BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No. 63 of 2019

      Date of Instt. 26.02.2019

      Date of Decision: 05.07.2023

Sh. Lubhaya Ram @ Ram Lubhaya r/o 13, Dr. Ambedkar Nagar, Basti Nau, Jalandhar.

..........Complainant

Versus

1.       The Oriental Insurance Co. Ltd. Original House, A-25/27, Asif         Ali Road New Delhi-110002.                                            

2.       The Oriental Insurance, Branch Office II, SCO 50, Jeevan       Raksha, PUDA Complex, Opposite Tehsil Complex, Jalandhar.

3.       Raksha TPA Pvt. Ltd. 15/5, Mathura Road, Faridabad, Through       its Managing Director/Director/General Manager.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)   

Present:       Sh. Akhil Chopra, Adv. Counsel for the Complainant.

                    Sh. A. K. Arora, Adv. Counsel for OPs No.1 and 2.

                   OP No.3 exparte.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that complainant had taken a health insurance policy bearing no.233108/48/2017/1878 having insured code no.69077982 issued by the office CBO 2 JALANDHAR i.e. opposite party no.2. The said policy was issued on 03- 09-2016 for the period from 09-09-2016 to 08-09-2017. At the time of taking policy, complainant has paid premium of Rs.6990/- to OPs. The persons insured under the said policy was complainant along with his wife namely Smt. Nirmal. The policy was dully issued by OPs to complainant. As per the policy, OPs were duty bound to indemnify the health risk of complainant &his wife. The photocopy of the Cards issued to the complainant & his wife Smt. Nirmal are on record. In the month of February 2017 i.e. within the policy period, wife of complainant Smt. Nirmal had an accident and thereby she suffered fracture on her left elbow (ULNA). She was operated in Ashtha Hospital Jalandhar by Dr. L.S Chaudri and accordingly Raksha TPA (OP No.3) was appraised about the whole incident of accident and her admission & operation in Ashtha Hospital, within time. Accordingly, Raksha TPA generated/assigned claim no:556221617543857. The wife of complainant Smt. Nirmal was admitted in Ashtha Hospital on 28-02- 2017 and after her treatment, she was discharged on 02-03-2017 having admission registration no.861/3/2017. The total expenditure incurred on the medical treatment of Smt. Nirmal was about Rs.44,359/-. Thereafter, complainant after completing all the formalities as asked by the Raksha TPA, had submitted the required/claim documents to OPs. The complainant immediately submitted the Claim Form to the OPs and the same was dully received by the OP No.3 on 16-03-2017. The wife of the complainant was discharged by Aastha Hospital on 02-03-2017. Thereafter complainant had approached OPs many a times for getting his claim, but OPs always avoided complainant on one pretext or the other. Moreover, wherever any document in furtherance of the medical claim of complainant, was demanded by the OPs, including Raksha TPA, the same was very much provided by complainant. Complainant had many a times written OPs through e-mails using the email ID of son of the complainant, but OP never gave any satisfactory reply to the same. Thereafter, the complainant has received a letter dated 11-10-2017 from OP wrongly alleging that the complainant had not complied with the submissions of claim documents and in reply the complainant wrote a detailed letter which was sent to OP No.2 on 17-10-2017 by registered post and requesting OPs to make the payment of claim of complainant but OPs did not even bother to give any reply to the said letter of complainant. Thereafter, the complainant has received a letter dated 24-10-2017 from OP wrongly alleging that the documents send by the complainant are incomplete and in reply the complainant wrote detailed letter dated 01-11-2017. The complainant thereafter wrote letter dated 23-11- 2017 to the OP and annexed along with said letter, the break-up of medical bill/Clarification of Doctor on bill no.862. Thereafter, the complainant wrote various letters in the shape of Reminders to the opposite party requesting opposite parties to make the payment of claim of complainant but no reply or response had been given by OPs. The complainant then send/served registered Legal Notice dated 09-11-2018 through his Advocate Sh. Akhil Chopra to the OPs calling upon them to make payment of Rs.44,259/- along with interest and Rs.20,000/- as compensation within 15 days of the date of receipt of the legal notice, but despite of receipt of legal notice, neither they have paid any amount to the complainant nor they have bothered to give reply of the said legal Notice. The OPs has indulged in malpractices by sale of substandard corrupted/malicious products/services which amounts to negligence in services or sub standard service and opposite parties are also indulged in unfair trade practices and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to value of the bill Rs.44,359/- and Rs.20,000/- as compensation for causing mental tension and harassment to the complainant and Rs.20,000/- as litigation expenses.

2.                Notice of the complaint was given to the OPs, but despite service OP No.3 did not appear and ultimately OP No.3 was proceeded against exparte, whereas OPs No.1 and 2 appeared through its counsel and filed joint written reply and contested the complaint by taking preliminary objections that the present complaint is not maintainable. It is further averred that there is no deficiency of service or unfair trade practice on the part of answering opposite parties and that being so the present complaint is not maintainable. It is further averred that the complainant is estopped by his own act and conduct from filing the present complaint. The complainant had purchased OBC- Oriental Royal Mediclaim Policy No.233108/48/2017/1878 for the period 09.09.2016 to 08.09.2017 for a sum of Rs.5 Lacs from OP No.2. The Complainant lodged a claim of Rs.44359.00 with the OP for his treatment of fracture left ulna and left radial head from Aastha Hospital for the period 28.02.2017 to 02.03.2017. Accordingly claim was registered by the opposite party i.e. M/s Raksha TPA Pvt. Ltd. OP No.3, the claim settling agency of OP, who wrote letter dated 22.03.2017 to the complainant asking for the following information:-

i)       Kindly provide Break up of Rs.260/- charged on account of lab dated 28.02.2016;

ii)      Kindly provide XRAY Films dated 28.02.2016;

iii)     Breakup of main Hospital bill on the Hospital Letter Head:

iv)     Kindly provide purchase invoice for implant used in surgery;

v)      Kindly provide pre and post Procedure X-ray films;

                   There after reminders dated 22.03.2017, 08.04.2017 and final reminder dated 18.04.2017 were written to the complainant by OP No.3. Despite letters and reminders written to the complaint by OP No.3, the complainant has failed to provide the desired information to the OP No.3. It was clearly mentioned in the letter dated 18.04.2017 that in case no reply is received within 15 days after the Final Reminder, claim will be repudiated. Accordingly, OP No.3 vide letter dated 19.02.2018 recommended the repudiation of claim to OP No.2 on the ground of breach of condition of policy of insurance i.e. all the documents which are necessary for settlement of claim is to be submitted within period of 7 days after discharge from the hospital. Acting on the recommendations of the OP No.3, OP No.3 repudiated the claim of the complainant. On merits, the factum with regard to taking health insurance policy by the complainant from the OPs which was effective from 09.09.2016 to 08.09.2017 for a sum of Rs.5,00,000/- is admitted and it is also admitted that the complainant lodged a claim of Rs.44,359/- with the OP for the treatment of his wife in Ashtha Hospital for the period 28.02.2017 to 02.03.2017, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement. 

4.                In order to prove their respective versions, both the parties have produced on the file their respective evidence.

5.                We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.

6.                It is admitted and proved that the complainant had taken a health insurance policy from the OPs, which was effective from 09.09.2016 to 08.09.2017 for a sum of Rs.5,00,000/-. The complainant has proved the cover note Ex.C-1. He has also proved the cards issued by the OPs in the name of complainant and his wife Smt. Nirmal Ex.C-2 and Ex.C-3. It is also admitted and proved fact that the complainant lodged a claim of Rs.44,359/- with the OP for the treatment of his wife in Ashtha Hospital for the period 28.02.2017 to 02.03.2017. The complainant has proved the claim intimation Ex.C-4 and claim form Ex.C-5. The complainant has proved on record the medical bills Ex.C-6 to Ex.C-13 and the discharge card of the wife of the complainant Ex.C14. The wife of the complainant Nirmal was admitted in Ashtha Hospital on 28.02.2017 for treatment of fracture left elbow (ULNA) and left radial head and after her treatment, she was discharged on 02.03.2017 during the validity of the insurance period.

7.                The OP has repudiated the claim of the complainant vide letter dated 11.10.2017 Ex.C-15 on the ground that the complainant had not complied with the submission of the claim documents. The OP has relied upon the letters and reminders written to the complainant by the OP seeking the documents for the settlement of the claim. They have relied upon the letters dated 22.03.2017, 08.04.2017 and 18.04.2017 as Ex.OP1-2/2, Ex.OP1-2/3 and Ex.OP1-2/4 respectively. The complainant has also relied upon the letters written to the OP in reply to their letters and claimed that all the documents have been supplied to the OPs.

8.                The OP has relied upon the letters Ex.OP1-2/2 to Ex.OP1-2/4. Perusal of these letters show that the OP has made queries from the complainant vide Ex.OP1/2/2 and asked him to provide the documents, break up of Rs.260/- charged on account of lab dated 28.02.2016, X-ray films dated 28.02.2016, main hospital bill on Hospitals Letter Head, purchase invoice for Implant used in the surgery and also provide Pre and Post Procedure X-ray films. Similar documents were sought for by the OP, vide Ex.OP1-2/3 and vide Ex.OP1-2/4. Two documents mentioned at Sr. No.4 and Sr. No.1 in Ex.OP1/2/2. Perusal of Ex.C-21, the email sent by the OP and by the complainant shows that the complainant has specifically mentioned in the email that all the relevant documents demanded have already been provided to their office of OP by speed post and all the documents have been received at their end. Similarly, vide Ex.C-22, the complainant has attached the documents with the email and has given the detailed reply of the letters regarding the documents sought for by the OP, vide Ex.OP1-2/2 to Ex.OP1-2/4. Vide Ex.C-23, he has categorically mentioned that the original of the X-ray and the documents have already been sent to the OP and he requires scanned copy of all the documents. Similarly, vide Ex.C-24, he has mentioned in detail the fact that the documents have already been provided to the OPs. Vide Ex.C-26 dated August 9, 2017, he has again asked the OP either to report back any shortcomings in the bill no.862 or to settle the claim. Vide Ex.C-29 again on 24.10.2017, despite all the emails and attachments and the fact that original documents were sent to the OPs as mentioned in all the emails prior to 24.10.2017. Same documents were again sought for by the OP. In reply to this letter, vide Ex.C-30, Ex.C-32 and Ex.C-33, the complainant has again sent the documents and has complied with all the letters and documents sought for by the OPs. The doctor’s certificate Ex.C-34 was also sent to the OP. The complainant has proved on record the reply to the reminders alleged by the OP as Ex.C-35 to Ex.C-40, in which he has time and again stated that the original of the documents have already been sent to their office by post dated 23.11.2017, 20.11.2017 and time and again the reminders are being sent to the complainant despite the fact that the documents have already been sent in original to the OPs.

9.                From the above circumstances, it is proved that the complainant has already complied with the requirements of the OPs and has sent the original documents and thereafter the copies of the documents sought for time and again by the OP, but despite receiving the documents, the OP is saying in emails that these documents are not available with them. If such is the scenario, then it is the negligence and responsibility of the OP and not of the complainant. The complainant is being mentally harassed by the OP. This is clear cut deficiency in service and unfair trade practice on the part of the OPs and the repudiation letter is hereby set-aside and thus the complainant is entitled for the relief.

10.              In view of the above detailed discussion, the complaint of the complainant is partly allowed and the OPs are directed to pay a sum of Rs.44,359/- i.e. value of the bill to the complainant. Further, OPs are directed to pay a compensation for causing mental tension and harassment to the complainant, to the tune of Rs.10,000/- and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

11.              Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

05.07.2023         Member                          Member              President