BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 72 of 2016
Date of Institution: 16.2.2016
Date of Decision: 08.08.2016
Ashwani Bhatia son of Sh.Manmohan Bhatia R/o 746, New 2383, Sharifpura, Street No.7, Amritsar
Complainant
Versus
- United India Insurance Company Limited, branch office 11 A, Lawrence Road, Amritsar through its Branch Manager
- United India Insurance Company Limited, 24, Whites Road, Chennai 600014 through Principal Officer/Authorized Representative
- Vipul Medcorp TPA Private Limited 122,123, First Floor Deep Complex, Court Road, Amritsar through its Principal Officer/Authorized Representative
- Vipul Medcorp TPA Private Limited 515, Udyog Vihar, Phase V, Gurgaon, Haryana through its Principal officer/Authorized Representative
Opposite Parties
Complaint under section 12 & 13 of the Consumer Protection Act, 1986 as amended upto date.
Present: For the Complainant : Sh.Anil Bhatia, Advocate.
For the Opposite Parties No.1 & 2: Sh.K.K.Thakur,Advocate
For the Opposite Parties No.3 & 4: Ex-parte
Coram:
Sh.S.S.Panesar President
Ms.Kulwant Kaur Bajwa, Member
Mr.Anoop Sharma, Member
Order dictated by:
Sh.S.S.Panessar,President.
- Sh.Ashwani Bhatia has brought the instant complaint under section 12 & 13 of the Consumer Protection Act on the allegations that complainant is peace loving and law abiding citizen of India . The complainant got mediclaim insurance from addressee No.1 vide ID Card No. 0320330006858601, policy No. 2002042815P100027403. The complainant fell ill and was diagnosed with Dengue fever and was hospitalized on 5.12.2015 at New Bhandari Hospital, Majitha Road, Amritsar and was discharged on 8.12.2015 . Intimation regarding hospitalization was immediately given to address No.3 through email by complainant himself on 5.12.2015. The complainant spent an amount of Rs. 23,139/- towards treatment/medicines/hospital charges etc between 5.12.2015 to 8.12.2015 vide different bills. After discharging from the hospital, complainant duly filled claim form before address No.3 personally on 12.12.2015 alongwith all the relevant documents as per demand raised by concerned official of addressee No.2 at his office. The complainant was assured by the concerned official of addressee No.3 that the claim amount will be released within a month. The complainant made several requests to the opposite party personally as well as telephonically to release the claim amount but opposite party has been dilly dallying the matter on one pretext or the other. The complainant has sought for following reliefs vide instant complaint:-
- Opposite parties be directed to make payment of the claim alongwith interest @ 18% p.a from the date of entitlement till its realization ;
- Opposite parties be also directed to pay compensation to the tune of Rs. 50000/- for causing mental harassment, agony etc to the complainant besides litigation expenses to the tune of Rs. 15000/-.
Hence, this complaint.
2. Upon notice, opposite parties No.1 & 2 appeared and contested the complaint by filing a joint written version , whereas opposite parties No.3 & 4 did not appear despite service, as such they were ordered to be proceeded against ex-parte vide order dated 28.3.2016.
3. Opposite parties No.1 & 2 in their joint written version have taken certain preliminary objections that complaint as framed is not maintainable and the same has been filed prematurely and without any basis ; that complainant has not filed/submitted some relevant papers concerning his medical treatment with the office of the opposite parties till date and as such no question of deciding the claim of the complainant arose at any stage ; that complainant has not come before this Forum with clean hands; that complainant has concealed true and material facts from this Forum and as such present complaint deserves dismissal. On merits, it is denied that complainant fell ill or was diagnosed for Dengue Fever or he remained hospitalized from 5.12.2015 to 8.12.2015. It is also denied that intimation regarding hospitalization was given by the complainant to addressee No.3 on 5.12.2015 personally . It is denied that complainant has spent an amount of Rs. 23,139/- towards treatment charges etc. between 5.12.2015 to 8.12.2015 vide different bills. It is admitted that complainant has filed claim form with addressee No.3 alongwith some papers but those papers were not complete in all respect. However, it is denied that officials of opposite party No.3 assured the complainant that claim amount will be released within a month. No claim amount can be paid unless all the requisite documents are produced by the claimants, are properly verified and genuineness of the same is confirmed. Only after that claim of the complainant was payable. However, in the present case, the complainant was time and again requested by opposite party No.3 and 4 to provide (i) original discharge summary with presenting complaints and line of treatment taken (ii) provide doctor’s prescription dated 5.12.2015 and 12.12.2015 against consultation and investigation charges claimed (iii) provide numbered receipt of 12,500/- against hospital bill. But no such documents were supplied or provided by the complainant. Ultimately intimation was given to the complainant by opposite party No.3 vide letter dated 26.2.2016 informing the complainant to provide abovementioned documents which were necessary to decide the claim of the complainant. But till date these documents have not been provided to the opposite parties rather the present complaint has been filed by the complainant against the opposite party which is premature action on the part of the complainant. So unless the complainant submits all the relevant documents concerning his medical treatment with the office of opposite parties, till then opposite parties will not be in a position to decide the claim of the complainant whether the same is genuine one or not. Remaining facts mentioned in the complaint have also been denied specifically and a prayer for dismissal of the complaint with cost has been made.
4. In his bid to prove the case Sh.Anil Bhatia,Adv.counsel for the complainant tendered into evidence affidavit of the complainant Ex.C-1 alongwith documents Ex.C-2 to Ex.C-20 and also summoned Sh.Jaswant Singh, Manager, New Bhandari Hospital, who appeared and filed patient treatment record Ex.C-21 and closed the evidence on behalf of the complainant.
5. To rebut the aforesaid evidence Sh.K.K.Thakur,Adv.counsel for opposite parties NO.1 & 2 tendered into evidence affidavit of Sh.Surinder Singh, Divisional Manager Ex.OP1,2/1, copy of letter dated 26.2.2016 Ex.OP1,2/2 and closed the evidence on behalf of opposite parties No.1 & 2.
6. We have heard the ld.counsel for the parties and have carefully gone through the record on the file as well as written synopsis of arguments submitted by ld.counsel for the complainant as well as ld.counsel for opposite parties No.1 & 2.
7. Ld.counsel for opposite parties have vehemently contended that complaint filed by the complainant alleging that he got medical insurance from the replying opposite party. Thereafter complainant fell ill from Dengue fever and was hospitalized at New Bhandari Hospital. Intimation was alleged to have been given to opposite party No.3. It is further the case of the complainant that amount of Rs. 23,139/- was spent by him on his treatment. It is further claim of the complainant that insurance claim was filed with opposite party No.3 alongwith all relevant documents. But however, claim has not been accepted and it is requested that the claimant is entitled for disbursement of the medical bill/hospital charges of Rs. 23,139/- alongwith compensation and cost of litigation. However, it has been contended that complainant has not supplied the original discharge summary while presenting complaints and line of treatment taken (ii) doctor’s prescription dated 5.12.2015 and 12.12.2015 against consultation and investigation charges claimed (iii) numbered receipt of Rs. 12,500/- against hospital bill. But however, despite issuing reminders for a number of times, complainant has failed to supply those documents. The claim has not been decided so far by the opposite parties on account of the fact that no such documents have been supplied to the opposite parties for the reasons best known to the complainant.
8. But , however, on the other hand, it is the case of the complainant that complainant was insured vide medical insurance policy No.2002042815P100027403. Copy of the insurance policy is Ex.C-2, which is an admitted fact. The complainant fell ill on 5.12.2015 and he remained admitted for treatment at New Bhandari Hospital, Majitha Road, Amritsar from 5.12.2015 to 8.12.2015, copy of the discharge summary accounts for Ex.C-4. The complainant incurred an amount of Rs. 23,139/- towards treatment/medicines/hospital charges. Copies of the medical treatment accounts for Ex.C-6 to Ex.C-15. After discharge from the hospital, complainant filed claim form personally on 12.12.2015 alongwith all necessary documents, detail of which has been mentioned on page 2 of the claim form Ex.C-5 at the office of opposite party No.3. The complainant was assured that payment of the claim amount shall be released within a month. The fact of filing the claim form has been duly admitted by opposite parties No.1 & 2 in para 5 of the written version and now ld.counsel for the complainant has vehemently contended that it does not lie in the mouth of the opposite parties to contend that requisite documents, necessary for deciding the insurance claim, have not been filed with the claim form. The objection appears to have been taken by the opposite parties simply to delay and prolong the matter and it is contended that complainant is entitled to the insurance amount of Rs. 23,139/- alongwith compensation and litigation expenses to be assessed by this Forum.
9. We have given thoughtful consideration to the rival contentions.
10. It is admitted case of the opposite parties that complainant had obtained life insurance policy from the opposite parties covering period from 10.4.2015 to 9.4.2016, copy of the Insurance policy accounts for Ex.C-2. It is also an admitted fact that complainant fell ill with Dengue Fever and was hospitalized at New Bhandari Hospital,Majitha Road, Amritsar and remained admitted for treatment w.e.f. 5.12.2015 to 8.12.2015 and incurred an expenditure of Rs. 23,139/- on his treatment. Copies of hospital bills account for Ex.C-6 to Ex.C-16 on record. It is the case of the opposite party that no doubt the complainant submitted claim form, but however, certain documents as detailed in the written statement, were not supplied to the opposite parties for deciding the claim and, therefore, the claim filed by the complainant could not be decided. But, however, the contention of the opposite party does not appears to be tenable , because if we peruse claim form Ex.C-5, it contains list of the documents which were supplied with the claim form and the said form has been admittedly received by the opposite party No.3 for deciding the claim case. It is seen that insurance companies show green pastures to the insured persons at the time of selling the insurance policy and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.
The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
11. As such it cannot be contended that instant complaint filed by the complainant is premature. Rather this shows recalcitrant attitude of the opposite parties that they can go to the extent of denying the receipt of documents, which were admittedly received by them alongwith the claim form, when it comes to the payment of the insurance claim. In our considered opinion, complainant has made out the case for grant of medical expenses to the tune of Rs. 23,139/- and the complaint filed by the complainant stands allowed. The complainant is also awarded compensation to the tune of Rs. 5000/- as well as litigation expenses to the tune of Rs. 2000/-. Opposite parties are directed to make the payment of the awarded amount within 30 days of the receipt of copy of the order ; failing which awarded amount shall carry interest @ 9% p.a. from the date of filing of the claim until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated: 8.8.2016.
/R/
