Chandigarh

DF-II

CC/1178/2019

Jaspal Singh - Complainant(s)

Versus

United India Insurance Co. Ltd., - Opp.Party(s)

Inderdeep Singh Adv.

03 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

Jaspal Singh son of Late Sh. Saroop Singh, resident of Village Balamgarh, Mandwara, Rupnagar, Punjab, 140108

....Complainant

Versus

1.  United India Insurance Co. Ltd., Divisional Office at 6A, Vulcan Insurance Building, Door No-6, 6th Floor, Veer Nariman Road, Church Gate, Mumbai, Maharashtra-400020

2.  Travel Track Cover More Pvt. Ltd. (Earlier known as Karvat Cover-More Assist Pvt. Ltd.), Mistry Bhawan, 4th Floor, Next to K.C.College, Dinshaw Vacha Road, Churchgate, Mumbai-400020

2nd Address:-

SCO-139-140, 2nd Floor, Office No.202, Sector-9C, Madhya Marg, Chandigarh

3. Medi Assist Insurance TPA Pvt. Ltd. (Earlier known as Dedicated Healthcare Services TPA India Pvt. Ltd.), Legal Cell, Aarpee Chambers, 4^th Floor, Behind Time Square Building, Andheri Kurla Road, Marol, Andheri (East), Mumbai-400059 (

SCO No.37, 2nd Floor, Office No. 202, Sector-31-D,Chandigarh

…. Opposite Parties

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

1.     The complainant has filed the present complaint pleading therein that on the persuasion/assurances of OP No.2, he purchased Medical Policy No. 0216002814P112216929/UI00043945 valid from 20.03.2016 to 19.03.2017, issued by OP No.1 (Annexure C-1) and copies of the Health card issued to the complainant and his mother is annexed as Annexure C- 2 Colly. Smt. Leela Devi, mother of complainant aged 66 years examined on 28.03.2016 and underwent a surgery of necrotizing fasciculitis right lower limb by the procedure of Debri diment at Katyayani Hospital Zirakpur-Panchkula Highway, Zirakpur, Punjab by incurring Rs.45,229/- and discharged on 31.03.2016 (Annexure C-4). The copies of Payment Receipts are annexed as Annexure C-3 Colly. The complainant-Mr. Jaspal Singh aged 42 was examined on 02.03.2017 and diagnosed as having B/E Cataract and underwent L/E Phacoemulafication with multifocal PCIOL implantation on 16.03.2017 at Life Care Masonic Charitable Eye Hospital, Sector 18-B, Chandigarh by incurring Rs.46,000/- and discharged on the same date i.e. 16.03.2017 (Annexure C-6). The copies of Payment Receipts of complainant are annexed as Annexure C-5 Colly.  Thereafter, the complainant submitted the separate claim applications for his mother and himself to OP No.2 for reimbursement of the claim on 17.08.2016 and 28.03.2017 ((Annexure C-8 & C-9 respectively) who forwarded the same to OP No.3. The complainant also submitted the requisite documents as required vide letters dated 15.10.2016 and 22.04.2017. As per directions of OP No.2, the complainant collected the complete copies of claim in both the cases from OP No.2 and submitted the same to OP No.3 and OP No.3 assured the complainant for processing the claim as soon as possible. The complainant came to know that OP No.3 passed/approved the claim but to deficient i.e. Rs.26,485/- in case of complainant and Rs.29,760/- in case of Smt.Leela Devi and OP No.3 has forwarded the claim to OP No.1 but till date OPs did not pay any heed to give the claim amount to complainant. Finally, the complainant got served a legal notice dated 20.06.2019 through his counsel upon the OPs but the same has also failed to yield any result. Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OPs to reimburse the claim amount of Rs.91,229/- i.e. Rs.46,000/- in case of complainant and Rs.45,229/- in case of his mother along with interest @ 18% from the date of submission of claim till decision of the complaint, compensation for mental agony and physical harassment as well as litigation expenses.
2.     After service of notice upon OP No.1, they appeared before this Commission and filed their written version admitting the factual matrix of the case and stated that they submitted the deficiency letters to the complainant requiring him to submit the documents so that the claim can be settled as per the terms and conditions of insurance policy and the claim is not repudiated till date but instead of submitting the documents the complainant filed the complaint.   It has further been stated that the complaint qua the claim of Smt.Leela Devi being major and not filed by her or signed by her nor there is any averment with regard to her disability or non-alive and the  complainant is not competent to file the complaint on behalf of her mother. Besides this, the complaint is premature as the claim has not been repudiated till date the same is kept pending for payment for want of documents. It has further been stated that the policy is "Karval Bronze Policy" there is a limit for cataract as 10% SI- Maximum Rs 15,000/- per eye is payable hence the claimant cannot claim more than that for surgery and medical bills during hospitalization. It has further been stated that the complainant claimed Rs.46,390/- whereas he is entitled to get Rs.26,485/- only after deductions as per the terms and conditions of the policy  subject to submit of documents. Similarly, Smt.Leela Devi claimed Rs.45,229/- whereas she is entitled to get Rs.29,760/- only after deductions as per the terms and conditions of the policy  subject to submit of documents. It has further been stated that both the claims are kept on hold by concern Department for want of documents to be submitted by the complainant.     The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on their part, the OPs prayed for dismissal of the complaint.
3.     The complainant filed rejoinder to the written version of OP No.1 controverting their stand and reiterating his own.
4.     Despite due service through registered post, OPs No.2 and 3 failed to put in appearance and as a result thereof they were ordered to be proceeded against exparte vide order dated 06.03.2020.
5.     Parties filed their respective affidavits and documents in support of their case.
6.     We have heard the Counsel for the contesting parties and have gone through the documents on record including written submissions.
7.     The main issue involved in the present case is whether the complainant is entitled to reimbursement of the claims submitted with the OPs or not?
8.     In order to find out answer to the above mentioned issue, it is important to take into consideration the following facts and circumstances of the present complaint.
9.     The facts with regard to the issuance of the mediclaim policy (Annexure C-1) to the complainant and his mother –Smt.Leela Devi; the expenses incurred by the complainant and his mother-Smt.Leela Devi in the hospitals aforesaid for the surgeries as mentioned in the opening para of the complaint and the submission of the claims for reimbursement of the aforesaid expenses incurred by them with the OPs have not been disputed.
10.     As regards the claim with regard to the expenses incurred by Smt.Leela Devi i.e. mother of the complainant in the hospital is concerned, the complainant has got no locus standi to claim the expenses thereof on behalf of his mother without any approval or authority to do so in his favour.  As per the provisions of the Consumer Protection Act, 2019, the  complainant is not entitled to file the complaint on behalf of her mother unless he has been given an specific approval/authority in this regard to do so by the mother herself. Even in the case where the mother of the complainant gives an approval/authority to file the complaint on her behalf even then also he has to file the complaint in the name of the original consumer through his name as an authorized representative and not directly in his own name as the consumer. As such the claim with regard to Smt.Leela Devi as claimed in the present complaint is rejected. However, the mother of the complainant i.e. Smt.Leela Devi is at liberty to seek reimbursement of the mediclaim with the OPs as per law.
11.     From the perusal of the documentary evidence especially the payment receipts of the hospital (Annexure C-5 Colly.) and the discharge summary (Annexure C-6), it is established that the complainant had incurred a sum of Rs.46,000/- on account of the treatment of L/E Phacoemulafication with multifocal PCIOL implantation on 16.03.2017 at Life Care Masonic Charitable Eye Hospital, Sector 18-B, Chandigarh and the aforesaid expenses have not been disputed even by the Insurance Company. Therefore, the complainant is held entitled to that amount because Rs.46,000/- (i.e. Rs.33,500/- towards IOL (LENS), Rs.4,500/- towards, surgeon charges, Rs.3,000/- for other charges, Rs.3,200/- for OT Medicines and Rs.1,800/- for nursing charges) were charged from him as is evident from the discharge & Eye Surgery Bill dated 17.03.2017 (Annexure C-6) issued by Life Care Masonic Charitable Eye Hospital, Sector 18-B, Chandigarh.
12.       As regards the plea of OP No.1 regarding non-submission of the requisite documents despite issuing of the deficiency letter is concerned, the same is tenable in the eyes of law because as submitted by OP No.1 itself, the claim of the complainant has already been approved/assessed by OP No.3 but the same has not been released, which itself sufficient to conclude that OP No.1 is unnecessarily harassing the complainant by writing letters instead of releasing the genuine claim to him. In view of the facts and circumstances of the present case, non-release of the claim by OP No.1 to the complainant certainly amounts to deficiency in service as also indulgence into unfair trade practice on their part.
13.     In view of the above discussion, the present complaint deserves to be partly allowed qua OP No.1 only and the same is accordingly partly allowed. OP No.1 is directed to reimburse mediclaim of Rs.46,000/- the complainant along with interest @ 9% p.a. from the date of its receipt till its actual realization.
14.      This order be complied with by OP No.1, within 90 days from the date of receipt of its certified copy.
15.     The complaint qua OPs No.2 and 3 stands dismissed.
16.     The pending application(s) if any, stands disposed of accordingly.
17.     Certified copy of this order be sent to the parties, as per rules. After compliance file be consigned to record room.