Haryana

Yamunanagar

CC/507/2011

Pawan Madia s/o Sh.Vijay Madia - Complainant(s)

Versus

United India Insurance co. Ltd. - Opp.Party(s)

Dinesh Sharma

04 Jan 2017

ORDER

BEFORE THE DISTT.CONSUMER DISPUTES REDRESSAL FORUM YAMUNA NAGAR JAGADHRI

 

                                                                                    Complaint No. 507  of 2011.

                                                                                    Date of Institution: 18.05.2011

                                                                                    Date of Decision: 04.01.2017

Pawan Madia aged about 21 years son of Shri Vijay Madia resident of 179, Shastri Colony, Yamuna Nagar, District Yamuna Nagar.                                                                                                                                                                                            

                                                                                                                         ..Complainant

           Versus

1. United India Insurance Company Limited, branch office near Telephone Exchange, Yamuna Nagar through its Branch Manager.
2. Vipul Medcorp TPA Private Limited, 515, Udyog Vihar, Phase 5, Gurgaon, Haryana through its Managing Director/Authorized Signatory.

                                                                                                                       ..Respondents.

 

BEFORE:         SH. ASHOK KUMAR GARG …………….    PRESIDENT

                          SH. S.C. SHARMA  …………………………MEMBER  

 

Present: Sh. Dinesh Sharma, Advocate, counsel for complainant.

              Sh. Parmod Gupta, Advocate, counsel for respondent No.1.

              Respondent No.2 already ex-parte vide order dated 20.07.2011.

             

ORDER   

1.                        The present complainant has been filed by the complaint u/s 12 of the Consumer Protection Act, 1986. 

2.                    Brief facts of the present complaint, as alleged by the complainant, are that the complainant purchased an individual health insurance policy bearing 110101/48/09/97/00001056 (Platinum Policy) valid from 28.01.2010 to 27.01.2011 for a sum of Rs. 1,50,000/- from the Op No.1 which was a continuing earlier policy bearing No.1101114808970001139 valid from 28.01.2009 to 27.01.2010 whose the OP No.2 was TPA. The complainant remained admitted in the Rockland Hospital, New Delhi from 14.05.2010 to 16.05.2010 and operated upon under the supervision of Dr. Pushpender Singh Bajaj, Orth. Surgeon and Traumatologist specialist in arthroscopy and joint replacement and whole amount of near about Rs. 40,000/- was spent by the complainant from his own pocket. Thereafter, the complainant had severe vomiting on 19.05.2010 in the night at about 9.00P.M.and as such he was immediately taken to R.K.Hospital, Yamuna Nagar and remained admitted there and discharged on next day i.e. 20.05.2010 at about 5.00 P.M. After that complainant submitted the claim with the Ops Insurance Company and all the required documents pertaining to his treatment in the above noted hospital as well as bills were also submitted. Op No.2 i.e. Vipul Med Corp. TPA vide different letters sought documents time and again which were made already available to OP No.1 by the complainant at the time of putting the claim but the OPs did not pay any heed. Thereafter, the complainant sent representation on 27.12.2010 and reminder on 26.01.2011 but all in vain which constitute the deficiency in service and unfair trade practice on the part of the OPs. Lastly, prayed for directing the OPs to make the payment of claimed amount and also to pay compensation as well as litigation expenses. Hence, this complaint.

3.                     Upon notice OPs failed to appear despite service, hence, they were proceeded ex-parte vide order dated 20.07.2011.

4.                     However, OP No.1 was allowed to join the proceedings vide order dated 14.02.2013 at the stage of evidence.

5.                 Complainant failed to adduce any evidence despite so many opportunities and his evidence was closed by court order dated 25.02.2016. However, at the time of filing of complaint, complainant placed on file photo copy of insurance policy as Annexure C-1, Photo copy of quarry letter dated 01.07.2010 as Annexure-2, Photo copy of reminder of quarry letter dated 19.11.2010 as Annexure-3, Photo copy of reply of letters as Annexure-4, Photo copy of quarry letter dated 16.10.2010 as Annexure-5, Photo copy of OPD slip dated 29.04.2010 as Annexure-6, Photo copy of MRI Report dated 29.04.2010 as Annexure-7, Photo copy of bill of Goyal Hospital as Annexure-8, Photo copy of OPD slip as Annexure-9 to Annexure-12, Photo copy of OPD slip and bill of Bajaj Hospital as Annexure 13 to 17, Photo copy of discharge summary of Rockland Hospital as Annexure-18 to 21, Photo copy of various medical bills, OPD slips, certificate and letters as Annexure-22 to 38 in support of his complaint.

6.                    On the other hand, counsel for the Op No.1 tendered into evidence affidavit of Sh. Ajay Sareen as Annexure RW/A and document such as photo copy of Emails as Annexure R-1 and closed the evidence on behalf of Op No.1.     

7.                    We have heard the learned counsel for both the parties and have gone through the pleadings as well as documents placed on file very carefully and minutely.

8.                   The only version of the complainant is that complainant had severe vomiting on 19.05.2010 in the night at about 9.00 P.M. and as such he was immediately taken to the R.K. Gupta Hospital and discharged on 20.05.2010 at 5.00 P.M. and submitted all the bills of Dr. R.K.Gupta Hospital near about amounting to Rs. 40,000/- to the OPs Insurance Company but the Ops Insurance Company failed to make the payment of the same whereas from the perusal of case file it is duly evident that complainant has failed to place on file any such evidence i.e. bills of amounting to Rs. 40,000/- submitted to the Ops Insurance Company. The complainant has placed on file only photo copy of bill issued by Dr. R.K. Gupta dated 20.05.2010 bearing No. 9495 Annexure 25/26 of amounting to Rs. 1650 except this bill no other bill has been placed on file. Other bills are relating to New Delhi treatment which was taken by the complainant from the Rockland Hospital under the treatment of Dr. Pushpinder Singh Bajaj and an amount of Rs.1,05,223/- of these bills had already been paid to the complainant which is duly evident from Annexure R-1. The amount of Dr. R.K.Gupta Hospital amounting to Rs. 1650/- was not paid by the Ops Insurance Company as the complainant could not clarify/submit the documents as required by the OPs Insurance Company vide its various letters and reminders dated 01.07.2010, 25.07.2010, 16.10.2010 and 19.11.2010 Annexure-2, Annexure-4, Annexure-5 and Annexure-3 respectively. as the complainant has not completed the formalities required by the OPs Insurance Company, hence we are of the considered view that there is no deficiency in service or unfair trade practice on the part of the OPs. Moreover, major claim amount had already been released to the complainant by the insurance company. Hence, we have no option except to dismiss the present complaint.

9.                   Resultantly, we find not merit in the present complaint and the same is hereby dismissed with no order as to costs. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court: 04.01.2017

                                                                                                (ASHOK KUMAR GARG)

                                                                                                PRESIDENT

                                                                                                D.C.D.R.F.YAMUNANAGAR

 

                                                    (S.C.SHARMA)

                                                    MEMBER