Haryana

Ambala

CC/341/2019

Sh Ghan Sham - Complainant(s)

Versus

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

S.K. Beri

29 Aug 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

         

Complaint case no.	:	341 of 2019
Date of Institution	:	29.10.2019
Date of decision	:	29.08.2022

 

Sh. Ghan Sham Wahee r/o 3738-42/1A, Timber Market, Ambala Cantt. aged about 77 years.                                                           

                                                                                      ……. Complainant.

                                                         Versus

1. United India Insurance Co. Ltd, Opp. Municipal Corporation Office, Punjabi Mohalla, Ambala Cantt.
2. Raksha TPA Pvt. Ltd, SCO-39, 1^st Floor Sector-26, Chandigarh-160047.
3. Adesh Medical College & Hospital, NH-1, Village Mohri, Tehsil Shahabad (M) Near Ambala Cantt-136135.

                                                                              ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.         

                            

Present:        Shri S.K. Beri, Advocate, counsel for the complainant.

                             Shri R.K. Vig, Advocate, counsel for the OP No.1.

                             OPs No.2 and 3 already ex parte.

 

Order:        Smt. Neena Sandhu, President

1.                Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

(i)To pay Rs.27,536/-, the amount spent by the complainant       alongwith interest  @ 18% per annum.

(ii) To pay Rs.20,000/- as compensation for the mental agony and physical harassment suffered by the complainant.

(iii) To pay the litigation costs. 

2.             Brief facts of the case are that the complainant took a staff group medi-claim policy from OPs No.1 & 2. By virtue of the said policy, the complainant and his wife Smt. Rama Wahee were insured for a sum of Rs.5,00,000/-. The member ID of complainant is UIC54511RTRD14919 and employee no. is 14919. In the month of December 2017 the complainant's wife Smt. Rama Wahee developed serious health problems and it was advised by the doctors to get her admitted with OP-3-Hospital. Accordingly, she remained admitted in the said Hospital from 21-12-2017 to 23-12-2017, where she could not survive and died on 23-12-2017. However, when claim was raised, it was not paid by OPs No.1 and 2, as a result whereof, the complainant was forced to pay Rs.27,536/- to OP-3-Hospital. Complainant server a legal notice dated 08-4-2019, upon the OPs, but to no avail.  Hence this consumer complaint.
3.           Upon notice, OP No.1 appeared and filed written version and raised preliminary objections with regard to maintainability etc. On merits, while admitting factual matrix of the case with regard to the fact of issuance of insurance policy in question, it has been stated that after the treatment of wife of the complainant, OP No.3 finally prepared bill of Rs.49,472/- on 24.12.2017. OP No. 1 and 2 took a decision to release Rs.44,668/- after necessary deduction towards full and final settlement of the claim. Accordingly, an amount of Rs.40,201/- after deducting TDS stood credited in the account of OP No.3  as per claim settlement voucher dated 10.01.2018 through NEFT. Thus nothing remained from the side of Insurance Company as well as TPA. It is only OP No.3 which is answerable as to why the payment has not been made to the complainant. Rest of the averments of the complainant were denied by the answering OP and prayed for dismissal of the present complaint with heavy costs.

4.       Upon notice, the opposite parties No.2 and 3 did not appear before this Commission and proceeded against ex parte vide order dated 18.12.2019  and 27.01.2020 respectively .

5.       Learned counsel for the complainant tendered affidavit of complainant and affidavit of Rakesh Wahee son of Ghan Sham Wahee r/o 3738-42/1A, Timber Market, Ambala Cantt, special power of attorney holder of complainant as Annexure C-A & C-B alongwith documents as Annexure C-1 to C-21 and closed the evidence on behalf of complainant. On the other hand, learned counsel for OP No.1 tendered affidavit of Shrija Jain, Assistant Manager of OP No.1 company, United India Insurance Company Limited, Divisional Office, Tirloki Chambers, 2^nd Floor, Ambala Cantt. as Annexure OP-1/A alongwith Annexure OP-1/1 to OP-1/6 and closed the evidence on behalf of OP No.1.

6.       We have heard the learned counsel for the complainant and learned counsel for the OP No.1 and carefully gone through the case file.

7.       Learned counsel for the complainant submitted that the complainant paid Rs.27,536/-, to the OP No.3 for the treatment of his wife. Since the OPs No.1 and 2 have already paid Rs.40,201/- to the OP No.3, therefore he is entitled for the refund of the amount of Rs.27,536/-. 

8.       On the other hand, learned counsel for OP No.1 submitted that since the amount of Rs.40,201/- after TDS deductions stood credited in the account of OP No.3  as per claim settlement voucher dated 10.01.2018 through NEFT, as such, no deficiency in service has been committed by it. It is only the OP No.3, which is answerable as to why the payment has not been made to the complainant and the complaint filed against it is liable to be dismissed.       

9        From the perusal of Annexure C-3, to C-5, C-7, C-9 and from Annexure C-11 to C-18, it is quite clear that complainant paid Rs.27,536/-, to the OP-3 hospital. A bare perusal of claim settlement voucher Annexure C-2 clearly shows that the amount of Rs.40,201/-, after TDS deductions stood credited in the account of OP-3-Hospital through NEFT on 10.01.2018. Meaning thereby, the OPs No.1 and 2 have done the needful and cannot be said to be deficient in providing the services to the complainant and the complaint filed by the complainant against them is liable to be dismissed. It may be stated here that once it is proved on record that the amount Rs.40,201/-, pertaining to the claim of the complainant, had been paid by OP No.1 to OP-3-Hospital, through NEFT dated 10.01.2018, then, the OP No.3 was under legal obligation to refund the amount of Rs.27,536/- paid by the complainant from his own pocket, to it for the treatment of his wife. Since, OP No.3 did not put in appearance, despite service and was proceeded against ex parte, therefore, an adverse inference can easily be drawn against it that it has nothing to say in its defence. In this situation we hold that by not refunding the amount of Rs.27,536/-, to the complainant, the OP No.3 has committed deficiency in service and is thus liable to refund the said amount to the complainant alongwith interest. It is also liable to pay compensation, to the complainant on account of mental agony and physical harassment caused to him and also litigation costs.

10.     In view of the aforesaid discussion, we hereby dismiss the present complaint against the OPs No.1 and 2 and allow the same against the OP No.3 and direct it, in the following manner:-

1. To refund the amount of Rs.27,536/-, to the complainant alongwith interest @4% per annum, w.e.f 10.01.2018, i.e the date when the amount of Rs.40,201/-, stood deposited by the insurance company through NEFT, in the account of the OP No.3, till realisation.
2. To pay Rs.3,000/- as compensation for the mental agony and physical harassment suffered by the complainant.
3. To pay Rs.2,000/- as litigation costs.  

The OP No.3 is further directed to comply with the aforesaid directions within the period of 45 days from the date of receipt of the certified copy of this order. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on: 29.08.2022.

 

          (Vinod Kumar Sharma)  (Ruby Sharma)               (Neena Sandhu)

              Member                         Member                       President