DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANSA.
Complaint No.11/10.01.2012
Decided on : 19.04.2012
Sh.Charan Dass S/o Sh.Hari Ram, Shadi Ram Musa Wali Gali, Ward No.17, Tehsil and District Mansa.
..... Complainant.
Versus
1. United India Insurance Company Ltd., Gaushala Road, Mansa through its Branch Manager.
2. Raksha TPA Pvt. Ltd., Escort Corporate Centre, 15/5 Mathura Road, Faridabad, Haryana through its M.D.
3. Raksha TPA Pvt. Ltd., 2nd Floor, SCO No.181, Sector 7-C, Chandigarh through its Manager.
..... Opposite Parties.
Complaint under Section 12 of the Consumer Protection Act, 1986.
.......
Present: Sh.Rakesh Singla, Advocate counsel for complainant.
Sh.Naval Goel, Advocate counsel for OP No.1.
OPs No.2 and 3 exparte.
Before Sh.S.D.Sharma, President,
Smt.Neena Rani Gupta, Member.
Sh.Shiv Pal Bansal, Member.
ORDER BY:-
S.D.SHARMA, PRESIDENT
Sh.Charan Dass, complainant (hereinafter referred as to CC for short) has preferred the present complaint against the Opposite parties (hereinafter referred as to OPs for short) on the ground, that he subscribed a medi-claim insurance policy of OP No.1 for himself and his family members by paying an amount of Rs.6,828/- on 24.8.2011. The policy was valid from 29.8.2011 to 28.8.2012. It is averred, that OP No.1 has tied up with OPs No. 2 and 3 and that OPs No.2 and 3 will decide the claim of the CC.
It is averred, that CC suffered from dengue fever, as such, got himself admitted in D.M.C. Hospital, Ludhiana on 23.11.2011. It is averred that he remained admitted till 27.11.2011 for treatment, as such, had to spend Rs.41,350/-.
It is averred, that on 7.12.2011, in order to get his medi-claim, CC, after completing all the formalities, filed all requisite papers with OP No.1 in their office at Mansa. It is averred, that OP No.1 further sent the papers to OPs No.2 and 3.
Surprisingly, on 21.12.2011, CC received a letter from OP No.3, wherein he was asked to give the original documents regarding the death of the CC and also asked for original ultrasound reports etc.
After receiving such an absurd letter, CC contacted the OPs in person and brought the matter to their knowledge. It is averred, that as DMC Hospital, Ludhiana keeps the entire original record with them, as such, he was not able to produce the same before the OPs resulting into the refusal of the claim by the OPs. Thus alleging deficiency in service on the part of the OPs, CC seeks following reliefs against the OPs:
i) CC has sought Rs.41,350/- the expenditure incurred by him for his treatment alongwith interest @ 12%.
ii) CC has further sought Rs.2,00,000/- as compensation and Rs.10,000/- as litigation expenses.
2. In reply, OP No.1 has raised a number of preliminary objections on the ground, that complaint is not maintainabl and also on the point of jurisdiction etc.
On merits, it is averred, that on the claim application and other documents of the CC, the answering OP sent a letter No.3764 dated 28.11.2011 to M/s Raksha TPA Services, Chandigarh. Thereafter the other OPs considered the case of the CC and found, that original discharge summary and original investigation report of USG and other investigations conducted during hospitalization of CC from 23,.11.2011 and letters dated 21.12.2011 and 28.12.2011 and 6.1.2012 were sent to the CC for providing the same. Subsequently the other OPs sent letter dated 21.1.2012 to the answering OP stating that “the claim case of the CC is under process and the aforesaid documents are required for the proper settlement”, but the CC has not produced the same till date. So, the answering OP cannot give the claim to the CC until the TPA i.e. OPs No.2 & 3 decide the claim of the CC. After denying the entire complaint of the CC, OP No.1 has prayed for dismissal of the complaint.
3. OPs No.2 and 3 are proceeded against exparte, as they have not preferred to contest the claim of the CC. 4. The CC in support of his case, has tendered into evidence Ext. C-1 to C-21. On the other hand the contesting OP has tendered into evidence Ext.OP-1 to OP-18, which includes the affidavits of respective parties.
4. After perusing the entire evidence on the file, complaint as well as version, we are of the considered view, that CC is successful in making out a case of deficiency in service on the part of the OPs.
FINAL ORDER
5. It is admitted case of the CC, that CC subscribed a medi-claim insurance policy of OP No.1 by paying an amount of Rs.6,828/-. It is admitted case of the CC, that policy of the OP was valid from 29.8.2011 to 28.8.2012. The CC in support of his contention has submitted the policy Ext.C-2. It is admitted case of the CC, that all of a sudden he suffered from dengue fever and remained hospitalized in DMC Hospital, Ludhiana from 23.11.2011 to 27.11.2011. It is proved case on file, that CC spent Rs.41,350/- on his treatment. It is further the admitted case of the CC, that he informed the OPs after leaving the hospital on 7.12.2011 about his illness and sought his medi-claim from OP No.1.
Surprisingly, CC even after handing over all the requisite documents to OP No.1, received letter Ext.C-4, wherein CC was asked to submit the original death summary along with original investigation reports.
We are surprised to see letter Ext.C-4, which further proves the working of the OP No.1 and the manner in which the claims are settled by the OPs in careless and callous manner. This further goes to prove, that OPs work with pre-determined mind not to settle even the genuine claims of the consumers. We feel, by not settling the claim of the CC “deficiency in service” on the part of OPs is writ large. We further feel, that OPs No.2 & 3, who are engaged by OP No.1, are only engaged to create complications for the genuine consumers, who are mostly illiterate and simpleton persons.
It is pertinent to mention here that OPs have no answer against letter Ext.C-4.
The CC in support of his complaint has tendered into evidence his own affidavit, which is cogent and confident inspiring. It is writ large on the file, that despite tendering all the requisite documents, the OPs , without any reasons, are withholding the genuine claim of the CC on flimsy and absurd grounds. The CC in support of his complaint has also tendered various bills Ext.C-5 to C-11. Further the CC has also tendered even the discharge summary of his treatment i.e. Ext.C-12. It is proved on file, that CC remained hospitalized in the hospital of D.M.C., Ludhiana from 23.11.2011 to 27.11.2011 and had to spend an amount of Rs.41,350/-.
We feel, OP No.1 cannot absolve its liability by referring the matter to OPs No.2 and 3, which is only an agency of OP No.1.
We further feel, that it is the duty of OP No.1 to verify the facts of their own and then settle the claim and should provide proper service to their customers.
There is nothing in the complaint, that the claim of the CC is not genuine. As such, we feel, the OPs have failed to bring any cogent and convincing evidence on the file, that claim of the CC is not genuine. We further feel, that OPs are intentionally and deliberately sitting on the claim file of the CC without any reason and are prolonging the payment.
We have also gone through the evidence submitted by the learned Advocate for OP No.1, wherein the OPs have tendered into evidence various bills, probably submitted by the CC in the shape of their evidence, which further proves, that documents were handed over to the OPs by the CC in time. There is no genuine reason for the OPs to withheld the payment of the CC.
6. In view of our discussion, we feel, that the claim of the CC is withheld by the OPs, as such, “deficiency in service” is proved. Therefore, we allow the present complaint and order the OPs, jointly and severally, to pay Rs.41,350/- with interest @ 9% p.a. We further order the OPs, jointly and severally, to pay consolidated amount of compensation to the tune of Rs.10,000/- to the CC. Exemplary compensation is paid due to the attitude of the OPs towards the CC, which is proved through letter Ext.C-4.
7. Compliance of the order be made by the OPs, within 30 days from the date of receipt of the copy of the order.
8. Let the copy of the order be supplied to the parties free of charge. The concerned Clerk of this Forum is directed to send the copies to the parties immediately.
9. We consign the record strictly in accordance with the rules.
Pronounced:
19.04.2012
Shiv Pal Bansal, Neena Rani Gupta, S.D.Sharma,
Member. Member. President.
