment rendered by OP-4 and thus, finding no other alternative, complainant no.1 paid Rs.35,073/-for his own treatment and Rs.49,618/-on account of treatment of complainant no.2 and in this way, complainant paid Rs.84,691/-to OP-4 as expenses of treatment. Thereafter, complainant lodged the claim with Bank authorities, but they refused to accept the claim papers. Vide letter dt 14.03.2017, complainant again submitted his claim to OP-1 to 3 and received a letter dt 27.03.2017from them stating that claim of complainants is being processed by them, but till today, they have not cleared the claim and did not pay even a single penny on account of reimbursement of medical expenses incurred by complainant on treatment of his own and on treatment of his wife /complainant no.2 who was also covered under the insurance policy for cashless mediclaim. All this act and conduct of OPs amounts to deficiency in service and has caused harassment and mental tension to complainant. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                    The counsel for complainant was heard with regard to admission of the complaint and vide order dated 23.06.2017, complaint was admitted and notice was ordered to be issued to the OPs.

4                                     On receipt of the notice, the OPs. No. 1, 2 and 5 filed written statement wherein asserted that there is no deficiency in service on the part of OPs as complainants have never lodged any claim with them and therefore, complaint filed by complainant is not maintainable in the present form. However, on merits, answering Ops admitted before the Forum that complainant purchased the insurance policy in question from them and he was insured under the said policy, but denied all the other allegations of complainant being wrong and incorrect on the ground that complainants neither approached them nor filed their claim regarding expenses incurred by them on their treatment at OP-4 with them. It is also admitted by OPs that they received letter dated 14.03.2017 from complainant and asserted that they duly replied the letter of complainant vide their letter dated 27.03.2017. however, all the other allegations are denied being wrong and incorrect and prayed for dismissal of complaint with costs.

5                                Op-3 filed reply taking preliminary objections that answering OP has been wrongly impleaded as party and their name be deleted from the array of OPs. However on merits, OP-3 has denied all the allegations of complainant being wrong and incorrect and asserted that policy in question is issued by OP-1 and therefore, privity of contract is also between complainant and OP-1 and claim of complainant is to be settled by only OP-1 and 2. It is further averred that complainant has no cause of action to file the present complaint and this Forum has no jurisdiction to hear and try the present complaint. As per OP-3 nothing is to be done by them and  there is no privity of contract between complainant and answering OPs and claim of complainant is to be settled by OP-1 and 2 and further submitted that there is no deficiency in service on the part of OP-3.

6                                    OP-4 also filed reply wherein it is admitted the fact that both complainant and wife were admitted in the hospital of OP-4 for  treatment of injuries sustained by them during the accident dt 23.01.2017 and it is also admitted that identity cards of complainant and his wife were submitted to them by complainant. It is asserted that preauthorization request was mailed to TPA for sanction of treatment expenses on 23.01.2017, but TPA did not sanction the preauthorization amount and denied the claim on 24.01.2017.  It is further averred that as TPA denied to pay hospital charges therefore, complainant was liable to clear the hospital bills at the time of discharge therefrom. It is further averred that as per excellent treatment alongwith relevant services was provided to complainants and there is no deficiency in service on their part. Amount paid by complainants is chargeable from them on account of expenses for treatment of his own and his wife. It is reiterated that there is no deficiency in service on the part of OPs. All the other allegations and allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

7                                              Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-21 and then, closed their evidence.

8                                                          In order to rebut the evidence of the complainant, Counsel for OPs.1, 2 and 5 tendered in evidence affidavit of Ashwani Kumar Ex OP-1, 2 & 5/1 and document Ex OP-1, 2 & 5/2 and then, closed the evidence.  Ld Counsel for OP-3 tendered in evidence affidavit of Hira Lal as Ex OP-3/1 and closed the evidence on behalf of OP-3. Representative of OP-4 tendered in evidence affidavit of Dr. Munish Gupta as Ex OP-4/1, documents Ex OP-4/2 and OP-4/3 and also closed the evidence on behalf of OP-4.

9                                                          We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

10                                   The case of the complainants is that they are insured under the policy in question and during the subsistence of said policy, they met with an accident on 23.01.2017 and for treatment of their accidental injuries, they were admitted in the hospital of OP-4. Though they were entitled for cashless treatment, but OP-4 charged amount of Rs.84,691/-from complainants as expenses of treatment. Complainant no.1 paid Rs.35,073/-for his own treatment and Rs.49,618/-on account of treatment of complainant no.2. Thereafter, complainant lodged claim with OPs and submitted all the relevant documents to them for processing of their claim, Though vide letter dt 27.03.2017, Ops assured to pass the claim, but Ops did not pay any amount on account of mediclaim lodged by complainants. In reply, OP-1, 2 and 5 stressed mainly on the point that there is no deficiency in service on their part as complainants neither approached them nor lodged any claim with them though in written statement it is admitted by them that vide letter dt 14.03.2017, complainants submitted their claim to OP-1 to 3 and also issued letter dt 27.03.2017 to them stating that claim of complainants is being processed by them, but till today, complainants have not lodged their claim with them. OP-3 has specifically denied all the allegations of complainant being wrong and incorrect and asserted that there is no privity of contract between complainant and Op-3 and claim of complainants is to be settled by OP-1 and 2 and they have no role to play in it and prayed for dismissal of complaint against them. OP-4 has also denied all the allegations of complainant being wrong and incorrect and asserted that sanction regarding preauthorization for cashless treatment of complainants was mailed to TPA on 23.01.2017, but they rejected the same on 24.01.2017 and in these circumstances, complainants were liable to make payment of expenses on their treatment. It is reiterated that there is no deficiency in service on their part and prayed for dismissal of case.

11                                                          From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainants with OPs. Ops have themselves admitted that complainant and his wife were insured with them for cashless treatment under the policy in question. It is also admitted that complainant and his wife suffered injuries in accident dt 23.01.2017 and they underwent treatment in the hospital of OP-4 and paid Rs.84,691/-on their  treatment i.eRs.35,073/-for treatment of complainant no.1 and Rs.49,618/- on treatment of complainant no.2. Plea taken by OP-1,2 and 5 is that complainants never informed them regarding the said accident nor lodged any claim with them. As per OP-1, 2 and 5, complainants never approached them regarding processing of their claim. On the other hand, OP-4 stressed mainly on the point that both complainant and his wife were admitted in the hospital of OP-4 for  treatment of injuries sustained by them during the accident dt 23.01.2017 and they submitted their identity cards to OP-4. It is asserted that preauthorization request regarding cashless treatment of complainants was mailed to TPA for sanction of treatment expenses on 23.01.2017, but TPA did not sanction the preauthorization amount and denied the claim on 24.01.2017.  It is further averred that as TPA denied to pay hospital charges therefore, complainant was liable to clear the hospital bills at the time of discharge therefrom. OP-4 argued that excellent treatment alongwith relevant services was provided to complainants and there is no deficiency in service on their part. Amount paid by complainants is chargeable from them on account of expenses for treatment of complainants. OP-3 has also denied all the allegations. It is observed that plea taken by OP-1, 2 and 5 that complainants never gave any intimation regarding accident and did not lodge any claim for reimbursement of treatment expenses incurred by them is not genuine on the ground that OP-1, 2 and 5 have admitted in their reply that they received letter dt 14.03.2017 from complainants and in reply to that they sent a letter dt 27.03.2017 to complainants and through thorough perusal of this letter dt 27.03.2017Ex C-8, it is revealed that this letter bears reference to earlier letter issued by complainant and in this letter they have assured complainant that processing is going on to consider the claim of complainant and therefore, in view of this letter, OPs cannot allege that  they have no information regarding said accident and complainants did not approach them or lodged any claim with them. Ex C-8 is totally contradictory of written reply filed by them wherein they assert that complainants never approached them for processing of their claim. Moreover, OP-4 has also mentioned in their reply that they informed TPA regarding accident of complainants and even to the mails sent by OP-4 regarding preauthorization of their treatment in hospital of OP-4, OP-1, 2 and 5 did not give sanction for cashless treatment. OP-1, 2 and 5 have forwarded no plausible reason to justify that why they have not made payment of claim amount.

12                                                            Ld Counsel for complainant argued that the OPs cannot deny the amount in dispute regarding claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims.

13                                         From the above discussion and case law produced by the complainant, we are of considered opinion that OP-1, 2 and 5 have wrongly and illegally not processed the claim of complainant, which amounts to deficiency in service. Therefore, present complaint is hereby accepted against OP-1, 2 and 5 and stands dismissed against OP-3 and 4 as they have no role in making payment of insurance claim. OP-1, 2 and 5 are directed to pay the claim amount of Rs.84,691/-to complainants, which they incurred in their treatment alongwith interest at the rate of 9 % per anum from 19.06.2017 i.e from the date of filing the present complaint till final realization. They are further directed to pay Rs.5,000/-to complainant as consolidated compensation for harassment and mental agony suffered by them and for litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 8.01.2019

                                     

                                       Member                                   President

                                                (Param Pal Kaur)              (Ajit Aggarwal)