BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.311 of 2018

Date of Instt. 03.08.2018      Date of Decision: 19.11.2019

1.       Rajbir Singh S/o Baljit Singh resident of 436, R, Model Town, Jalandhar.

2.       Baljit Singh S/o Shamsher Singh resident of 436 R, Model Town, Jalandhar.

..........Complainants

Versus

1.       The Oriental Insurance Company Limited. Through its Authorized Signatory, Having its Regd & Head office at A-25/27, Asaf Ali Road, New Delhi-110002.

2.       The Oriental Insurance Company Limited. Through its Branch Manager, CBO-3, Civil Lines, Rattan Tower, Near Namdev Chowk, Jalandhar.

3.       E-Meditek Insurance TPA Limited, Through its Authorized Signatory, Having its Corporate Office at Plot no.157, Udyog Vihar, Phase-V, Gurgaon, Haryana.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Sh. Karnail Singh           (President)

Smt. Jyotsna                   (Member)

Present:       Sh. A. K. Gandhi, Adv Counsel for the Complainants.

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

OP No.3 exparte.

Order

Karnail Singh (President)

1.                This complaint has been filed by the complainants, wherein alleged that the complainant No.2 purchased a Happy Family Floater Policy Schedule under Silver Plan from the OPs No.1 and 2, bearing policy No.233102/48/2016/19 valid for a period 27.04.2015 to 26.04.2016. The complainant paid a premium of Rs.18,193/- to the OPs No.1 and 2 for the above said policy. The policy in question is the continuous of the previous policy No.233102/48/2015/65 issued by the OPs No.1 and 2. At the time of execution of the policy, the agent of the OPs No.1 and 2 gave assurance to the complainant that all the hospital expenses upto Rs.5,00,000/- are covered under the policy. Upon the assurance of the agents of the OPs No.1 and 2, the complainant purchased the said family floater policy of the OPs No.1 and 2 for himself and for his family members. It is worthwhile to mention here that the complainant No.1 is a beneficiary in the family floater policy as his name has mentioned in the policy as beneficiary. So, he is also a consumer.

2.                That the complainant No.1 when he was minor was suffering from fever, burning micturation and diarrhea. He was also detected to have urosepsis and was admitted in the Satguru Partap Singh Hospital, Ludhiana on 11.07.2015 and was discharged on 18.07.2015. The complainant No.2 spent Rs.2,00,000/- on the treatment. The complainants lodged the insurance claim with the OPs No.1 and 2, who issued a Claim Reference No.103121500168 to the complainants. The complainants have submitted all the necessary documents to the OPs as per their request, even then the OP No.3 sent false and fibulas letters to the complainants and demanding certificate from the treating doctor regarding the prolonged stay in the hospital, which was sent by the complainants to the OPs at their office, even the complainants enquire the status from the OPs time to time by submitting letters. But the OPs with malafide intention linger on the claim of the complainant No.1 without any reasons.

3.                That the complainants shocked to receive a letter dated 16.11.2016 from the OPs No.1 and 2 that the claim of the complainant No.1 has declared as “No Claim” by the OPs No.1 and 2 on the ground that “Non submission of all the necessary documents despite sending reminder by our TPA E-meditek”. The declaration of the claim of the complainant No.1 as “No Claim” is unlawful and illegal one and without any reasons. Moreover, no opportunity of hearing was afforded to the complainants. The complainants have sent all the documents to the OPs at their office. It is worthwhile to mention here that the complainants received a letter dated 07.02.2016 from the OP No.3, wherein it demanded certificate from the treating doctor for prolonged stay of the complainant No.1 in the Hospital. The complainants supplied the certificate in this regard issued by treating doctor at the office of OP No.3 at Chandigarh on 04.08.2016. The complainants sent letters dated 06.12.2016, 18.12.2016 and 10.01.2017 to the OPs No.1 and 2, which were duly received by the OPs No.1 and 2, wherein the complainants demanded the letter issued by the TPA i.e. OP No.3 pertaining to the “No Claim” against the complainant, but the said letter allegedly issued in the month of February never supplied to the complainant. So, it is clear from the conduct of the OP that they are harassing the complainant and their act and conduct is tantamount to deficiency in service and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainants may be accepted and OPs be directed to pay the claim amount of Rs.2,00,000/- as medical expenses spent on the treatment of the complainant No.1 alongwith interest @ 18% per annum as well as litigation expenses and further, OPs be directed to pay compensation to the complainant for causing mental tension and harassment, to the tune of Rs.1,00,000/-.

4.                Notice of the complaint was given to the OPs, but OP No.3 despite service miserably failed to appear and ultimately, OP No.3 was proceeded against exparte.

5.                OPs No.1 and 2 appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the complainant is stopped by his own act and conduct from filing the present complaint against the OPs. On the receipt of the claim for the treatment of complainant from 11.07.2015 to 18.07.2015 from Satguru Partap Singh Hospital, Ludhiana, Claim No.1033121500168 was registered by the OP. The said claim was lodged by the complainant on 16.12.2015 i.e. after about 5 months with the OP. The OPs No.3 i.e. claim settling agency of OPs No.1 and 2 asked for condonation of delay in lodging the claim by the complainant from the competent authority of OPs No.1 and 2, but it was not granted. The complainant has also failed to give any justification for delay in lodging the claim despite letter dated 07.02.2016. Since, there was no justification for the prolonged delay in lodging the claim by the complainant and as such, the claim of the complainant was made “No Claim’’. Letter dated 29.02.2016 to this effect was sent to S. Baljit Singh, who had lodged the claim with the OP. It is further averred that there is no deficiency in service or unfair trade practice on the part of the OPs and that being so, the present complaint is not maintainable. On merits, it is admitted that the complainant purchased Happy Family Floater Policy for the period 27.04.2015 to 26.04.2016 and further admitted that the insurance medical claim of  Complainant No.1 has been filed, but the same was admittedly filed as “No Claim”. 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.

6.                Rejoinder of the written statement of OPs No.1 and 2, filed by the complainant, whereby reasserted the entire facts as detailed in the complaint and denied those of the written statement.

7.                In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents Ex.C-1 to Ex.C-56 and then closed the evidence.

8.                Similarly, counsel for the OPs No.1 & 2 tendered into evidence affidavit of Sh. Sandeep Thapa as Ex.OPA along with some documents Ex.OP/1 to Ex.OP/4 and then closed the evidence.

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

10.              There is no dispute that the complainant got insurance policy for the period 27.04.2015 to 26.04.2016, the said policy known as ‘Happy Family Floater Policy Schedule’ under Silver Plan purchased by Baljit Singh/Complainant No.2 for himself as well as for the family members including complainant No.1/Rajbir Singh. The complainant No.1 remained admitted in the hospital from 11.07.2015 to 18.07.2015 and got a treatment and spent there a sum of Rs.2,00,000/- and after discharge there-from, he submitted an insurance claim and thereafter, a Claim Reference No.103121500168 was issued by OPs No.1 and 2 to the complainants. Despite repeated request, the insurance claim of the complainant was not disbursed rather the same was declared “No Claim” on 16.11.2016, vide letter Ex.C-37 on the ground that the complainant miserably failed to submit all the necessary documents and thereafter, the complainant approached the OP number of times that he has already submitted all the documents, but claim was not cleared, thus, the instant complaint filed by the complainants.

11.              The case of the complainants is refuted by the OPs simply on the ground that the complainant got discharged from the hospital on 18.07.2015, whereas the claim was lodged on 16.12.2015 i.e. after about five months delay and the same was not got condoned by the complainant from OPs No.1 and 2 and accordingly, the claim of the complainant was declared “No Claim” and its intimation was given to the complainant, vide letter dated 29.02.2016 Ex.OP/3 and further alleged that there is no deficiency in service or unfair trade practice on the part of the OPs.

12.              We have analyzed the respective plea of both the parties and find that the complainant alleged that his insurance claim was declared “No Claim”, vide letter dated 16.11.2016 and the said letter is brought on the file by the complainant as Ex.C-37.

13.              On the other hand, the OP alleged that the said claim was declared “No Claim”, vide letter dated 29.02.2016 and copy of the letter placed on the file Ex.OP/3. We find that there are two letters available on the file, one is dated 16.11.2016 Ex.C-37 and other is dated 29.02.2016 Ex.OP/3 and both the letters were issued by the OP and it is the primary duty of the OP to establish that the letter produced by the complainant dated 16.11.2016 Ex.C-37 is fake or it was not issued by the office of the OPs No.1 and 2, but no such plea has been taken by the OPs, which itself shows that the letter dated 16.11.2016 Ex.C-37, which bears the signature of the Branch Manager and it was written on the Letter Pad of the office of the OPs No.1 and 2. So, there remains no doubt that the letter dated 16.11.2016 Ex.C-37 is not issued by the OP rather it is established the same was issued by the OP and the other letter Ex.OP/3 dated 29.02.2016 is manipulated later on, just to save its skin from the liability. It is the case of the OP that the claim was submitted by the complainant on 16.12.2015, if so, then why the claim of the complainant remained un-decided for about one year i.e. till 16.11.2016, if there was deficiency of documents, then the OP are bound to settle the case of the complainant on either side within a period of 30 days from the date of receipt of the claim, but for the best known reason, the OP has miserably failed to decide the claim of the complainant within a reasonable time of 30 days, which is tantamount to deficiency in service on the part of the OPs.

14.              Furthermore, the OP took a plea in Para No.2 of the written statement on merits that the complainant has only lodged a claim of Rs.1,08,503/- with the OP, but in the instant complaint, the complainant demanded an amount of Rs.2,00,000/-, which itself contrary to the claim form and pleadings.

15.              We have considered the said submission of the OP and find that the copy of the Claim Form Ex.OP/4 placed on the file by the OP itself established that the complainant submitted a claim amount of Rs.1,08,503/- and as such, we are of the affirmed opinion that the complainant is entitled for the claim as demanded in the Claim Form Ex.OP/4 i.e. Rs.1,08,503/- along with compensation and litigation expenses.

16.              As an upshot of our above detailed discussion, the complaint of the complainant is partly accepted and OPs No.1 and 2 are directed to pay the aforesaid amount of Rs.1,08,503/- to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 16.11.2016, till realization and further, OPs No.1 and 2 are directed to pay compensation of Rs.20,000/- for causing mental tension and harassment to the complainant and further, OPs No.1 and 2 are directed to pay litigation expenses, to the tune of Rs.10,000/-. The entire compliance be made within one month 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.

17.              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                                       Jyotsna                           Karnail Singh

19.11.2019                                        Member                          President