DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Complaint No.CC/15/142 of 10.7.2015

                                      Decided on: 9.2.2016

Sarabjeet Singh son of Late Sh.Harbans Singh R/o House No.10, Preet Nagar, Tripuri Road, Patiala Punjab.

                                                                   …………...Complainant

                                      Versus

1.      The Senior Branch Manager, National Insurance Co.Ltd. Branch Office-25, Factory Area, Patiala-147001.

2.      The National Insurance Company Limited, 3, Middleton Street, Post Box No.9229, Kolkata- 700 071.

3.      Vipul Medcorp TPA Private Limited, S.C.O.No.98, First Floor, Industrial Area, Phase-2,Chandigarh-160 002.

                                                                   …………….Ops

                                      Complaint under Section 12 of the

                                      Consumer Protection Act.

                                      QUORUM

                                      Sh. A.P.S.Rajput, President

                                      Smt.Neelam Gupta, Member

                                      Smt.Sonia Bansal,Member                               

Present:

For the complainant:   Sh.P.S.Baweja , Advocate

For Ops:                       Sh.D.P.S.Anand,Advocate            

                                         ORDER

A.P.S.Rajput, PRESIDENT

1. Complainant, Sarabjeet Singh S/o Late Sh.Harbans Singh, R/o House No.10, Preet Nagar, Tripuri Road, Patiala, has filed this complaint against the Opposite Parties (hereinafter referred to as the OPs) under Sections 11 to  14 of the Consumer Protection Act. The brief facts of the complaint are as under:
2. It is alleged by the complainant that on the assurance given by Op no.3 on behalf of Ops no.1&2 he purchased the insurance policy covering medical insurance of the complainant alongwith his family members depending upon him firstly for the period from 12.3.2011 to 11.3.2012 bearing mediclaim policy No.401406/48/10/8500000270, then for the period from 12.3.2012 to 11.3.2013 bearing policy No.401406/48/11/8500000286, then for the period from 12.3.2013 to 11.3.2014 bearing policy No.401406/48/12/8500000260 and then for the period from 12.3.2014 to 11.3.2015 bearing policy No.401406/48/13/850000026 , having deposited regular premiums continuously for the medical claims of Rs.4,00,000/-. In this regard insurance cards were also issued by Op no.3 on behalf of Op no.2.
3. It is alleged that on 18.6.2013 his wife Smt.Gurjeet Kaur felt severe pain and restlessness and was admitted in Sadbhavna Medical & Heart Institute Patiala on the same day where she remained admitted till 22.6.2013, the claim of which was repudiated by the Ops on 22.6.2013 and 30.8.2013 on the vague grounds that, “ the patient is suffering K/C/O DM and HT since last five years. All diseases which are pre existing when the cover incepts for the  first time shall be excluded. This exclusion shall be dealt after three consecutive continues claim free policy years” but on filing the complaint before  this Hon’ble Forum the same was accepted vide order dated 16.5.2014.
4. It is alleged in the complaint that after decision of the earlier complaint filed before the Forum, the complainant claimed his pending claim of Rs.2053/- of post treatment expenses incurred within 60 days after the date of discharge from the hospital i.e. from 22.6.2013 to 22.8.2013 having submitted original bills with the office of Op no.3 and fulfilled all the formalities vide letters dated 10.9.2014, 11.9.2014, 21.11.2014, 15.1.2015 and  13.2.2015 but the same was repudiated by Op no.1 vide letter No.40406/Claims/GS/2015/1776 dated 18.3.2015 on the same grounds, which is totally unjust, illegal and arbitrary.A legal notice dated 24.4.2015 was also got sent to the Ops through Sh.Jasjit Singh Sabhikhi,Advocate but to no effect.Hence this complaint with a prayer for a direction to the Ops to pay the claim of Rs.2053 of post treatment expenses i.e. from 22.6.2013 to 22.8.2013, to continue his policy No.401406/48/14/800000279 and also to pay Rs.25000/- as compensation on account of the harassment, humiliation and costs of litigation.
5. The cognizance of the complaint was taken against Ops no.1&2 only who on notice appeared and filed the written version. It is stated that the Ops had issued medi claim insurance policy for the period from 12.3.2011 to 11.3.2012, 12.3.2012 to 11.3.2013, 12.3.2013 to 11.3.2014 covering the risk of Sarabjit Singh, Smt.Gurjeet Kaur, Sh.Manjit Singh and Chanpreet Kaur in a sum of Rs.4lacs each.The current policy has been cancelled as per the terms and conditions of the policy and the premium has been refunded on pro-rata basis to the complainant. It is denied by the Ops that the policy is continuously in operation for the last 4 and 5 years. It is also denied that the claim of the complainant for the period from 18.6.2013 to 22.6.2013 has been repudiated without any logic and vague grounds as the same has been rejected on the ground that the dispute has already been decided on 16.5.2014.It is stated that the insurance policy was cancelled as per terms and conditions of the policy and the remaining premium of Rs.3838/- was refunded to the complainant on pro-rata basis and the complainant is not entitled to any other claim. All other averments made in the complaint against the ops have also been denied and it is prayed to dismiss the complaint.
6. In support of his complaint, the complainant tendered in evidence Ex.CA his sworn affidavit alongwith the documents Exs.C1 to C17 and his counsel closed the evidence.
7. On the other hand, on behalf of the Ops, their counsel tendered in evidenceEx.OPA, the sworn affidavit of Sh.Gulzar Singh, Sr.Branch Manager alongwith the documents Exs.OP1 to OP7 and closed the evidence.
8. The parties failed to file the written arguments. We have heard the learned counsel for the parties and gone through the evidence on record.
9. The ld. counsel for the complainant has submitted that the medical claim i.e Ex.C4 of the complainant had been repudiated in an arbitrary manner by the Ops. He stated that the policy taken by the complainant is a medical policy and as and when, the complainant will take treatment the OPs are liable to reimburse the same. The ld. counsel further stated that as per the terms and condition of the policy  i.e Ex.OP16 and Ex.OP17, under clause; “Reimbursement of Pre/Post Hospitalization”  the insurer is liable to file his claim before 60 days. He pleaded that the complainant as per the prescribed period filed his medical claim but the OPs rejected the same and moreover even cancelled the policy of the complainant without intimating the reasons for the same i.e Ex.C1 and ExC4. The ld. counsel argued that earlier also the complainant had approached this Forum,  vide order dated 16.05.2014, this Forum had accepted the same. He also argued that in the earlier case also the OPs had repudiated the claim on the same and similar grounds and the present complaint also deserves to be accepted.
10. On the other hand, the ld.counsel for the OPs has submitted that the present complaint filed by the complainant is not maintainable as the principle of resjudicata is applicable to the case in hand. He also stated that the second complaint on the same cause of action is not maintainable and relied upon the case; Force Motors  Limited Vs. DPS Secondary School&  Anr, IV(2014)CPJ 683(NC) of the Hon’ble National Consumer Disputes Redressal Commission,New Delhi, wherein it has been observed:   “Second complaint on same cause of action before District Forum, is barred by principle of resjudicata. It amounts to misuse and gross abuse of process of law.Impugned order set aside”. The ld. counsel pleaded that the claim of the complainant was rightly repudiated by the OPs, keeping in view the exclusion clause of the policy. The ld. counsel further pleaded that since the present bills had been settled vide order dated 16.05.2014 passed by this Forum, therefore the same cannot be claimed.
11.  After hearing the Ld. Counsel for the parties and going through the pleadings, evidence produced by the parties and the oral arguments and written submissions,  we are of the opinion that the principle of Resjudicata is not applicable to the case in hand, as the complainant never claimed the reimbursement for the bills in question. Thus in our opinion the case law citied by the ld. counsel for the OPs is not applicable to the facts of the present case. The OPs had also not challenged the order dated 16.05.2014, thus it had became final and binding on the OPs. As per the Ex.C16 for claiming Pre/Post-Hospitalization expenses,  the insurer is suppose to file his claim of expenses i.e 60 days after discharge from the hospital. In our view the complainant had filed the reimbursement for his claim, as per the prescribed terms and conditions i.e Ex.C16. It is also evident from the letters and reminders i.e Ex.C8,Ex.C9,Ex.C11,Ex.C12 , that the OPs had been neglecting and hesitating to reimburse the claimed amount in the present case in hand. Thus we find that the OPs have committed deficiency in service by not reimbursing the claim of the complainant, despite the earlier decision of this Forum on the same and similar point.

12       Accordingly in view of our aforesaid discussion, we are of the view that the complainant had filed his claim as per the terms, conditions and procedure prescribed in the policy. Hence we direct the OPs to pay the claim of post treatment expenses amounting to Rs.2053/- .Complainant is also entitled to cost for compensation, on account of mental agony alongwith litigation costs amounting to Rs.5000/-.The OPs are directed to comply with this order within 45 days from the date of receipt of the same, otherwise the OPs  shall be liable to pay interest @6% p.a, till its realization. The present complaint stands accepted.

Pronounced

Dated: 9.2.2016

               Sonia Bansal           Neelam Gupta                        A.P.S.Rajput

        Member                Member                                  President