Chandigarh

DF-I

CC/388/2014

Ishar Singh - Complainant(s)

Versus

The Oriental Insurance Company - Opp.Party(s)

S.S. Kamboj

02 Feb 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

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Consumer Complaint No.	:	CC/388/2014
Date of Institution	:	09/06/2014
Date of Decision	:	02/02/2015

 

 

Ishar Singh son of Shri Mangat Singh resident of VPO Mote Majra, Tehsil and District SAS Nagar (Mohali) Punjab.

….. Complainant

V E R S U S

1. The Oriental Insurance Company, Madan Mohan Malviya Road Amritsar, District Amritsar through its Manager.
2. The Manager, The Oriental Insurance Company Limited Regional Office : S.C.O 109-111, Sector 17-D, Chandigarh.
3. The Manager, Alankit Healthcare TPA Ltd. #378-A, 1^st Floor, Silver Plaza Madan Mohan Malviya Road Amritsar District Amritsar.

…… Opposite Parties

 

 

 

QUORUM:	P.L.AHUJA	PRESIDENT
	MRS.SURJEET KAUR	MEMBER

                                               

                                               

                       

ARGUED BY:	Sh. S.S. Kamboj, Counsel for complainant
	Ms. Anamika Mehra, Counsel for OPs 1 & 2.
	OP-3 ex-parte

                       

                 

PER P.L.AHUJA, PRESIDENT

1.         Sh. Ishar Singh, complainant has filed this consumer complaint under Section 12 of the Consumer Protection Act, 1986, against The Oriental Insurance Company and others, Opposite Parties (hereinafter called the OPs), alleging that he is an employee of the Shiromani Gurudwara Parbandak Committee, having group insurance policy and on the beginning of every year the premium amount is being deducted from his account.

                According to the complainant, he had a tailor made policy for the period from 1.1.2012 to 31.12.2012 and the total sum insured was Rs.4.00 lac.  It has been averred that the complainant submitted two bills of Rs.1,000/- each (for treatment of himself and his wife) on 31.12.2012 through registered post.  However, despite approaching the OPs a number of times, the amount has not been disbursed.

                The complainant has alleged that similarly he had Mediclaim policy for the period from 1.1.2013 to 31.12.2013 having total sum insured of Rs.5.00 lac.  The complainant’s wife was operated in the Government Medical College and Hospital, Sector 32, Chandigarh and he submitted bills of Rs.8,715/- on 31.10.2013. However, out of that only an amount of Rs.6,800/- was passed and Rs.1,915/- were deducted under various heads.  The complainant also submitted bill of Rs.2,179/- out of which again an amount of Rs.554/- was passed and the remaining amount of Rs.1,625/- was not passed.  It has been contended that the complainant submitted all the bills to the OP/Insurance Company through his employer. The said bills were checked and verified by the concerned doctors of Government Medical College and Hospital, Sector 32, Chandigarh and as such the deductions made were totally uncalled for and against the policy and law.  When no amount was reimbursed, the complainant served a legal notice dated 7.4.2014 (Annexure C-5) on the OPs for reimbursement of the amount.  In response, OP-1 sent a vague reply dated 23.4.2014 (Annexure C-6) mentioning therein that amount after deductions had been received by the insured/ beneficiary.  Thereafter the complainant sent another legal notice dated 7.5.2014 (Annexure C-7) refuting the stand taken by OP-1 in its reply. According to the complainant, he himself and through his employer had requested the OPs to deposit the claimed amount in his account alongwith interest but all in vain.  Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the OPs, the complainant has filed the instant complaint. 

2.         In their joint written reply, OPs 1 and 2 have pleaded that the complainant is not their consumer because the policy of contract was between SGPC (Shiromani Gurudwara Parbandhak Committee) and the Oriental Insurance Company.  It has been averred that the claims were settled by the TPA as per the terms and conditions of the policy. It has been contended that OPs had paid four claims through ECS to SGPC as both the policies were in the name of Manager, Gurdwara Darbar Sahib sub office SGPC Chandigarh and Secretary SGPC respectively.  It has been pleaded that the deductions have been rightly made. It has been averred that the complainant had wrongly claimed the pre-hospitalization from the company. Pleading that there is no deficiency in service or unfair trade practice on their part, prayer for dismissal of the complaint has been made.
3.         OP-3 did not appear despite service, therefore, it was proceeded exparte vide order dated 28.7.2014.
4.         In his replication, the complainant has controverted the stand of the OPs and reiterated his own.  It has been contended that till date no amount has been received by him.
5.         The parties led evidence in support of their contentions.
6.         After going through the entire evidence, written arguments submitted by both sides and hearing the learned Counsel for the parties, we feel that the complaint of the complainant is liable to be dismissed for non-joinder of necessary party.   
7.         It is the admitted case of the complainant that he is an employee of Shiromani Gurudwara Parbandak Committee having group insurance policy and the amount (premium) is being deducted from his account (salary). The complainant has also contended in his complaint that he submitted all the bills to the OP company through his employer i.e. SGPC pertaining to the claim amount.  The copy of the document at Annexure C-2 shows that policy No.235302/48/12/1711 for the period from 1.1.2012 to 31.12.2012 was a tailor made policy and Gurudwara Shiromani Parbandhak Committee was the proposer and insured.  The document at Annexure C-1 shows that the corporate policy was obtained by Gurudwara Shiromani Parbandhak Committee.  The subsequent insurance policy No.235300/48/13/1646 (as detailed in Annexure C-4) was obtained by the sub office, S.G.P.C. Chandigarh for the period from 1.1.2013 to 31.12.2013. Thus, the complainant had no privity of contract with the Oriental Insurance Co.  The details of insurance policy for this period (from page 16 to 19 of the documents produced by OP-1) show that the name of the insured is indicated as sub office Srimoni G.P.C. Sector 5 and Gurdwara Sri Kalgidhar Niwas, Sec.27.  The annexure attached with the policy shows that it covered 49 persons including the employees and their dependents. The names of Sh. Ishar Singh, complainant and his, wife Smt. Harjinder Kaur find mention at Sr. No.34 & 35 of the annexure. It is quite evident from the record that the complainant did not approach OPs 1 & 2 for obtaining the policies. Rather the insurance policies were obtained by Shiromani Gurudwara Parbandhak Committee for its employees. The amount of premium was deducted from the salary of the employees and paid to the Oriental Insurance Co.  It is the Shiromani Gurudwara Parbandhak Committee who could tell as to what were the terms and conditions of the insurance policy in question and whether the deductions in the amount of reimbursement of the medical expenses in the amount claimed i.e. Rs.8,715/- and Rs.2,179/- were rightly made or not (Annexure C-3 and C-4). As per the averments of OPs 1 & 2, they have already made the payment of Rs.1,000/- in respect of claim No.2413 and 2412 in the bank account of SGPC through electronic fund transfer on 2.5.2013. It has also been mentioned in the written statement of OPs 1 & 2 that the amounts of Rs.6,800/- and Rs.554/- respectively after deduction were deposited in the said account of SGPC on 8.7.2013. Though there is a discrepancy in the dates of payment of these two amounts because in para 3 of preliminary submissions these dates are also indicated as 8.7.2014 yet, it was the SGPC who could tell whether the above amounts were deposited in its account through electronic fund transfer or not. It is quite probable that the amounts in question were transferred by the Oriental Insurance Company in the account of the SGPC and the dates mentioned in the written statement are not correct. Hence, the presence of Shiromani Gurudwara Parbandhak Committee, the employer of the complainant, was quite necessary for effectually and completely deciding the controversies involved in this complaint.  The complainant has not produced any such document which could show that the reimbursement of the claim was to be directly paid to him by the Insurance Company. In this view of the matter, we are of the considered opinion that the complaint is bad for non-joinder of necessary party i.e. Shiromani Gurudwara Parbandhak Committee (SGPC).
8.         For the reasons recorded above, we do not find any cogent evidence of deficiency in service or unfair trade practice on the part of the Oriental Insurance Company/OPs.  Consequently, the complaint is dismissed leaving the parties to bear their own costs.
9.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
02.02.2015	[Surjeet Kaur]	[P. L. Ahuja]
hg	Member	President