Complainant Gurmeet Singh through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that the necessary directions may kindly be issued to the opposite parties to honour the claim of the complainant and make the payment of insured amount qua the claim of the complainant immediately along with interest @ 18% P.A. from the date of his treatment till actual realization. He has further claimed Rs.50,000/- as compensation on account of mental agony, physical harassment and deficiency in service on the part of the opposite parties. Complainant has also claimed Rs.5000/- as litigation expenses, all in the interest of justice.
- The case of the complainant in brief is that on 12.5.2015 complainant had gone abroad i.e. USA and before leaving India for abroad he himself insured for the period 12.5.2015 to 30.6.2015 under the scheme of overseas mediclaim policy and paid premium of Rs.3534/- to the opposite party no.2. Opposite parties issued policy bearing No.2002022815P101459329 to the complainant. It was pleaded that while living abroad complainant fell ill on account of short breathing on 9.6.2015 and he had taken treatment from Dr.Narinder S. Arora, M.D. at his Hospital M.R.C.P. F.A.C.P. F.C.C.P. 308, 10th Street, N.E. Suite 2, Charlottesville, Richmond, Virginia (US) and had also spent 380 Dollars (aprox Rs.25,000/- of Indian currency) on his treatment. It was pleaded that prior to it complainant never suffered from any disease. It was pleaded that complainant had paid premium for the period from 12.5.2015 to 30.6.2015 and the opposite parties also issued cover note for the above said period but while issuing the policy the period of the policy was mentioned from 12.5.2015 to 25.6.2015. Complainant approached the opposite parties orally and telephonically from Batala, Delhi and even from USA but the opposite parties did not pay any heed to the request of the complainant. It was further pleaded that as per the terms and conditions of the policy opposite parties were responsible for making the payment to the concerned hospital where complainant had taken his treatment. It was pleaded that concerned doctor also made telephone call to the opposite parties on Phone No.+13056987757 which was attended by a lady namely Pamela who replied to receive money from the complainant whatsoever was due for his treatment and the same will be reimbursed to the complainant on arriving India. It was also pleaded that on 2.7.2015 complainant came to India and submitted his claim for reimbursement to the opposite party No.2 on 7.7.2015. It was pleaded that complainant was surprised when his claim was repudiated by the opposite parties vide letter No.Misc/SPD/2015/1264 dated 7.9.2015 with the observations “As per our DOI/Asr letter No.Misc/Claims/2015/405 dated 21.7.2015, as per specific conditions of the policy no claim will be paid in respect of routine physical examination or any other examination” but these observations of the opposite parties are illegal, imaginary, against the law and instructions and not sustainable in the eyes of law. It was next pleaded that it was not a routine check up because complainant had suffered from short breathing problem all of sudden which necessitated him to seek treatment immediately. It was pleaded that earlier complainant was not suffered from such problem nor he ever taken medical treatment for the same so the question of routine medical check up does not arise. Opposite parties were trying to wriggle out of their obligations of making payment of medical claim to the complainant by taking such like false and frivolous pleas. The act of the opposite parties for not making the payment of claim is illegal null & void and the decision of the opposite parties is liable to be set aside. It was pleaded that there was deficiency and gross negligence in service on the part of the opposite parties who did not pay the amount spent by the complainant on false and flimsy grounds, hence this complaint.
3. Notice of the complaint was served upon the opposite parties who appeared through their counsel and filed their written reply by taking the preliminary objection that complaint is not maintainable. On merits, it was stated that it was a simple check up and physical examination as per the medical bills. It was stated that the policy in question was effective from 12.5.2015 to 25.6.2015. It was further stated that no promise was made by any official of the Company that the money will be paid to the complainant on his arrival to India whereas he had neither suffered from any illness nor was he hospitalized for any treatment and as such he is not entitled for any claim. It also stated that a letter dated 7.9.2015 was written to the complainant as per the terms and conditions of the policy in question and the observations of the opposite parties are legal and there is no illegality in it. There was absolutely no deficiency of service on the part of the opposite parties or any of its officials. All other averments made in the complaint have been specifically denied and prayed for dismissal of the complaint with cost.
4. Complainant had tendered into evidence his own affidavit Ex.C1, along with documents Ex.C2 to Ex.C17 and closed his evidence.
5. Counsel for the opposite parties had tendered into evidence affidavit of Pardeep Singh Sr.Branch Manager Ex.OP-1 along with letter dated 7.9.2015 Ex.OP-2 and closed the evidence on behalf of the opposite parties.
6. We have examined all the documents evidence produced on record and have also considered and perused the arguments duly put forth by the learned counsels of the contesting parties, while adjudicating the present complaint. As per the documentary evidence on record the complainant produced copy of cover note and policy of United India Insurance Company Limited which was valid from 12.5.2015 to 30.6.2015 and premium of Rs.3534/- was paid. But policy was issued from 12.5.2015 to 25.6.2015 bearing policy No. 2002022815P101459329 which was an overseas Mediclaim B & H Policy Schedule. The complainant had gone abroad to U.S.A. on 12.5.2015 and complainant fell ill on account of short breathing on 9.6.2015 and he had undergone treatment from Dr.Narinder S. Arora, M.D. at his Hospital M.R.C.P. F.A.C.P. F.C.C.P. 308, 10th Street, N.E. Suite 2, Charlottesville, Richmond, Virginia (US) and had also spent 380 Dollars on his treatment. Copies of bills are Ex.C5 to Ex.C11 and Ex.C17. Intimation regarding treatment was sent to opposite parties but the opposite parties had repudiated the claim as no claim will be paid in respect of routine physical examination or any other examination where there is no objective indication of impairment of normal health. But this objection of the opposite parties is not tenable. As per the terms and conditions of the policy, the opposite parties were responsible for making the payment to the concerned hospital, where from the complainant taken treatment. All the relevant record has been produced by the complainant in his evidence. The observation made by the opposite parties that it was a simple check-up, it is imaginary, against the law and instructions and not sustainable in the eyes of law. It was not a routine check-up because the complainant suffered from short breathing problem all of sudden which necessitated him to seek treatment immediately. The complainant was earlier not suffering from such problem and he never taken medical treatment for the same. The opposite parties are trying to wriggle out of their obligations of making payment of medical claim to the complainant by taking such like false and frivolous pleas. The act of the opposite parties of not making payment to claim to the complainant is illegal against the law and instructions. The decision of the opposite parties for repudiation of claim is set aside. As such the opposite parties are liable to pay the medical claim to the complainant.
7. In the light of the all above, we partly allow the complaint and order the opposite parties to pay the medical claim of 380 U.S. dollars to the complainant Gurmeet Singh within 30 days of receipt of the copy of this order besides Rs.3000/- as cost of litigation. If the opposite parties fail to pay the amount to the complainant within one month from the receipt of the copy of order then the complainant is further entitled for 9% interest on the ordered amount from the date of orders till its realization.
8. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to the record room.
(Naveen Puri)
President.
ANNOUNCED: (Jagdeep Kaur)
MAY 12, 2016 Member.
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