| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No. 330 of 9-12-2019 Decided on : 16-5-2023 Chanchal Kumar Verma aged about 39 years S/o Ramesh Kumar Verma R/o # Kothi No.6, Bharat Nagar, Bathinda. ........Complainant Versus United India Insurance Company Ltd., Divisional Office at 100ft Road, near Maheshwari Chowk, 1st Floor, Big Shot Restaurant, Through Divisional Manager. M/s Raksha TPA Pvt.Ltd., Medi Claim Department, SCO 359-360, Sector-44-D, Chandigarh-160047 through Managing Director/ Authorized Person.
.......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh. Lalit Mohan Dogra, President Sh. Shivdev Singh, Member Present : For the complainant : Sh. M.K. Batta, Advocate. For opposite parties : Sh. M.L. Bansal, Advocate, for OP No.1 Opposite party No.2 Ex-parte. ORDER Lalit Mohan Dogra, President The complainant Chanchal Kumar Verma (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986, ( Now C.P. Act, 2019 here-in after referred to as 'Act') before this forum (Now Commission) against United India Insurance Company Ltd., and another (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that he purchased medical Insurance policy No.2004002817P101417442 in the month of April 2017 for the period 19.4.2017 to 18.4.2018 in his name through party No.2 and deposited premium with the company. This policy covered the medical Insurance of whole family member of the complainant including complainant. It is alleged that during the policy period, complainant suffered from stone problem and was admitted in Garg Nursing Home, Bathinda for treatment and remained admitted there from 27.5.2017 to 1.6.2017. The complainant was treated for the ailment and doctor concerned charged a sum of Rs.42,173/- from the complainant for treatment including admission fee, OT charges, room charges, doctor visit fee etc. This amount was paid by the complainant vide receipt No.9652617 dated 2.6.2017. The complainant also purchased medicine and spent approx. Rs. 42,173/-. It is also alleged that as per term and conditions, complainant applied for reimbursement of amount spent by him on treatment and supplied to the opposite parties original copies of bills issued by the doctor as well as bills issued by chemist and all the requisite documents including treatment record. The complainant also sent bills by e-mail to the opposite parties on 25-7-2017. It is further alleged that after sometime again complainant suffered stone problem and remained admitted for treatment from 25.7.2017 to 29.7.2017. The complainant supplied copies of bills issued by doctor as well as medicine bills accrued by the complainant for treatment. Complainant also sent bills by email to opposite parties on 25-7-2017 and complainant spent a total sum of Rs.42,173/- for his treatment. It is also alleged that after sometime complainant's son fell ill and suffered medical problem and he was got admitted in Mahashwary Hospital, Bathinda. The complainant spent Rs. 7,528/- on the treatment of his son. Thereafter complainant applied for reimbursement of amount spent by him. The complainant alleged that whenever he approached the opposite parties for reimbursement of medical claim, opposite parties asked him to firstly deposit the original bills with the company office then the amount will be reimbursed. It is alleged that complainant submitted all original Bills with the company office but no payment was made. The opposite parties have not paid the claim as per terms and conditions of the policy inspite of completion of all the formalities. The complainant alleged that due to illegal and arbitrary act of the opposite parties, he has suffered great mental tension, agony, botheration, harassment and financial loss for which he claims compensation to the tune of Rs. 50,000/- in addition to Rs. 11,000/- as cost of litigation. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to refund the aforesaid total amount of Rs. 49,000/- with upto date interest @ 12% p.a. w.e.f. 29.7.2019 and pay any other additional or alteranative relief. Registered A.D. Notice of complaint was sent to the opposite parties, but none appeared on behalf of opposite party No. 2. As such, exparte proceedings were taken against opposite party No. 2. Upon notice, opposite party No. 1 appeared through counsel and contested the complaint by filing written reply raising legal objections that the present complaint has been filed by complainant only to injure the goodwill and reputation of the opposite party. Even otherwise, the complaint is false, frivolous and vexatious to the knowledge of the complainant. That intricate questions of law & facts are involved in the present complaint, which requires voluminous documents and evidence for determination which is not possible in the summary procedure under the 'Act' and appropriate remedy, if any, lies only in the Civil Court. It has been pleaded that true facts are that on receipt of claim of the complainant, the same was forwarded to opposite party No.2, which is deputed as TPA (Third Party Administrator) to decide the medi-claims and while processing the claim, TPA/opposite party no.2 found that the claim of the complainant pertaining to his treatment from Garg Nursing Home is of Rs.17,173/ and on scrutinizing the documents and information gathered during the course, opposite party No.2 observed that Original Pre numbered, Pre-printed duly signed and stamped receipt against final bill of the Hospital was not provided and only bill given for Rs. 4673/-. Accordingly, opposite party No.2 wrote two letters dated 25.09.2017 and 10.10.2017 requesting the complainant to submit the original documents, but the complainant did not provide the required documents/information to opposite party No. 2 and ultimately, opposite party No.2 vide letter dated 25.10.2017 sent final reminder to the complainant to provide the aforesaid requisite documents and information to process and settle the claim and vide the aforesaid final reminder, it was clearly conveyed to the complainant that 'The claim will be repudiated if no reply is received within 15 days after the Final Reminder', but even then, the complainant kept mum and did not provide the required documents and information. The claim of the complainant was filed as 'No claim'. Therefore, it is crystal clear that the complainant has miserably failed to provide requisite documents in support of his claim and all these material facts have been concealed by the complainant from this Commission. The other legal objection are that the complainant is estopped by his own act, conduct & acquiescence from filing the present complaint. That the complainant has no locus standi or cause of action to file the present complaint. That the present complaint is not maintainable in its present form. That the complaint is bad for non-joinder of necessary parties and that there is no deficiency in service or unfair trade practice on the part of the opposite party. On merits, opposite party No. 1 has reiterated its version as pleaded in legal objections and detail above. After controverting all the averments of the complainant, the opposite party No. 1 prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 9.12.2019 (Ex. C-1) and documents (Ex.C-2 to Ex.C-31). In order to rebut the evidence of complainant, the opposite party No.1 has tendered into evidence affidavit of Baldev Singh dated 30.1.2020 (Ex. OP-1/1) and documents (Ex. OP-1/2 to Ex.OP-1/5). We have heard learned counsel for the parties and gone through the file carefully. The learned counsel for the complainant argued that complainant had purchased medi-claim insurance policy which was valid w.e.f. 19-4-2017 to 18-4-2018 and the entire family of the complainant was covered under the said policy. It is further argued that during the continuation of the policy, complainant remained admitted for treatment at Garg Nursing Home, Bathinda w.e.f. 27-5-2017 to 1-6-2017 and doctors charged Rs. 42,173/- from the complainant. The complainant had to pay said amount from his pocket. The claim was lodged with the opposite parties but was not paid. It is further argued that again complainant remained admitted in the same hospital w.e.f. 25-7-2017 to 29-7-2017 and again Rs. 42,173/- was spent on treatment and was not reimbursed by the opposite parties. It is also argued that son of the complainant namely Yamya remained admitted in the hospital i.e. Maheshari Children Hospital, Bathinda due to illness w.e.f. 2-9-2017 to 5-9-2017 and the said claim of Rs. 7528/- was lodged with the opposite parties through e-mail. The complainant lodged all the claims through e-mails Ex. C-8 to Ex. C-11 and has also paid Rs. 18,800/- to Garg Nursing Home on 6-6-2017 as per Ex. C-12. On the other hand, learned counsel for opposite party No. 1 argued that policy of insurance is admitted. However, on receipt of claim of the complainant, it was forwarded to opposite party No. 2 which is deputed as TPA (Third Party Administrator) to decide the medi-claims and while processing the claim, TPA (opposite party No. 2) found that claim of the complainant was of Rs. 17,173/- and it was observed that original pre-numbered, pre-printed duly signed and stamped receipt against final bills of the hospital was not provided and only bill given was for Rs. 4673/-. Accordingly, opposite party No. 2 wrote two letters Ex. C-5 & Ex. C-6 requesting the complainant to submit original documents, but the complainant failed to submit the documents, as such, his claim was closed and there is no deficiency in service on the part of the opposite parties. We have considered rival contentions and gone through the record carefully. It is admitted fact that complainant and his family had obtained medi-claim policy of insurance which is Ex. C-13 valid from 19-4-2017 to 18-4-2018. It is further admitted fact that complainant remained admitted at Garg Nursing Home, Bathinda, two times and authorities of Garg Nursing Home charged Rs. 13,500/- vide Ex. C-14 and Rs. 18,800/- vide Ex. C-16. However, in Ex. C-14 & Ex. C-16, authorities of the hospital have not mentioned duration of treatment. Similarly, bill and medical record Ex. C-18 to Ex. C-31 pertain to treatment obtained by minor son of the complainant namely Yamya from Maheshwari Children Hospital, Bathinda, as per which son of the complainant remained admitted w.e.f. 2-9-2017 to 5-9-2017. The above referred documents and the evidence established that complainant and his son remained admitted under treatment during validity of the policy of insurance and as such, are definitely entitled to receive reimbursement of medical expenditure made during said treatment as per terms and conditions of the policy. Accordingly, present complaint is partly allowed with following directions : 1) Complainant is directed to submit admission and discharge record of his treatment w.e.f. 27-5-2017 to 1-6-2017 and w.e.f. 25-7-2017 to 29-7-2017 alongwith medical bills of Rs. 13,500/- and Rs. 18,800/- respectively with opposite party No. 2. 2) Complainant is further directed to submit entire treatment record and medical bills of Rs. 7528/- in respect of treatment obtained regarding illness of his son Yamya w.e.f. 2-9-2017 to 5-9-2017. 3) The opposite parties are directed to settle and pay the claim to the complainant as per terms and conditions of the insurance policy (Ex. C-13), within 45 days from the date of receipt of documents. 4) Since the complainant has established and proved to have lodged claims vide e-mail Ex. C-8 to Ex. C-11 and the said e-mail have not been replied and denied by the opposite parties, as such, complainant has definitely suffered harassment and had to indulge in uncalled litigation. Accordingly, complainant is held entitled to receive Rs. 5,000/- from the opposite parties on account of mental tension, harassment and cost of litigation. The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced 16 -05-2023 - (Lalit Mohan Dogra)
President (Shivdev Singh) Member
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