Chandigarh

DF-I

CC/451/2023

NAVEEN CHANDER JOSHI - Complainant(s)

Versus

THE ORIENTAL INSURANCE COMPANY LIMITED - Opp.Party(s)

DEVINDER KUMAR

04 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/451/2023
Date of Institution	:	18/09/2023
Date of Decision	:	04/09/2024

Naveen Chander Joshi (Age 43 years) son of Sh.Keshav Dutt Joshi, R/o H.No.704, New Indira colony, Manimajra, U.T. Chandigarh.

… Complainant

V E R S U S

1.     The Oriental Insurance Company Limited, Regional Office through its Regional Manager,SCO No.109-111, Sector 17-D, Chandigarh.

2.     M/s PARK Mediclaim Insurance TPA Pvt. Ltd through its Authorized Signatory, 702, Vikrant Tower Rajendra Place, Delhi-110008.

3. M/s EMEDLIFE Insurance Broking Services Limited, through its Authorized Signatory Pottipati Plaza, 2nd Floor, No.77, Nungambakkam, High Road, Chennai-600034.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Devinder Kumar & Sh.Ashwani Arora, Advocate for complainant
	:	Sh. Sahil Abhi, Advocate for OP-1
	:	OP-2 ex-parte
	:	OP-3 deleted vide order dated 12.03.2024

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Naveen Chander Joshi, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that the complainant is an employee of Okaya Power Private Limited, New Delhi since the year 2021 and was posted at Zirakpur, District SAS Nagar, Mohali as Sr. Executive – Channel Sales. During his service, complainant was insured by his employer under the Group medi-claim Tailor made policy (Annexure C-1) issued by OP-1 w.e.f. 25.5.2022 to 24.5.2023 (hereinafter referred to as “subject policy”). OP-2 was the third party administrator of the OP/insurer whereas OP-3 was the agent broker. Copies of health card and employment ID card of the complainant are Annexure C-2 & C-3.  On the noon of 29.11.2022 at around 1.30 p.m., when the complainant was driving his motorcycle bearing registration No.CH01-AX-9141 on Zirakpur-Lalru road and reached near Lalru powerhouse, all of a sudden a stray dog came on the road and the complainant applied brakes as a result of which the aforesaid motorcycle got imbalanced and had fallen on the road, which resulted in causing multiple injuries to the complainant and the motorcycle was also damaged.  The complainant was taken to the nearby hospital at Lalru by the people gathered on the spot from where he was taken to Govt. Medical College & Hospital, Sector 32, Chandigarh (hereinafter referred to as GMCH-32) in the ambulance for treatment.  The matter was reported to the police in pursuance to which rapat (Annexure C-4) was also recorded. The complainant remained admitted in the aforesaid GMCH-32 Hospital w.e.f. 30.11.2022 and was discharged on 13.12.2022 and copy of the medical record is Annexure C-7 Colly. The complainant lodged claim (Annexure C-5) of ₹1,56,946/- which was acknowledged by OP-2 on 13.2.2023 (Annexure C-6). Thereafter complainant approached OPs by sending emails to know about the status of his claim and on 20.3.2023, the representative of OP-3 namely Lovely Arora sent email to the complainant with regard to the discrepancies in his documents and objection with regard to chronic smoking and chronic alcohol intake history and he was directed to submit certain documents. The documents asked by OP-3 were submitted by the complainant including the certificate from Dr.Anshu Garg, who treated the complainant immediately after the accident.  However, the complainant was shocked to receive email dated 4.9.2023 (Annexure C-10) vide which they had repudiated his claim by intimating that as he is having history of chronic smoking and chronic alcohol intake, OP-1 is not liable to make any payment.  In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OP-1 resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, concealment of facts, cause of action and estoppel.  However, it is admitted that the employer of the complainant had obtained the subject policy which was valid w.e.f 25.5.2022 to 24.5.2023 and as per the terms and conditions of the policy schedule (Ex.OP-1), the answering OP is not liable to make any payment in respect of any expenses whatsoever incurred by any insured person in respect of treatment for alcohol/drug or substantive abuse or any addictive condition. It is further admitted that the complainant had lodged claim with respect to his alleged treatment for accidental injury and he was asked to submit certain documents required for processing the claim and when the said documents were received from him, it was found that the complainant is chronic smoker and chronic alcoholic and accordingly his claim was repudiated vide email dated 4.9.2023 (Annexure C-10).  However, it is denied that the complainant has incurred amount of ₹1,56,946/- or he is entitled for the same and submitted that in case this Commission comes to the finding that the answering OP is liable to reimburse the claim amount as per the terms & conditions of subject policy, the maximum liability which can be burdened on the answering OP is ₹1,31,210/- as per the assessment sheet (Ex.OP-4). On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. OP-2 did not turn up before this Commission, despite proper service, hence it was proceeded against ex-parte vide order dated 17.11.2023.
4. In view of the statement given by the learned counsel for the complainant, name of OP-3 was deleted from the array of OPs vide order dated 12.3.2024 of this Commission.
5. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, contesting parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties contesting parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant has been covered under the subject policy, obtained by his employer, w.e.f. 22.5.2022 to 24.5.2023, as is also evident from the policy schedule (Annexure  C-1) and health card (Annexure C-2), and the complainant had met with an accident on the relevant date, time and place and suffered injuries, as is also evident from the GDD (Annexure C-4), as a result of which he was firstly taken to Community Health Centre, Lalru and thereafter he was taken to GMCH-32 for further treatment where he remained admitted from 30.11.2022 to 13.12.202, as is also evident from the prescription slip and discharge summary (Annexure C-7) and the claim lodged by the complainant has been repudiated by OP-1/insurer vide email dated 4.9.2023 (Annexure C-10) on the ground that the complainant was having history of chronic smoking and chronic alcohol intake, the case is reduced to a narrow compass as it is to be determined if OP-1/insurer is unjustified in repudiating the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly repudiated the claim of the complainant and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical policy and the repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Annexure C-1 is the copy of policy schedule and Annexure C-2 is the copy of health card issued to the complainant, which clearly indicate that the complainant was covered under the subject policy. Annexure C-4 is copy of GDD which clearly indicates that on the relevant date, time and place, complainant had met with an accident and he was treated firstly at Community Health Centre, Lalru and thereafter at GMCH-32, as is also evident from the certificate (Annexure C-9) and the medical record (Annexure C-7).
   4. The defence of the OP/insurer is that, in fact, during investigation it was unearthed that the complainant is a having history of chronic smoking and chronic alcohol intake and his claim was repudiated only after receiving the medical record from the complainant. 
   5. However, perusal of the certificate (Annexure C-9) issued by the doctor at Community Health Centre, Lalru, nowhere indicates that the complainant was found under the influence of liquor at the time when he was immediately taken to the aforesaid health centre for treatment, rather it indicates that the complainant had sustained injuries in the motor vehicular accident which itself shows that the ground of repudiation of claim has no connection, whatsoever, with the injuries sustained by the complainant in the accident and the OPs have wrongly repudiated the claim of the complainant on the ground that the complainant is having history of chronic smoking and chronic alcohol intake, especially when the complainant has not sought any claim for the same.  On the contrary, complainant had lodged the claim for the expenses borne by him for the treatment of the injuries suffered by him in the motor vehicular accident. 
   6. Not only this, even medical record (Annexure C-7) issued by GMCH-32, nowhere indicates that the complainant is having history of chronic smoking and chronic alcohol intake making it clear that, in fact, OP-1/insurer has repudiated the genuine claim of the complainant on flimsy ground by clearly ignoring the fact that the claim of the complainant is with respect to the treatment which he had taken after sustaining injuries in the motor vehicular accident and the same has otherwise no connection with the alleged history of chronic smoking and chronic alcohol intake.
   7. In view of the foregoing discussion, it is unsafe to hold that OP-1/insurer was justified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed. 
   8. Now coming to the quantum of amount, no doubt complainant had lodged claim of ₹1,56,946/-, but, since OP-1/insurer had made deduction of ₹25,736/- with respect to certain items provided to the complainant for his treatment, which were not covered under the subject policy as per assessment sheet (Ex.OP-4), it is safe to hold that OP-1/insurer is liable to make the payment of the balance claim to the tune of ₹1,31,210/-, which otherwise has not been disputed by OP-1, alongwith interest and compensation etc.
4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP-1 is directed as under :-

1. to pay ₹1,31,210/-, to the complainant alongwith interest @ 9% per annum (simple) from the date of repudiation of the claim i.e. 4.9.2023 onwards.
2. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OP-1, within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Since no deficiency in service or unfair trade practice has been proved against OP-2, the consumer complaint against it stands dismissed with no order as to costs.
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

04/09/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/-
	[Suresh Kumar Sardana] Member