DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 227 of 19.9.2022

                                      Decided on:         9.9.2024

Jaswinder Pal Singh aged about 55 years son of Anoop Singh, resident of House No.508/3, Khalsa Mohalla, Near Twakli , Patiala.

                                                                   …………...Complainant

                                      Versus

1. United The Insurance Company Ltd., Branch Office Do Catholic Center No.64 Amrenian Street, Channai.
2. Sh.Sumit Chauhan Vice Manager Indoasis Bank Opposite Polo Ground, Lower Mall Road, Patiala.

                                                                   …………Opposite Parties

Complaint under the Consumer Protection Act

QUORUM

                                      Sh.Pushvinder Singh, President

                                      Sh.G.S.Nagi, Member   

ARGUED BY

                                      Sh.Dilpreet Singh, counsel for complainant.

                                      Opposite parties No.1&2 ex-parte.                              

 ORDER

                                                PUSHVINDER SINGH, PRESIDENT

1. The instant complaint is filed by Jaswinder Pal Singh (hereinafter referred to as the complainant) against United The Insurance Company (hereinafter referred to as the OP/s) under the Consumer Protection Act (for short the Act).
2. It is averred in the complaint that the complainant purchased a Health Insurance policy bearing No.01050020211484100000824995 in PLANB2A2C in his name and in the name of his family members valid from 12.8.2021 to 11.8.2022 for a sum assured of Rs.70,0000/- against the premium paid by the complainant, through OP No.2.
3. That during the period of said policy the wife of the complainant hospitalized in MAX hospital having cashless facility and an amount of Rs.5,47,685/-in the medical treatment. The treatment was also taken from Tata Memorial Cancer hospital at Sangrur where no cashless facility was available. Complainant spent Rs.1,53,766/- on the treatment of his wife who expired on 18.2.2022. That complainant filed claim before OP who only deposited cashless amount of Rs.5,47,685/- in the account of Max Hospital but the remaining amount of Rs.1,53,766/- was not paid by the OPs. Complainant requested OPs for the payment of said amount vide claim No.309860 who demanded some documents which were supplied by the complainant but OPs did not pay any amount and later on flatly refused to pay the said remaining amount to the complainant. That complainant sent legal notice on 22.7.2022 which was replied by OP No.2.That the act and conduct of OPs amounts to deficiency in service and caused mental agony and harassment to the complainant. Hence this complaint with the prayer to accept the same by giving directions to the OPs to pay Rs.1,53,766/-; to pay the compensation of Rs.2 lac alongwith Rs.11000/-as litigation expenses to the complainant.
4. Notice of the complaint was duly given to the OPs but they did not bother to appear and to contest the complaint and were accordingly proceeded against exparte.
5. In exparte evidence, ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents i.e. Ex.C1 copy of insurance policy, Ex.C2 copy of bill,Ex.C3 original courier receipt,Ex.C4 legal notice,Ex.C5 and Ex.C6 postal receipts,Ex.C7 reply to legal notice and closed the evidence.
6. We have heard the ld. counsel for the complainant and have also gone through the record of the case, carefully. 
7. The complainant has purchased health insurance policy from the OP No.1 as per Ex.C1 which was valid from 12.8.2021 to 11.8.2022 for the sum insured of Rs.7,00,000/-.The complainant himself, his wife Jagjit Kaur and daughters Baljinder Kaur & Gurnoor Kaur were covered under the said policy. It is alleged that wife of the complainant fell ill and was admitted in Max Hospital, Mohali. The complainant has further alleged that Rs.5,47,685/- was spent on the treatment of his wife and which was paid by the OPs to the hospital directly as cashless facility was available in the said hospital. The complainant has further alleged that his wife has taken further treatment from Tata Memorial Cancer Hospital, Sangrur and an amount of Rs.153766/- as per four bills,Ex.C2 was spent by the complainant , payment of which was not done by the OPs to the hospital authorities as cashless facility was not available at Tata Memorial Cancer Hospital, Patiala and the complainant was forced to pay this amount to the hospital authorities. Unfortunately wife of the complainant expired on 18.2.2022.
8. The complainant has alleged that the claim was then lodged with the OPs for settlement of Rs.5,47,685/- due for Max Hospital and Rs.1,53,766/- which was due for Tata Memorial Cancer Hospital, Sangrur. It is alleged by the complainant that an amount of Rs.5,47,685/- then paid by the OPs in the account of the Max Hospital, Mohali  but the amount of Rs1,53,766/- was not paid. The complainant has alleged that a representation was then made to the OPs to settle the claim which was registered vide claim No.309860 but the same was denied. Additional documents were also supplied to the OPs for settlement of the claim. Legal notice dated 22.7.2022 was also served upon the OPs as per Ex.C4 but no action was taken by the OPs. The complainant has alleged that reply to legal notice was then received by him as per Ex.C7, wherein a demand of documents was again made by the OPs as per the earlier letters dated 2.5.2022, 9.5.2022 and 16.5.2022 Ex.C7.The complainant has alleged that he had already submitted all the documents with the OPs and sent the documents through courier on 13.4.2022 as per consignment No.16581666 and has alleged that the OPs are denying the claim of the complainant on frivolous grounds. The complainant has prayed for the settlement of the claim to the tune of Rs.1,53,766/- alongwith compensation and litigation charges.
9. The averments and evidence lead by the complainant have remained unrebutted & uncontroverted as the OPs chose to not appear.
10. On going through the averments of the complainant and the evidence produced on record, it transpires that the complainant has taken a Health Insurance Policy for himself and his family members from the OPs for the sum insured of Rs.7,00,000/- which was valid from 12.8.2021 to 11.8.2022.The complainant has not produced on record any document with regard to the treatment taken by his wife at Max Hospital, Mohali and the settlement of the cashless claim by the OPs. The complainant has produced bills,Ex.C2 for the treatment taken by his wife from Tata Memorial Cancer Hospital, Sangrur from 17.1.2022 to 8.2.2022  for different durations. The complainant during the argument in the case has also produced on record a discharge summary in respect of his wife wherein it has been remarked that the disease is INOPERABLE and his wife was discharged on 8.2.2022. It is also a fact that the complainant has lodged a claim with the OPs for the treatment taken at Tata Memorial Cancer Hospital, Sangrur and which was duly registered vide claim No.309860. However, the claim was not settled and various documents were demanded from the complainant. The complainant has produced on record copy of consignment ship No.16581666 dated 13.4.2022 and stated that all the documents were sent to the TPA of the OPs.
11. The complainant has produced the bills for the treatment taken at Cancer Hospital, which are to the tune of Rs.1,53,406/-alongwith discharge summary dated 8.2.2022.The complainant has also stated on record that a reimbursement of Rs.547685/- has already been made by the OPs. The complainant and his family members were insured for a sum of Rs.7lac only. As such the complainant is entitled for the balance amount i.e. Rs.1,52,315/-only.
12. In view of above, we partly allow the complaint and direct the OPs to settle the claim of the complainant to the tune of Rs.1,52,315/- alongwith interest @6% per annum from the date of submission of claim documents on 13.4.2022.The OPs are also directed to pay Rs.5000/-as compensation for causing mental agony and harassment and Rs.5000/- as litigation expenses. Compliance of the order be made by the OPs within a period of 45 days from the date of receipt of certified copy of this order.   
13.           The instant complaint could not be disposed of within stipulated period due to heavy rush of work  and for want of Quorum from long time.
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                                              G.S.Nagi                           PUSHVINDER SINGH

                                              Member                          President