BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.90 of 2020

Date of Instt.04.02.2019 Date of Decision:20.04.2021

Ashok Kumar Gupta resident of 736, J. P. Nagar, Jalandhar.

..........Complainant

Versus

1. United India Insurance Co. Ltd. Head Office, 24, Whites Road, Chennai, Tamil Nadu.

2. Local Office at United India Insurance, 19, Floor No.1 G. T. Road, Jalandhar 144001.

3. Health Insurance TPA of India Ltd. A-110, Block A, Sector 4, Noida, Utter Pardesh 201301.

….….. Opposite Party

Complaint Under the Consumer Protection Act.

Before: Sh. Kuljit Singh (President)

Smt. Jyotsna (Member)

Present: Complainant in Person.

Sh. P.P.S. Ahluwalia, Adv. Counsel for the OPs No.1 & 2.

OP No.3 exparte.

Order

Kuljit Singh(President)

1. The instant complaint has been filed by the complainant, wherein alleged that he is a retired manager from Punjab National Bank with PF No.102101. He has taken Group Insurance Cover from United India Insu. Co. Ltd. That his wife Sushma Gupta got a fracture and taken the treatment. That he has sent the reimbursement claim of Rs.2,69,485/- to TPA on 24.08.2019. That the claim Ref is 191100180970. That TPA Health Insurance approved the claim for Rs.1,72,426/- on 22.11.2019. That TPA sent approved claim for payment to United India Insurance for payment. That more than two months have passed, the insurance company has not made the payment. That the complainant has suffered mental tension and harassment and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to apologize for the inconvenience caused to the complainant and further OPs be directed to immediately make payment of the claim and further OPs be directed to pay a sum of Rs.1,00,000/- towards mental agony suffered by the complainant and further OPs be directed to pay Rs.5000/- as litigation expenses.

2. Notice of the complaint was given to the OPs, but despite service OP No.3 failed to appear and ultimately, OP No.3 was proceeded against exparte, whereas OPs No.1 & 2 appeared through its counsel and filed written reply, whereby contested the complaint by taking preliminary objections that the complainant is not a consumer in the eyes of law. That there is no deficiency in service on the part of the answering OPs nor the same can be attributed to the insurance company. It is further alleged that the matter is of technical nature and relate to complicated questions of the law and facts, which requires in depth investigation, framing of issues, cross-examination of witness and evidence which requires appreciation by the Civil Court. The summary procedure before this Forum would not be appropriate to come to definite conclusions and prove the documents in question, as such, this Commission is not competent to try, entertain and decide the present complaint. That the liability of the insurance company, if any, is strictly as per terms and conditions of the insurance policy. That the complainant has no locus-standi to proceed with the present as the claim amount was settled and approved for Rs.1,72,426/- as admitted in the complaint itself. That the complainant has concealed material facts before this Commission and is stopped by his act and conduct to raise any claim against the OP. That the claim under dispute was not repudiated by the OPs and there is no undue or unnecessary delay in settling the claim of the complainant as such, the present complaint is pre-mature and beyond the scope of insurance cover as such, no cause of action accrued within the jurisdiction of this commission to try, entertain and decide the present complaint. On merits, the factum in regard to take group insurance cover from the OPs No.1 & 2, is admitted and it is also admitted that the complainant has submitted the reimbursement claim of Rs.2,69,485/- to TPA on account of fracture and hospitalization of his wife Sushma Gupta. It is also admitted that TPA Health insurance approved the claim of Rs.1,72,426/- and sent approved claim for payment to the United India Insurance for payment, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3. Rejoinder not filed.

4. In order to prove their respective versions, both the parties produced on the file their respective evidence.

5. We have heard the argument fromcomplainant in person and counsel for the OP No.1 & 2 and also gone through the case file very minutely.

6. Firstly, we deal with this point, as to whether complainant being is a 'consumer' with OPs or not? The complainant who was insured with OP No.1&2. It is settled principle of law that 'Contract of Insurance' is for indemnification of loss and not for any commercial activity. The Hon'ble National Commission has also examined this point in M/s Harsolia Motors Vs. M/s National Insurance Co. Ltd reported in First Appeal No.159 of 2004 decided on 03.12.2004, wherein it has been held that hiring of services of the insurance company by taking insurance policy. The insurance policy is taken for reimbursement or for indemnity for the loss, which may be suffered due to various perils. There is no question trading or carrying on commerce in insurance policies by the insured.

7. It is an admitted fact that the complainant alongwith his wife had obtained group insurance policy from Ops. It is also an admitted fact that during the period ofinsurance, the wife of fell ill and was hospitalized and had paid a sum of Rs.2,69,485/- and the same admitted by OPs. It was argued by the counsel for the complainant that although it wasthe duty of the Ops to provide cashless facility but instead of providing the cashless facility they hadnot even reimbursed the bill when it was submitted to the Ops. Therefore, it was argued by the counsel for the complainant that the claim of Rs.1,72,426/- has already approved by OP-3.

8. The dispute remains between the parties is only that the complainant submitted a medi claim for treatment of his wife Sushma Gupta, was submitted to the OPs for reimbursement the said total medical expenditure amount was Rs.2,69,485/-, but out of that amount, the OP-3 has approved of Rs.1,72,426/- but the Op No.1&2 has not paid the same and through this complaint, the complainant alleged that there is a deficiency in service as well as unfair trade practice on the part of the OPs.

9. On the other hand, the contesting OP No.1 &2 alleged that the claim has been approved but still not paid by the Ops to complainant. The Ops have failed to produce any cogent evidence for not making of the payment of said approved amount. Moreover, than period of 2 years has already been lapsed and claim of complainant not settled yet. As such, the Ops are deficient in providing service to complainant.

10. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to reimbursement the approved payment to the complainant. Further, OPs are directed to pay compensation of Rs.5000/- to the complainant for causing mental tension and harassment including litigation expenses. The OPs have no right to keep and misappropriate the public money. It must go back to the public. We, therefore, order that the OPs will deposit a sum of Rs.3000/, with the legal aid account of this Commission.

11. Further, the entire compliance be made within 45 days qua compensation, litigation expenses and deposit of cost in legal aid account of this Commission by Ops from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room after due compliance.

Announced in open Commission

20^th of April 2021

Kuljit Singh

(President)

Jyotsna

(Member)