BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.144 of 2016

Date of Instt. 29.03.2016

Date of Decision: 26.03.2019

Gurpreet Singh S/o Sh. Jagat Singh, 124/30 Basti Sheikh Road, Jalandhar.

..........Complainant

Versus

1. United India Insurance Co. Ltd., Divisional Office No.2, 3^rd Floor, Syal House Lajpat Nagar Market, Jalandhar through its Divisional Manager.

2. Raksha TPA, Company Ltd. SCO 359, 1^st Floor, Sector 44-D, Chandigarh, through its Director.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Jyotsna (Member)

Present: Sh. K. C. Malhotra, Adv Counsel for the Complainant.

Sh. R. S. Arora, Adv Counsel for the OPs No.1 & 2.

Order

Karnail Singh (President)

1. The instant complaint has been filed by the complainant, wherein alleged that he obtained Family Medicare Insurance Policy covering risk to reimburse/indemnify expenses to the insured persons expenses incurred for hospitalization and for medical/surgical treatment at any hospital/nursing home and for any disease or suffer from any ailments, disease or injury sustained from OP No.1 through its authorized agent for the period stated in the policy schedule by renewal effective from 20.07.2014 to 19.07.2014. The complainant has been continuously and un-interruptly and his wife Smt. Gaganpreet Kaur and Master Harkran Singh-son since year 2010 without any gap/break. Policy number was allotted 201300/48/120/06/0000069. The insured person covered by Family Medicare Policy for Medical benefit are as under:-

2. That cover note and policy schedule of policy was issued in the name of complainant. The total amount of renewal premium of Rs.4556/- as consideration was paid to the OP No.1 through its authorized agent, which was accepted after satisfying the continued insurability and without questioning the credentials of the insured persons without any demur and strings. The OP No.1 delivered to the complainant cover note and policy schedule of Family Medicare Policy only from the inception of the risk coverage and on its renewal. The policy document was not delivered to the complainant by the OP No.1 during the whole of the period of the policy, whereas it was mandatory and obligatory upon the OP No.1 to have issued policy document to the insured person, but the OP has violated the said regulation.

3. That the OP No.1 has agreed and undertaken to indemnify for medical and surgical expenses for illness/sickness, accident and surgical operation etc. contracted between the period of insurance to the full extent without any deduction in any manner. Accordingly, the complainant has the right of indemnification/reimbursement for whole amount of medical and surgical expenses incurred and for any loss or damage of peril covered during the term of Family Medicare Policy. That Harkran Singh, son of the complainant, co-insured with the OP No.1, complained and on examination was diagnosed Acute Tonsillitis and was advised surgery. He was admitted on 29.05.2015 for surgical operation and discharged on 30.05.2015 in Kataria Eye & Ent Hospital Pvt. Ltd., Gujaral Nagar, Jalandhar. After discharge from the hospital, the complainant made a claim for amount of Rs.31,917/- for medical and surgical expenses incurred by the complainant for reimbursement for hospitalization and treatment for surgery Acute Tonsillitis to the OP No.1 duly completed claim on prescribed form, bills receipts and discharge certificate along with clinical tests report etc. were submitted. All these documents are with OPs. The complainant completed and complied with all the requirements whichever were asked for the settlement of mediclaim of the complainant for full amount of Rs.31,917/-. The claim was duly registered by OP No.1, vide claim No.54551516067873.

4. That to utter surprise and dismay of the complainant unilaterally, oppressively and arbitrarily, the OPs reduced mediclaim reimbursement in the sum of Rs.19,117/- from total claim of Rs.31,917/- and remitted reduced amount of Rs.19,117/- through NEFT to his banker, IDBI Bank, Bombay Palace, Jawahar Nagar, Cool Road, Jalanddhar in his Bank Account, after deduction of Rs.12,800/- from mediclaim amount of Rs.31,917/- of the complainant on the purported grounds that deductions are strictly as per the terms and conditions of family medicare policy issued by OP No.1 without stating any such conditions and exclusion clause and without providing details of such purported deductions. This was revealed from the bank statement. The OP has wrongly drastically reduced the mediclaim, which is tantamount to deficiency in service on the part of the OPs and accordingly, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse balance mediclaim amount of Rs.12,800/- along with interest @ 12% per annum from the date of lodgment of complaint upto the date of actual payment to the complainant and further OPs be directed to pay compensation of Rs.50,000/- for causing mental tension to the complainant as well as also directed to pay litigation expenses of Rs.10,000/-.

5. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the respondent insurance company out of Rs.31,917/- assessed the total claim at Rs.19,117/- as per the insurance conditions and paid the same after due application of mind, but the complainant has gone in for the frivolous and vexatious litigation in abuse of the process of law. It is further alleged that the complainant is estopped by his act and conduct to bring the complaint and even the complaint is frivolous and vexatious, therefore, deserves to be dismissed with heavy cost and further averred that there is no ground for enhancement of claim. If the complainant is to go in for litigation by raising dispute over the quantum, he is liable to be relegated to the Civil Court. On merits, the factum in regard to purchase of Medicare Insurance Policy by the complainant himself as well as his family, is admitted and it is also admitted that a claim was submitted by the complainant regarding his son and the same was considered and appropriate amount was paid to the complainant to the insured as per terms and conditions, but the remaining allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

6. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA and supplementary affidavit of the complainant Ex.CB along with some documents Ex.C-1- to Ex.C-3 and closed the evidence.

7. Similarly, counsel for the OPs tendered into evidence affidavit Ex.OA along with some documents Ex.O-1 and Ex.O-2 and closed the evidence.

8. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

9. Before considering the claim of the complainant on merit, we preferred to take into consideration a legal aspect whether the complainant is a consumer as per the definition of the Consumer Protection Act. Keeping in mind the above query, we have gone through the complaint and find that Medicare Insurance Policy was obtained by the complainant Gurpreet Singh along with his wife Gaganpreet Kaur and his son Master Harkran Singh. From the averments of the complaint, it reveals that a treatment was obtained not by the complainant rather his son Harkran Singh and further in Para No.7 of the complaint, the complainant himself stated that Harkran Singh son of the complainant is co-insured with the OP No.1 and further the documents placed on the file by the complainant himself i.e. Claim Settlement Voucher Ex.C-1 also described the claimant/patient Harkran Singh not the complainant Gurpreet Singh and similarly, the documents of Kataria Hospital Ex.C-3 also shows the patient was Harkran Singh, not so the copy of the insurance policy placed on the file by the OP as Ex.OP-2 also described the name of the insured persons i.e. Gurpreet Singh, Gaganpreet Kaur and Harkran Singh. All are individually insured not through Gurpreet Singh only and even the amount of insurance of each has been explained and even nominee of the each has been very well explained in the said policy. So, it means that the insured Harkran Singh is the consumer not his father because the said Harkran Singh is individually got insurance policy though it is a family policy, but we cannot say that they are collectively insured rather it is clear that they are individually insured, if so, then only Harkran Singh is entitled to file the instant consumer complaint not his father. If the said Harkarn Singh is minor, then the complaint can be filed through his father or mother not directly through his father. So, from the above discussion, it has become clear that the complainant Gurpreet Singh is not a consumer qua the facts of the complaint in hand, therefore, the complaint is dismissed and consumer Harkarn Singh has right to file his individual complaint by authorizing any person or through any authorized person and the period consumed in this complaint will be condoned according to the law of limitation and accordingly, this compliant is dismissed being not maintainable. This complaint could not be decided within stipulated time frame due to rush of work.

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

Dated Jyotsna Karnail Singh

26.03.2019 Member President