Before the District Consumer Dispute Redressal Commission [Central District] - VIII,      5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi

                                      Complaint Case No. 37/29.01.2016

Smt Shakuntla  r/o 3A, Kilokari Village,

PO Jungpura, New Delhi-110014                                                    …Complainant      

                 Versus

OP1- United Insurance Company Ltd.,

30/31B Jeevan Vikas Building,

Asaf Ali Road, New Dehli-110002.   

OP2-   Vipul Medicorp TPA Pvt. Ltd.

515 Udyog Vihar, Phase-V, Gurgaon

Haryana- 122016                                                                             ...Opposite Parties

                                                                                    Date of filing:              29.01.2016

                                                                                    Date of Order:             05.06.2024

Coram:                                                                      

Shri Inder Jeet Singh, President

Ms Rashmi Bansal, Member -Female

                                                       ORDER

Inder Jeet Singh , President

This case scheduled for Order today (item no.12)

1. (Dispute of parties) - The complaint was filed with allegations of negligence, deficiencies of services and unfair trade practice against OPs since complainant/insured was not reimbursed medical bills of Rs. 65,872/- in respect of treatment of her son Deepak. The complaint informed the OP2, immediately on hospitalisation of her son. Then claim was lodged with original documents but the complainant was not informed of status of settlement of claim. The web-site  of OP2 was browsed to ascertain the status, then complainant was shocked to see a query of document was raised despite the those documents already furnished, however, copies were again sent. Again information was not delivered about settlement of claim but on website of OP2 it was being shown that matter was referred to OP1, who closed the claim.

1.2 The complaint is opposed by other side that neither there was negligence, deficiency of services nor unfair trade practice. The complainant failed to furnish requisite documents to OPs despite requests so enable them to process the claim and then it was closed, the complainant is at fault.

1.3. It is material to mention at this stage of order that the written statement was filed by United India Insurance Company Ltd/OP1 under the illegible signature and without stating the name and designation of author of the written statement. The vakalatnama in favour of the counsel is executed in same fashion by OP1. However, it bears seal of the OP1 Company.

            But the subject/heading of written statement is mentioned as written statement of OP1 [United India Insurance Co. Ltd] and  also of OP2  [Vipul Medicorp TPA Pvt Ltd] but there is no authority or  SPA by OP2 in favour of OP1 or else to write, verify, sign and file the written statement. The written statement does not bear signature of OP2.  Therefore, at the outset OP1 has no authority to sign, verify and file the written statement for and on behalf of OP2. Consequently, the written statement on record will be considered of OP1 exclusively and accordingly case will be narrated. There is no written statement of OP2. Similarly, affidavit of evidence filed on behalf of OP1 also mentions as if is for OP2, it is also without any authority.

2.1 (Case of complainant) - The matrix of case of the complainant is that she took medi-claim policy no. 040200/48/13/06/00002514 valid from 21.01.2014 to 20.01.2015 (hereinafter referred as insurance policy) from OP1 by paying premium amount of Rs.7,503/-. The OP2 is TPA of OP1. The complainant's son Deepak was suffering from Acute Urinary Tract Infection   and he visited Ekansh Nursing Home, where doctor advised him for admission and treatment; thus he was admitted there on 25.10.2014. The OP2 was informed of his hospitalization through email dated 25.10.2014 [paragraph 3 of the complainant mentions all email addresses of OP2]. The complainant’s son was discharged on 01.01.2014. Thence, complainant submitted claims for Rs.65.872/- with all original medical documents with covering letter dated 03.11.2014 to OP2 through speed post vide receipt no.ED358867000IN on 03.11.2014.  The complainant waited for the response but no response was received for their side, then she visited website of OP2; she was shocked to see that one query was raised by OP2, for which no communication was delivered to the complainant. However, the complainant replied the said query by issuing covering letter/reply dated 27.11.2014 alongwith required documents through speed post receipt no. ED358867075IN dated 27.11.2014.

            That the complainant sent the reply but OPs have not settle the claim, even OP2 uploaded the same query and finally they have mentioned on 18.03.2015 in their website that the claim has been referred to OP1 and close the claim due to non-compliances; whereas the complainant had issued the reply to their queries but no reminder was received by the complainant. It is crystal that they have no intention to settle and pay claimed amount under mala-fide with ulterior motive. The OPs played fraud with the complainant, they indulged in deficiency of services and unfair trade practice to the disadvantage of complainant, they have caused harassment, mental tension and agony. They are liable for the same. That is why, the complaint was filed for reimbursement of medical claim of Rs.65,872/-, compensation of Rs. 50,000/- for harassment and agony, and cost of Rs. 25,000/- besides other consequential reliefs.

2.2  The complaint is accompanied with copies of – letter dated 03.11.2014  to OP2 in respect of submitting of the papers, emails, copy of insurance policy, claim form, medical certificate, cancelled cheque, prescriptions dated 22.10.2014, medical bills/receipts, discharge summary, physician’s progress notes and orders, email/pending query detail  (12.11.2014, 24.11.2014, 05.12.2014, 25.02.2015 and 18.03.2015) on the website of OP2, copy of letter dated 27.11.2014, further prescriptions and authorization for admission by Ekansh Nursing Home.  

3.1 (Case of OP1) - The OP1's case, as set up in the written statement, is it does not dispute of issue of Policy no. 040200/48/13/06/00002514 for the period 21.01.2014  to 20.01.2015 to the complainant. The OP2 is an intermediary service provider for settlement of all the claims and disputes on behalf of OP1. The parties are bound by conditions of insurance policy.

3.2. The complainant has concealed material fact from the complaint and there is no cause of action in her favour. The complainant failed to disclose, rather concealed, by not disclosing that insured was suffering from high fever, therefore, the complaint is not maintainable. Moreover, certain queries were raised followed by reminders to furnish all documents prior to hospitalization consultation taken for last five days and prescriptions of the doctors or family physician, who referred him to Ekansh Nursing Home, besides doctor’s progress notes and nursing notes in detail date-wise. The complainant failed to complete the formality and to furnish the documents.

3.3.  The written statement  also  makes reply on merits and in fact all the facts, figures, dates and other circumstances are simply denied by the OP1 but it has set up its case in preliminary objections/submissions. The OP1 further supplements that neither there is any negligence nor deficiency of services nor unfair trade practice but there was non-compliance by the complainant of requisite documents, therefore, the complaint is liable to be dismissed. The written statement is not accompanied with any document record.

3.4 (What is case of OP2?) – As already mentioned in para 1.3 above, there is no written statement by and on behalf OP2. Thus there is no plea or defence of OP2.

4.1 (Evidence of parties) - The complainant led his evidence by filing detailed affidavit, duly supported by the record filed with the complaint.

4.2. OP1 also led its evidence by filing affidavit of Sh. Virbhan, Senior Divisional Manager, the affidavit is on the lines of written statement.

4.3. There is no evidence on behalf of OP2, however, the affidavit of Sh. Virbhan, Sr. Divisional Manager of OP1, also mentions to be affidavit of OP2. Whereas, in terms of observation recorded in paragraph 1.3 above, when there is no written statement by OP2, there cannot be evidence for want of pleading. In addition, the OP1 has abused the process of law as for want of any authority in favour of Sh. Virbhan, Sr. Divisional Manager to lead evidence on behalf of OP2, he could not file affidavit for OP2.

5. (Final hearing) - Both the sides filed their respective written arguments, which are on the lines of complaint and evidence led by them. Sh. Tanuj Sharma, Advocate for complainant made the oral submissions. However, Shri Sahil, Advocate/associate of Shri Umesh Kaushik, Advocate for OP1 requested to consider the written arguments as oral submissions of OP1.

6.1 (Findings)- The contentions of both the sides are considered, keeping in view the evidence of the parties and provisions of law. After taking into account stock of all such materials, the following conclusions are drawn:-

(i)  The complainant has proved letter dated 03.11.2014 with postal ticket that all the documents were furnished to OP2 but the OP1 has denied all the circumstances in the written statement inclusive of receipt of any of documents vis-à-vis the OP1 pleads deficiency of two documents. The deficiency of two documents could be said only when other documents are received. Therefore, OP1’s plea that no document was ever since received is contrary to proved record by the complainant. The complainant has also proved other letter dated 27.11.2014 with postal receipt when copies were sent again, alongwith previous reference of 3.11.2014 & other detail.

(ii)  There is no written statement of OP2 to challenge the testimony of the complainant or want of receipt of record.

(iii)  The OP1 has not proved any document that its TPA/OP2 has asked the complainant for such documents vis-à-vis there is no proof of any letter or any documentary record filed either by OP2 or OP1. 

(iv)   The complainant has proved record of browsing the website of OP2 and then an email dated 25.10.2014 was sent to medical officer of OP2 in a very strong wordings that intimation of high grade fever with vomiting was informed as well as hospitalization of son of the complainant. There is no contrary evidence by the OP1 that OP2 was not informed of such information.

 (v)  The complainant has also proved letter dated 27.11.2014 that the documents were already furnished and information was also provided, this letter was also written in strong wordings that the investigator is just showing queries with mala-fide intention despite that information was already furnished. The record of website of OP2 is also proved that even after 27.11.2014 the OP2 was showing that such information is yet to be received. The complainant had furnished entire document record in original to the OPs.

(vi) The sub-clauses (i) to (v) above, clearly depict that the OPs were furnished all information and documentary record, which is corroborated with the letters, email etc. and despite it the OP1 is maintaining about non-receipt of few documents. It would be normal course for OPs to write that out of record furnished, some record was not received, if it was not actually received; but OP1 is putting entirely different plea that no documents were received nor some other documents. The OP1 could not prove its stand as well as the testimony of complainant remained unchallenged so far OP2 is concerned.

(vii) The OP1 is a professional insurance company and OP2/TPA is also body incorporate governed by the regulations framed by IRDA, the documents were received by them and despite receipt of documents and asking them again and again showing that the same were not received, when complainant protested it in strong wordings, then OP2/TPA referred the matter to OP1.  This is not expected from a professional body and in fact it manifest that this was adopted as a devise to avoid contractual obligation under the  insurance contract to reimburse valid medical claim of complainant. This bad practice is deprecated.

6.2. At the outset, the complaint was filed for reimbursement of medical bills of Rs. 65,872/-, besides other relief vis-à-vis the hospitalization of son of complainant and medical expenses incurred are not disputed by the OPs but their plea is that complainant failed to furnish prescription. Whereas, it is already held in paragraph 6.1 above, that the OPs were provided with all documentary record in original and other information to OP2. The complainant has also proved in this complaint that medical record inclusive of hospitalisation of complainant’s son from 25.10.2014 to  01.11.2014, discharge summary, medical bills and expenses paid during hospitalisation. The complainant has spent total amount of Rs. 65,872/- on the treatment of her son.

6.4   In view of above conclusions, it is established that complainant's son was advised admission for treatment and he was hospitalized. The claim was lodged with all original papers but valid claim was declined on the ground that  some medical  prescriptions were not furnished, which OPs could not prove. There is deficiency of services. Therefore, the complainant is held entitled for refund of paid medical bills amount of Rs.65,872/- against OP1, which is within the sum insured of Rs.4,00,000/-.

7.1       The complainant claims compensation of Rs. 50,000/- on account of harassment and agony. It is apparent that OPs have not settled the valid claim within the normal course under the policy. The valid claim was declined on the pretext the some prescriptions were not furnished, despite receipt of record twice - firstly in original and secondly copies, that too the complainant had furnished of her own after information byh browsing the website of OP2, as complainant was not informed so. The circumstances are suggesting that complainant deserves compensation, in lieu of harassment, un-certainty, inconvenience, agony which ought to be reasonable to the situation, therefore, compensation of Rs.20.000/- is awarded in favour of complainant and against OP1.

7.2  The complainant also claims cost of Rs. 25,000/- besides other consequential relief. Since, complainant has to file the complaint to seek reimbursement of valid claim after exhausting all efforts, had it been settled and paid,  she was not requiring to file complaint. Hence, costs of Rs.15,000/- is allowed in favour of complaint and OP1.

7.3 The complainant has also claimed other relief. Since she had parted with money from her pocket to clear medical bills for treatment her son and it also remained unpaid for want of settlement of claim. It is appropriate to award reasonable interest, therefore, interest @ 6% per annum is allowed [on amount of Rs.65,872/-] from the date of complaint till realisation of amount in favour of complaint and against OP1.

7.4 The complainant also claims other appropriate  relief against OPs under such peculiar situation of this case. Would  it be a fit case to award punitive damages?.

            Firstly, what is punitive damages and what is its purpose? The punitive damages (exemplary damages) are assessed and awarded in order to pinch respondent for outrageous/intolerant behaviour and/or to refrain it or to deter others from engaging in conduct similar to that which formed basis of law suit. Punitive damages are also  imposed to reform defaulting party as well as to deter other from indulging in such wrongs. Punitive damages are generally given in civil action, however, there is also provision in section 14(1)(d) the Consumer Protection Act, 1986 for punitive damages.  The punitive damages are not fine or penalty as fine is imposed in criminal trials.            

            It needs to refer the evidence on record. The complainant had informed the OP2 immediately on hospitalization of her son and subsequently after discharge of her son, that too after payment of entire medical bills. The claim for reimbursement of medical bill was lodged and complainant has furnished all original documents with the covering letter, however, the complainant was not informed of progress or settlement of claim or for any further requirement. The complainant gained information by browsing the website of OP2 that a query was raised; it was addressed by the complainant and despite furnishing the documents initially, again copies were furnished. The complainant was also not informed the status of the claim and subsequently she came to know on the website. Whereas, the OPs are professional institutions and OP2 was acting for facilitation of process of the claim, being its prime duty under the Regulations but the complainant was not apprised of status of the claim. The OP1 maintains the same stand in the written statement and it failed to prove if there was any communication made to the complainant either directly by OP1 or OP1 through OP2. The circumstances are speaking to what extent the complainant was dealt with by the OP1, she was kept in dark but because of own efforts by the complainant by browsing the web-site and compliance, again she was not informed of status of claim. It is a classic example of avoiding the obligations under contract and harassing the deserving claimant. They are required to be  dealt in manner so that they may not repeat it again. Thus, it is fit case to award punitive damages and the same are quantified as Rs.15,000/- (being meager amount) in favour of complainant and against OP1, keeping in view all circumstances, so that OP1 may not repeat this kind of practices.

7.5   It is also not out of context to mention that OP1 is knowing well that written statement is by OP1 exclusively, however, the title of written statement is mentioned as if it is also written statement for OP2, it is unfair on the part of OP1 and also mis-representation by OP1 to treat the written statement of OP1 for OP2 also, without having any authority. Further, it was also repeated while filing the affidavit of evidence on behalf of OP1 but the name of OP2 was included despite there was no authority or pleading from OP2. The OP1 should resist from repeat of this practice in other prospective cases. OP1 is also imposed cost of Rs.5000/- to be deposited in the State Commission  Consumer Welfare Fund (Legal Aid.

7.6.   The role of OP2 is of a facilitator to process the claim, the OP2 is TPA of OP1 but the OP1 is Insurer and complainant is Insured inclusive of her son Deepak/patient. As such an agent/TPA cannot be fastened with any liability.

8.1  Accordingly, the complaint is allowed in favour of complainant and against the OP1 to refund/reimburse medical bill amount of Rs.65,872/- along-with simple interest @ 6%pa from the date of complaint till realization of amount; apart from to pay compensation of Rs.25,000/-. punitive damages of Rs.15,000/- & costs of Rs.15,000/- to complainant. The OP1 will pay the amount within 45 days from date of this order, failing which the OP1 will be liable to pay enhanced interest at the rate of 8% per annum on amount of Rs.65,872/-.The OP1 may deposit the amount in the Registry of this Commission by way of valid instrument in the name of the complainant.

8.2.  The OP1 will also deposit the costs of Rs.5,000/- in State Commission Welfare Fund (Legal Aid) [the account no.00000010310544717, IFSC Code SBIN0001187. MICR code 110002049]. This compliance will be done by Divisional/Principal officer OP1, within 45 days and furnish the receipt of deposit of amount of its own, without further notice from this Commission. The non-compliance will have legal consequences and concern Officer will be  liable there-for..

8.3. The complaint against OP2 is dismissed. 

9.  Announced on this 5th day of June 2024 [ज्येष्ठ 15, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.

 [ijs-69]