| ORDER | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.403 of 09-08-2011 Decided on 16-05-2012
Vikram Garg, aged about 34 years, son of Sh. Madan Lal Garg, Resident of H.No.5146, Cozy Home, Nai Basti, Gali No.6, Bathinda. ...Complainant Versus
Reliance General Insurance Co. Ltd., 570, Naigaon Cross Road, Next to Royal Industrial Estate, Wadala (W), Mumbai-400031, through its M.D./Chairman. Reliance General Insurance Co. Ltd., Reliance Office, Prime Time, SCO-5, Ahata Pritam Singh Sidhu, Amrik Singh Road, Bathinda, through its Manager. Reliance General Insurance Co. Ltd., 7th Floor, Surya Towers, 108, The Mall, Ludhiana, Punjab, through its Authorized Representative. ...Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986
QUORUM
Smt. Vikramjit Kaur Soni, President Sh. Amarjeet Paul, Member Smt. Sukhwinder Kaur, Member Present:- For the Complainant: Sh. Vikas Singla, counsel for the complainant For Opposite parties: Sh. M.R.Gupta, counsel for opposite party No.2 Sh. Sunder Gupta, counsel for opposite party No.3 Opposite party No.1 ex-parte
ORDER
Vikramjit Kaur Soni, President:-
The present complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 as amended up-to-date (Here-in-after referred to as an 'Act'). In brief, the case of the complainant is that he purchased one Gold Plan Medical Insurance Policy No.282510392497 from the opposite parties w.e.f. 14.02.2009 to 13.02.2010 after payment of Rs.3,060/- for a sum assured of Rs.2 Lacs. The complainant alleged that he fell ill due to Acute Febrile Illness and Hepatitis. He was got admitted in Deep Multi/Super Specialty Hospital, Bathinda on 18.07.2009 and remained there upto 24.07.2009. He spent Rs.50,572/- on his treatment which includes Doctor/Nursing Fee, Medical Bills, Pathological Lab Expenses, Daily Hospitalization Allowance and other misc. expenses. He lodged the claim for the said amount with the opposite parties vide claim No.4305404 on 10.08.2009. The opposite parties put query regarding the said claim vide letter dated 15.10.2009. Accordingly, the complainant furnished all the documents on 30.10.2009 i.e. original bills and documents as required by the opposite parties along with covering letter through courier services and requested them to honour his claim. The opposite parties repudiated his claim vide their letter dated 06.01.2010 without any basis. The complainant also wrote a letter dated 20.01.2010 to the opposite parties, requesting them to settle his lawful claim, but no heed was paid to his requests. Hence, the complainant has filed the present complaint seeking directions of this Forum to the opposite parties to reimburse his medical insurance claim to the tune of Rs.50,572/- and pay cost and compensation. Registered AD notice of the complaint was sent to the opposite party No.1, but despite service of notice, none appeared on its behalf. Hence, ex-parte proceedings were taken against opposite party No.1. The opposite party Nos.2&3 have filed their separate written statements. The opposite party No.2 pleaded that the complainant purchased the insurance policy in question through his wife Isha Garg, agent of the company. As per the contract rules of the company, all the claims of the medical and health wise are taken care by TPA. The Medi Assist India Pvt. Ltd. Bangalore was the authorized TPA of the company who investigated the claim of the complainant and repudiated the same with the remarks that the complainant is not co-operative in providing the details of the treatment and also treatment record was not maintained by the hospital, as such the claim is not payable as it is fraudulent. The opposite party No.2 has pleaded that on 20.09.2010, it has been relieved from the services of the company without any process and as such it has no direct or indirect concern with the complainant or the company in question. The opposite party No.3 in its separate written statement, has pleaded that the complainant has filed the present complaint on the basis of false & forged documents and medical bills which were got prepared by him from Deep Multi-Super Specialty Hospital, Bathinda. Moreover, the opposite parties moved an application for directing the complainant to produce medi-claim policies obtained by him from different Insurance Companies along with complete Medi-Claim policies but he neither supplied any complete record nor produced any medical bills for the aforesaid period. He has violated the terms and conditions of the medi-claim policy. The complainant himself runs the medical shop under the name and style of M/s R.S. Medical Agencies and has got procured false medical bills of his own shop. Vide letter dated 15.10.2009, the complainant was put certain queries and he was asked to submit few documents but he failed to supply the same. The opposite part No.3 has further pleaded that it deputed Mr. Satish Kunar Bansal, Investigator to investigate the claim of the complainant. The said Investigator submitted his report dated 25.11.2009 and stated that the complainant has not cooperated and did not supply the required documents. Further, the hospital has not maintained the record of treatment, provided to the complainant, as such the claim of the complainant is not payable and accordingly it was repudiated by it vide letter dated 06.01.2010. The opposite party No.3 has further pleaded that the complainant has filed various consumer complaints regarding medi-claim before this Forum and the opposite parties have only record of complaint No.415 of 10.09.2010, decided on 11.07.2011 titled as Vikram Garg Vs HDFC ERGO and complaint No.295 dated 24.06.2011, decided on 12.09.2011 titles as Vikram Garg Vs ICICI Prudential Insurance Co. Ltd. He has also filed more complaints regarding medical reimbursement of medi-claim which have been attached with this complaint as such the complainant is committing fraud on the opposite parties. Moreover, the complainant has not intimated the opposite parties within stipulated period rather the intimation regarding the said treatment was given very late. Parties have led their evidence in support of their respective pleadings. Arguments heard. Record along with written submissions submitted by the parties perused. These are undisputed facts between the parties that the complainant purchased medial insurance policy of the opposite parties bearing policy No.282510392497 under Gold Plan in his name, valid from 14.02.2009 to 13.02.2010 for a Sum Assured of Rs.2 Lacs. The allegation of the complainant is that he fell ill due to Acute Febrile Illness and Hepatitis and remained admitted in Deep Multi/Super Specialty Hospital, Bathinda from 18.07.2009 to 24.07.2009 and spent about Rs.50,572/- on his treatment. He lodged the clam with the opposite parties vide claim No.4305404 on 10.08.2009 for a sum of Rs.50,572/-. He submitted all the required documents with the opposite parties as well as replied to the queries put by them. The opposite parties repudiated his claim vide letter dated 06.01.2010. The pleadings of the opposite parties for repudiation of the claim of the complainant is that they have repudiated his claim as Sh. Satish Kumar Bansal, Investigator who was deputed to investigate the case of the complainant has submitted his report dated 25.11.2009 wherein he has mentioned that the complainant has not cooperated him and has not supplied the required documents. A perusal of file reveals that the opposite parties vide letter dated 06.01.2010 Ex.C-11 have repudiated the claim of the complainant. The relevant portion of the said letter is reproduced hereunder:- Clause | Description |
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Condition 2 | Duty of disclosure – The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or non-disclosure of any material particulars in the proposal form, personal statement, declaration and connected documents or any material information having been withheld....... under the policy | Condition 6 | The Insured/Insured person shall keep an accurate record containing all relevant particulars regarding his/her health & shall allow the company to inspect such record. The insured/insured person shall within one month after the expiry of the policy furnish such information as the company may require. | Condition15 | Fraudulent claims – if any claims is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured/insured person or anyone acting on his/her behalf to obtain any benefit under this policy or ....... all benefits under this policy shall be forfeited. |
On perusal of the claim documents, it is found that patient was admitted at Deep Multi Specialty Hospital, Bathinda for the treatment of Acute Hepatitis on 18.07.2009 & Discharged on 24.07.2009. As per the investigation performed it is evidence that the client is not cooperative providing the details of the treatment and the Hospital has not maintained the records of the treatment provided. Therefore, this claim is not payable as it is fraudulent. Hence, we regret our inability to admit this liability under the present policy conditions and claim is being repudiated under policy condition 2, 6 & 15 of above mentioned policy. We also reserve the right to repudiate the claim under any other grounds available to us subsequently. The opposite parties letter vide Ex.C-4 required some documents from the complainant which he sent vide letter Ex.C-5. The opposite parties have taken shelter of condition Nos.2, 6 & 15 in repudiating the claim of the complainant. The complainant has not violated the condition No.7 as the opposite parties have not proved on file that any wrong statement in any of the document was given by the complainant. The complainant has furnished all the documents to the opposite parties as required under the condition No.6 of the policy. Further, the opposite parties have utterly failed to prove on file that fraudulent claim was filed by the complainant and in this way, he violated the condition No.15 of the policy. The opposite parties have also taken shelter of Investigation report Ex.R-2. The said investigator after verification of policy, insured and sum assured etc. has stated in his report that he visited Deep Super Specialty Hospital, Bathinda and verified the records and collected the Bed Head Tickets of the patient Vikram Garg. He opined that the Hospital had not maintained the Bed Head Ticket and having only two pages. Dr. Amit Gupta who treated the patient Vikram Garg had left the hospital. The observations and remarks given by Sh. Satish Kumar Bansal in investigation report Ex.R-2 reads as under:- “OBSERVATION AND REMARKS:- Under the circumstances, I find that Vikram Garg who was suffering Acute Hepatitis and Jaundice got treatment from Deep Multi Super Specialty Hospital, Bathinda, and the treating doctor Amit Taneja had left the Hospital, and the History of the patient and other facts are not known”. In view of what has been discussed above, the evidence especially the aforesaid conditions and the investigation report on the basis of which the opposite parties have repudiated the claim of the complainant is of no help to them. The complainant has not violated any condition of the policy. Moreover, the investigator has admitted the fact that the complainant was suffering from the disease and he got the treatment from the hospital. If the record was not maintained by the hospital, the complainant cannot be penalized for the same because it is not the case of the opposite parties that they have provided any list of specific hospitals to the insureds to get treatment in case of any suffering. The support can be sought by the precedent laid down by the Hon’ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh, in case titled The Oriental Insurance Co. Ltd.& Another Vs. M/s Puneet Pasricha, First Appeal No.1579 of 2004, decided on 05.03.2010 wherein the Hon’ble State Commission has held that :- “......The appellants cannot be permitted to frustrate the insurance claim on the technicalities.” Keeping in view the facts, circumstance and evidence placed on file, this Forum is of the view that there is deficiency in service on the part of the opposite parties in repudiating the genuine claim of the complainant without any basis. Hence, this complaint is accepted with Rs 5,000/- as cost and compensation against all the opposite parties. The opposite parties are directed to pay the claim to the tune of Rs.50,572/- to the complainant. The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of copy of this order. In case of non-compliance within the stipulated period, the complainant shall entitled to the interest @9 % on the claim amount of Rs.50,572/- from the date of this order till realization. A copy of this order be sent to the parties concerned free of cost and file be consigned for record.
Pronounced 16-05-2012 (Vikramjit Kaur Soni)
President
(Amarjeet Paul) Member
(Sukhwinder Kaur ) Member
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