DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi- 110016

Case No.203/19

Pradeep Kumar Patel

S/o Mr. Rampati Patel

R/o H-5/23B, Upper Ground Floor

Krishna Nagar, Near Vijay Chowk

Delhi-110051.                                                              .…Complainant

                                                VERSUS

United Insurance Company Ltd.

Through Branch Manager

Having office at Mool Chand Commercial Complex

Door No.42-C, Floor No.3

Opp. Moolchand Flayover

New Delhi-110024.

United Insurance Company Ltd.

Through General Manager Claims

Having office at 24, Whites Road, Channai

Tamil Nadu-600014.

M/s Paramount Healthcare

D-39, Okhla Industrial Area Phase-I

Near ESIC Hospital, New Delhi-110020.          ….Opposite Parties

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Sh. U.K. Tyagi, Member

ORDER

Date of Institution:16.07.2019

Date of Order       :07.12.2023

Member: Shri U.K.Tyagi

          Complainant has requested to pass an award directing M/s United Insurance Co. Ltd. (hereinafter referred to as OP) to pay Rs.19,25,500/- towards loss and suffering etc.

          Brief facts of the case are as under:-

          The complainant was employed with M/s Celeriti Fintech  Services India Pvt. Ltd. The complainant stated that he got his wife admitted in Tripathy Hospital for caesarean delivery in the month of Nov. 2017.  After birth of child due to which the condition became critical. She was shifted to Yasodha Hospital.  The complainant settled the bill of Rs.2,50,000/-.  It was stated that the employer of the complainant got him insured by taking a mediclaim policy from the OP.  Since his wife was being treated at Yasodha Hospital. The TPA i.e. M/s Paramount Healthcare submitted the claim of complainant for sanction an amount of Rs.3,00,000/-initially. The OP rejected the claim and approved an amount of Rs.50,000/- under maternity claim.  One Sr. Officer of the M/s Paramount pursued the case of the complainant with OP and TPA and agreed to settle the claim upto the sum of Rs.50,000/-. After the approval of claim, the date of renewal of Health Insurance policy became due. The representative of OP-1 approached to the management of the complainant’s employer company.  But due to some reasons, not known to the complainant, his company discontinued health insurance and his employer opted for other insurance Co. After discharge of his wife, he lost his claim paper.  He approached the Yasodha Hospital and got the duplicate copy of the bills and submitted with OP alongwith affidavit regarding loss of original papers for claim of Rs. 6,45,500/-.

          The OP did not settle the claim.  As such, the complainant had to take loan for settling the claim of the Hospital. True copy of the said bill is enclosed as Annexure C-1. On 03.04.2018, the complainant got e-mail from OP stating that the physical file of the claim had been sent to UIIC and waiting for reply from UIIC.  On 04.06.2018, the complainant received mail from OP stating that his claim stands repudiated as per policy clause 5.6 and accordingly claim was closed.  True copy enclosed at Annexure C-3.  The complainant got the legal notice served on 03.07.2018.  It was stated that on 14.09.2018, he received a reply dated 30.08.2018 stating that “you had submitted duplicate bills and receipts from Hospital for re-imbursement of claim.  But as per condition No.5.6 of CSC Corporate Group Mediclaim Policy” – “the insured shall obtain and furnish to the TPA with all original bills.  Hence claim was repudiated.  Annexure C-5.  He pursued the case with OP but of no avail.  The present claim was filed for Rs.10,00,000/- towards mental agony + Rs.6,45,000/- towards medical expenditure and rs.2,80,000/- towards interest.  Finding no resolution, hence, the complaint.

          OP-1 & 2 on the other hand filed its reply interalia raising preliminary objections.  It was stated that the contract of insurance is a contract of utmost good faith and OP had delivered complete set of policy cover to each and every insured at the time of acceptance of premium.  The instant complaint was liable to be dismissed on account of misjoinder for necessary parties as there was no privity of contract between the complainant and OPs.  It was the employer of the complainant who ought to have been impleaded in the present complaint and some sort of employee code would have been issued to the complainant.  The complainant had not submitted original bills and other documents upon which claim is based.  On the breach of the terms and conditions of the policy, the OP also assailed the working of the complainant with M/s Celeriti Fintech  Services India Pvt. Ltd. and complainant be put to the strict proof to this effect.  The OP also denied for want of knowledge the admission of the complainant’s wife with Tripathy Hospital and Yasodha Hospital.  And also denied for want of knowledge for settlement of bills of Rs.2,50,000/- as raised by Tripathy Hospital.  OP also denied for want of knowledge that claim was settled for Rs.50,000/- instead of Rs.3,00,000/- under maternity claim.  In this regard OP also asked that complainant be put to strict proof.  No material evidence was put to this effect that loan was taken @4% per month.

          Both the parties filed evidence in affidavits OP was exparte vide order dated 30.09.2022, hence OP did not file written submissions.  Written statement is on record so is rejoinder.  Arguments were heard and concluded.

          This Commission has gone into the entire gamut of issues placed on record.  Due consideration was given to the arguments.  It would be seen from the material before this Commission.  There had been contention on this point that the claim of the complainant was repudiated on ground of submission of duplicate bills.  There was no objection on behalf of the subsistence of the policy cover provided to the insured. However, the OP denied most of the averments with cautious approach stating that for want of knowledge OP denied the facts.  It is beyond comprehension why the TPA of the OP could not verify the duplicate bills from the Hospital mentioned hereinabove.

          The complainant has referred the case of Gurmel Singh Vs. Br. Manager, National Insurance Co. Ltd., decided by Hon’ble Supreme Court in Civil Appeal no.4071 of 2022, had held that “when the appellant had produced the photocopy of Certificate of Registration and other particulars as provided by RTO, solely on the ground that the original certificate (which was stolen) is not produced, the claim cannot be denied. Non-settlement of the claim can be said to be deficiency in service.  Therefore, appellant has been wrongly denied the insurance claim.”

          In view of the facts and circumstances and discussion as held above and respecting the decision of Hon’ble Apex Court, this Commission is of the considered view that OP is deficient in service for non-consideration of claim.  Accordingly, OP is directed to process the claim of the complainant within three months and disburse the due amount thereafter within seven days from the receipt of the order the amount of claim should be disbursed within 15 days thereafter failing which interest shall be levied @7% per annum till its realisation.

File be consigned to the record room after giving copy of the order to the parties as per rules.