DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/94

Date of Institution : 08.02.2018/29.11.2021

Date of Decision : 16.08.2022

Sukhpal Singh s/o S. Pritam Singh R/o 108-F, A-Block, Sandhu Colony, GT Road, Chheharta, Amritsar.      …Complainant

Versus

1. United India Insurance Company Limited, BO. 11-A, Lawrence Road, Amritsar through its Branch Manager.

2. Vipul MedCorp TPA Private Limited, 515, Udyog Vihar, Phase-5, Gurgaon, Haryana.

…Opposite Parties

Complaint U/S 12 and 13 of The Consumer Protection Act as amended up to date.

Present: Sh. SS Channa Adv counsel for complainant.

Sh. Sandeep Khanna Adv counsel for opposite party No. 1.

Opposite party No. 2 exparte.

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant filed the present complaint under Section 12 and 13 of the Consumer Protection Act against United India Insurance Company Limited, Amritsar and another. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant got insured himself by taking the family medicare policy from the opposite party No. 1 valid for the period from 16.10.2015 to 15.10.2016 and after receiving the premium a policy bearing No. 2003012815P108423967 was issued to the complainant but no terms and conditions were supplied to the complainant alongwith policy. 

3. It is further alleged that in the first week of September 2016 the complainant was having pain in his both upper limbs, so he approached Randhawa Hospital, Amritsar from where he came to know that he is suffering from heart ailment and he spent an amount of Rs. 17,915/- there. After that on 12.9.2016 the complainant approached Dr. Arun K Chopra DM Cardiology at Fortis Escorts Hospital, Amritsar and after investigation the complainant was diagnosed with CAD, Single Vessel disease, unstable Angina and hypertension and doctor advised hospitalization to the complainant. So, complainant got admitted in Fortis Escorts Hospital, Amritsar where he remained admitted from 12.9.2016 to 14.9.2016 and during admission PTCA and RCA procedure was performed upon the complainant and he spent Rs. 2,00,750/- on his treatment. Due to emergency the family members of the complainant could not intimated the opposite parties regarding the said ailment and later on the complainant himself informed the opposite parties regarding the treatment and expenditure and opposite parties asked to sent all the original bills alongwith discharge card and investigation reports and complainant sent all the original documents to the opposite parties where were necessary for the reimbursement of the claim on 2.10.2016. Opposite parties assured that the complainant that they have initiated action on the matter within 72 hours but till filing of complaint they did not reimburse the amount of Rs. 2,18,665/- which amounts to deficiency in service and unfair trade practice on their part. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to make payment of claim amount of Rs. 2,18,665/- alongwith interest at the rate of 18% per annum.

2) To pay Rs. 50,000/- on account of compensation for mental agony and harassment. 

3) To pay Rs. 50,000/- as litigation expenses.

4) Any other relief to which the complainant is found entitled. 

4. Upon notice of this complaint, the opposite party No. 1 filed written version taking preliminary objections that the complainant has violated the terms and conditions of the insurance policy so the present complaint is not maintainable. The opposite parties requested the complainant vide letter dated 13.2.2017 to submit the requisite documents but the complainant neither furnished the said documents nor given any explanation or reasons thereof. So, the opposite parties repudiated the claim vide letter dated 25.3.2017 stating that the claim was not payable due to No reply of query and non submission of the pending documents/formalities. The complaint is bad for non joinder of necessary parties and complainant has not approached this Commission with clean hands. The complainant has no cause of action to file the present complaint as the claim has been repudiated due to non cooperation and omission on the part of the complainant. 

5. On merits, it is submitted that the complainant purchased the policy from the opposite party No. 1 and terms and conditions were supplied to the insured at the time of issuance of the policy. Further, the complainant had failed to intimate the opposite parties immediately regarding the alleged hospitalization so he violated the terms and conditions of the insurance policy. The contract of insurance is based on utmost faith and in this regard it is submitted that by producing fake documents it is apparent that the insured has used fraudulent means for getting wrong claim, so as per general conditions of the contract of insurance it has been clearly held that the insurance company will not be liable to pay any claim if the claim is found to be in any respect fraudulent or if any false declaration be made or used in support thereof or if any fraudulent means or devices are used by the insured or any one act is done on his behalf to take benefit under the policy, all the benefits under the said policy shall be forfeited. Rest of the submissions on merits already submitted in preliminary objections so there is no need to repeat the same. However, lastly the opposite party No. 1 prayed for the dismissal of the present complaint with costs.

6. The opposite party No. 2 preferred to remain exparte. 

7. To prove his case the complainant tendered in evidence his  own affidavit Ex.CW-1/A, copy of policy Ex.C-1, copy of details of  hospitalization charges Ex.C-2, copy of receipt of payment Ex.C-3, copy of bill Ex.C-4, copy of receipt Ex.C-5, copy of registration fee receipt Ex.C-6, copy of payment receipt dated 12.9.2016 Ex.C-7, copy of inpatient bill of complainant dated 14.9.2016 Ex.C-8, copy of receipt Ex.C-9, copy of receipt of Rs. 1,00,000/- Ex.C-10, copy of discharge summary dated 14.9.2016 Ex.C-11, copy of investigation list Ex.C-12, copy of letter issued by opposite party No. 2 Ex.C-13, copy of claim intimation form Ex.C-14 and closed the evidence. 

8. To rebut the case of the complainant the opposite party No. 1  tendered in evidence affidavit of Sat Pal Assistant Manager Ex.OP-1/1, copy of letter dated 13.2.2017 Ex.OP-1/2, copy of letter dated 25.3.2017 Ex.OP-1/3 and closed the evidence.   

9. We have heard the learned counsel for the parties and gone through the record on the file.

10. It is not disputed between the parties that the complainant purchased the Family Medicare Insurance Policy Ex.C-1 from the opposite party No. 1. It is also not disputed that the complainant got the treatment within the validity of the insurance policy. 

10. Learned counsel for the complainant argued that in the first week of September 2016 the complainant was having pain in his both upper limbs, so he approached Randhawa Hospital, Amritsar from where he came to know that he is suffering from heart ailment and he spent an amount of Rs. 17,915/- there. He further argued that on 12.9.2016 the complainant approached Dr. Arun K Chopra DM Cardiology at Fortis Escorts Hospital, Amritsar and after investigation the complainant was diagnosed with CAD, Single Vessel disease, unstable Angina and hypertension and doctor advised hospitalization and complainant got admitted in Fortis Escorts Hospital, Amritsar where he remained admitted from 12.9.2016 to 14.9.2016 and he spent Rs. 2,00,750/- on his treatment. He further argued that complainant himself informed the opposite parties regarding the treatment and expenditure and sent all the original documents to the opposite parties on 2.10.2016 but they did not reimburse the amount of Rs. 2,18,665/- which amounts to deficiency in service and unfair trade practice on their part.

11. On the other hand the learned counsel for the opposite party argued that the opposite parties requested the complainant vide letter dated 13.2.2017 to submit the requisite documents but the complainant neither furnished the said documents nor given any explanation or reasons thereof and the opposite parties repudiated the claim vide letter dated 25.3.2017 stating that the claim was not payable due to No reply of query and non submission of the pending documents/formalities. He further argued that the complainant had failed to intimate the opposite parties immediately regarding the alleged hospitalization so he violated the terms and conditions of the insurance policy. 

12. We have perused the copy of letter dated 25.3.2017 Ex.OP-1/3 in which the opposite party No. 1 mentioned that the claim of the complainant cannot be entertained for query reply not received and file closed. We have also perused the copy of letter dated 13.2.2017 Ex.OP-1/2 vide which the opposite party demanded some documents from the complainant. The complainant filed his discharge summary Ex.C-11 on the file which was demanded by the opposite parties vide letter Ex.OP-1/2. He also filed copy of investigation list Ex.C-12 in which all his tests reports are mentioned. In this way, there is no hitch to the complainant to provide the same to the opposite party. Further, the complainant also filed copies of bills and receipts Ex.C-2 to Ex.C-10. The opposite party can also take the copies of documents from the file and settle the claim of the complainant but the opposite party has not taken any steps to settle the claim of the complainant except to write letters to the complainant which proves that the opposite party is not interested to pay the claim of the complainant. This act of the opposite party No. 1 is clear cut deficiency in service and unfair trade practice on their part. 

13. The complainant filed copies of bills and receipts  Ex.C-2 to Ex.C-10 and from these documents it is proved on the file that the complainant spent Rs. 2,18,665/- on his treatment. 

14. In view of the above discussion, present complaint is partly allowed against the opposite party No. 1 and opposite party No. 1 is directed to pay the amount of Rs. 2,18,665/- to the complainant on account of insurance claim alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite party No. 1 is also directed to pay Rs. 3,300/- to the complainant as compensation for mental tension and harassment and Rs. 2,200/- as costs and litigation expenses. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        16th Day of August 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Navdeep Kumar Garg)

Member