Punjab

Faridkot

CC/17/196

Vir Singh - Complainant(s)

Versus

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

Sandeep Khosla

19 Dec 2018

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     196

Date of Institution: 19.06.2017

Date of Decision :   19.12.2018

 

Vir Singh aged about 71 years, son of Sh Kheta Singh s/o Budha Singh resident of Village Ran Singh Wala, Tehsil Jaitu, District Faridkot.                                           

 

                                                                           .........Complainant

Versus

1. The Oriental Insurance Company, Branch Office, Mal Godam Road, Kotkapura, Tehsil Kotkapura District Faridkot.
2. MD India Health Care Services, Mohali.

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

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum:  Sh. Ajit Aggarwal, President,

                 Ms. Param Pal Kaur, Member.

 

Present:  Sh Sandeep Khosla, Ld Counsel for Complainant,

               Sh Vinod Monga, Ld Counsel for OPs.

 

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 Rs.1,75,380/- on account of insurance claim alongwith interest and for further directing OPs to pay Rs.50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.25,000/-.

2                        Briefly stated, the case of the complainant is that complainant retired as Teacher from Govt Primary School, Behbal Khurad, Faridkot and was covered under Punjab Government Employees and Pensioners Health Insurance Scheme. As per policy, complainant and his wife are entitled for cashless treatment and OPs are liable to pay the cashless insurance claim. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant It is further submitted that wife of complainant suffered a severe heart problem and was advised  PTCA to RCA i.e stenting in the heart. Due to essentiality of treatment, she was admitted as indoor patient in Adesh Institute of Medical Sciences and Research Barnala Road, Bathinda on 14.12.2016 and was discharged therefrom on 24.12.2016. complainant spent about Rs.1,75,380/-on treatment of his wife from his own pocket and after getting discharged therefrom, complainant lodged reimbursement claim with Oriental Insurance on 22.02.2017 and submitted all documents to OPs through registered post on 2.03.2017, but OPs failed to make any reimbursement till today. All this amounts to deficiency in service and action of Ops in not making reimbursement of amount spent by complaint on treatment of his wife has caused great harassment and mental agony 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 3.07.2017, complaint was admitted and notice was ordered to be issued to the OPs.

4                                     On receipt of the notice, the OPs 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. It is averred that complainant has violated the terms and conditions of PGEPHIS Scheme and policy of insurance. Complainant went for cashless treatment but hospital did not upload on freedom software and thus, treatment availed by complainant was on reimbursement basis subject to submission of claim to the TPA within 30 days from the date of discharge from the hospital. As per complainant, his wife was admitted in hospital on 14.12.2016 and was discharged therefrom on 24.12.2016 and complainant submitted the documents for reimbursement on 2.03.2017 i.e much beyond the period of 30 days. Claim of complainant cannot be entertained and accordingly, same was repudiated and therefore, complainant is not entitled for any relief as sought by him. However, on merits, answering Ops admitted before the Forum that complainant was insured under the said policy, but denied all the other allegations of complainant being wrong and incorrect on the ground that complainant did not file his claim within time as complainant submitted his documents through registered post on 2.03.2017 much beyond the period of 30 days of treatment of his wife. Being late, his claim for reimbursement cannot be entertained and is therefore, repudiated and complainant is not entitled for any claim as sought by him. It is reiterated that there is no deficiency in service on the part of OPs and all the other allegations are denied being wrong and incorrect and prayed for dismissal of complaint with costs.

5                                              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-15 and then, closed their evidence.

6                                                          In order to rebut the evidence of the complainant, Counsel for OPs tendered in evidence affidavit of Ashwani Kumar Ex OP-1 and document Ex OP-2 and then, closed the evidence.

7                                               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.

8                                        The case of the complainant is that complainant alongwith his wife was insured under the policy in question and during the subsistence of said policy, wife of complainant suffered severe heart problem and was advised  PTCA to RCA i.e stunting in the heart and due to essentiality of treatment, she was admitted as indoor patient in Adesh Institute of Medical Sciences and Research Barnala Road, Bathinda on 14.12.2016 and was discharged therefrom on 24.12.2016. Complainant spent Rs.1,75,380/- on treatment of his wife from his own pocket and after getting discharged therefrom, he lodged claim for  reimbursement with Oriental Insurance on 22.02.2017 and submitted all documents to OPs through registered post on 2.03.2017, but OPs failed to make any reimbursement and have not paid a single penny. All this amounts to deficiency in service and action of Ops in not making reimbursement of amount spent by complaint on treatment of his wife has caused great harassment and mental agony to complainant. Complainant has prayed for directing the OPs to reimburse the amount spent by him on treatment of his wife. In reply, ops stressed mainly on the point that complainant lodged the claim with Ops very late. He was required to submit the relevant documents within 30 days of treatment of his wife, but he sent documents relating treatment of his wife on 02.03.2017, i.e much beyond the period of 30 days and being late, claim sought by complainant is not payable and it was repudiated accordingly. And in these circumstances, OPs are not liable to make payment of expenses spent by complainant on treatment of his wife. It is reiterated that there is no deficiency in service on their part and prayed for dismissal of case.

9                                         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 complainant 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’s wife suffered from heart trouble and she underwent treatment and was hospitalized on 14.12.2016 and was discharged on 24.12.2016 and complainant spent Rs.1,75,380/-to hospital authorities for treatment of his wife. Plea taken by OPs that complainant delayed in submitting requisite documents to them as he submitted documents for processing the claim for reimbursement much beyond the period of 30 days from the date of discharge from the hospital, seems inappropriate. Moreover, in the light of notification issued by Insurance Regulatory And Development Authority dated 20.09.2011 which reads that it is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning claim, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances. It is also stated that such intimation clause does not work in isolation and is not absolute. Merits of the case must be seen and rejection of claims on purely technical grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise to excessive litigation. It is also advised as per order that the insurer must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time. There is no denial to the fact that complainant informed OPs regarding treatment of his wife to Ops and also submitted requisite documents before them but OPs have forwarded no plausible reason to justify that why they have not made payment of claim amount.

10                                                  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 of delay in intimation. 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. Instructions dated 20.09.2011 issued by Insurance Regulatory and Development Authority mentioned above can also not 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. Action of Ops in not passing the claim of complainant is wrong and it amounts to deficiency in service on their part.

11                                         From the above discussion and case law produced by the complainant, we are of considered opinion that OPs have wrongly and illegally not processed the claim of complainant, which amounts to deficiency in service. Therefore, present complaint is hereby accepted and OPs are directed to settle the claim lodged by complainant. Reimbursement be made by Ops as per PGI rates alongwith interest at the rate of 9 % per anum from 19.06.2017 i.e from the date of institution of present claim till final realization. They are further directed to pay Rs.5,000/-to complainant as compensation for harassment and mental agony suffered by him besides Rs.3000/- as 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 as per law. File be consigned to record room.

Announced in Open Forum

Dated : 19.12.2018

                                      Member                        President

                                                (Param Pal Kaur)           (Ajit Aggarwal)