Haryana

Karnal

CC/324/2019

Ajay Sharma - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

P.K. Mandi

27 Mar 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 324 of 2019

                                                        Date of instt.10.06.2019

                                                        Date of Decision:27.03.2023

 

Ajay Sharma son of Shri Ramesh Chand Sharma, resident of house no.E-85, Poultry Area, near Government Press, Nilokheri, District Karnal.

                                               …….Complainant.

                                              Versus

 

United India Insurance Company Ltd. through its Divisional/Branch Manager, having its office at Durga Mata Mandir Complex, 1^st floor, old G.T. Road, near bus Stand Karnal.

 

                                                                      …..Opposite Party.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.

              Shri Vineet Kaushik……Member

              Dr. Rekha Chaudhary….Member       

              

Argued by: Shri P.K. Mandi, counsel for complainant

                   Shri Abhishek Chaudhary, counsel for the OP.

 

                    (Jaswant Singh President)

 

ORDER:   

                

                The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a family health policy from the OP in the year 2011. The said policy was got renewed from time to time and in the year 2017 the said policy was got renewed vide no.1107012817P111230149 and same was effective from 08.11.2017 to 07.11.2018. As per the terms and conditions of the policy, the entire family including complainant, Smt. Rajni spouse, Raghav Sharma son, Vani Sharma daughter were covered under the aforesaid policy and an amount of Rs.7788/- was paid, vide receipt no.10111070117111376494 dated  07.11.2017. In the month of April, 2018 the complainant was having some problems in the body including some cramps and also having some appetite problem. The complainant got his full body test done from Modern Diagnostic and Research Centre (P) Limited, New Railway Road, Gurugram on 18.04.2018. The complainant contacted the doctors I.V.Y hospital, Sector-71, Mohali and where some tests were also got conducted on 01.05.2018 from Polo Labs IVY hospital, Sector-71 Mohali. Then complainant was found suffering from some kidney disease and complainant got the treatment of the aforesaid disease from the aforementioned hospital as well as from Sanjiv Bansal Cygnus Hospital, Railway Road, Karnal and Rama Super specialty and Critical Care hospital, Karnal, thereafter from Mool Chand Kidney Hospital, Karnal other hospital and also got the dialysis from time to time as per advice of the doctor concerned and still getting the said treatment and dialysis from the above mentioned hospitals.  The complainant spent an amount of more than Rs.2,00,000/- on the aforesaid treatment, tests and dialysis etc. during the subsistence of the insurance policy. The complainant also purchased another Family Health Policy from Star Health and allied insurance Company Ltd. and also filed the claim regarding the present ailment/treatment, the said claim has been ordered to be repudiated, for which the complainant is also going to file a complaint before this Commission. The complainant applied for the reimbursement of the amount which was spent by him on his treatment to the OP and submitted all the required documents. Thereafter, complainant requested the OP several times through emails, reminders and also visiting personally but OP did not pay any heed to the request of complainant. The complainant received a mail from E-Meditek (TPA) on 26.02.2019, through this email OP informed the complainant that “we are unable to process the claim  on the ground that No Claim Reason: $NVRCHECKLIST$DOCUMENT-PENDING”.  It is averred that complainant already sent a mail to the OP and requested that the entire documents which the complainant was having has already been sent to the OP and requested for the reimbursement of the aforesaid claim of medicines/treatment bills etc. and flatly refused to make the payment of the aforesaid claim. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OP appeared and filed its written version, raising preliminary objections with regard to maintainability; cause of action; mis-joinder and non-joinder of parties; jurisdiction and concealment of true and material facts. On merits, it is pleaded that because for one problem the complainant can get medical benefits from one company. In this complaint, the complainant himself has admitted that he is having another policy with Star Health Insurance Company and has lodged claim with that company, hence the complaint filed by the complainant deserves dismissal. It is further pleaded that complainant has not supplied all the bills include the admission and discharge report etc. TPA, E-Meditek Insurance TPA Limited had written letter to complainant dated 04.05.2018 requesting him to submit the following documents to enable to process claim further:

1.     Claim form duly filled and signed by insured and attending doctor.

2.     Certificate from attending medical practitioner mentioning the first symptoms and date of occurrence of ailment.

3.     All treatment papers of current ailment including previous treatment papers if any.

4.     Original discharge card from the hospital.

5.     All original medical investigation report.

6.     Original hospital bill and receipts.

7.     Original bills of chemist, medical practitioner, medical investigation etc. supported by Doctors prescription.

8.     NEFT details: cancelled cheque of policy holder, PAN Card of policy holder, copy of bank passbook/statement of policy holder if cancelled cheque do not contain name of the policy holder.

9.     Know your customer (KYC) details viz. address proof and photo ID. (applicable for claims more than Rs.one lac).

However, complainant failed to submit the above documents due to which the claim of the complainant was closed as “No Claim”, vide letter dated 21.07.2018.  There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel or the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copies of letters and reminders through emails Ex.C2 to Ex.C6, copy of claim document receiving receipt Ex.C7, copy of no claim letter dated 21.07.2018 Ex.C8, copy of complaint Ex.C9, copy of receiving of claim reimbursement dated 28.08.2019, 14.11.2019, 14.11.2018 Ex.C11 to Ex.C13 and closed the evidence on 05.10.2021 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Raj Kamal, Assistant Manager Ex.RW1/A, copy of claim registration acknowledgement Ex.R1, copy of no claim letter Ex.R2, copy of no claim information letter Ex.R3 and Ex.R4, copy of insurance policy Ex.R5 and closed the evidence on 02.05.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a family health insurance policy from the OP in the year 2011. The said policy was got renewed upto the year 2017-2018. In the month of April, 2018 the complainant was found suffering from some kidney disease. Complainant got the treatment of the aforesaid disease from the various hospitals and spent an amount of more than Rs.2,00,000/- on his treatment. The complainant submitted the claim and approached the OP several times through emails, reminders and also visiting personally for the reimbursement of the amount and submitted all the required documents but OP repudiated the claim of the complainant on the false and frivolous ground and lastly prayed for dismissal of the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that complainant is having another policy with Star Health Insurance Company and said company has already repudiated the claim of the complainant. He further argued that complainant filed the complaint before the Commission against the abovesaid repudiation letter and said complaint has been dismissed by this Commission on 02.05.2022. He further argued that complainant has not supplied required documents despite various repeated requests and reminders. In the absence of requisite documents the OP was unable to decide the claim and due to non-submission of documents, OP closed the claim of complainant as “No Claim”, vide letter dated 21.07.2018 and lastly prayed for dismissal of the complaint.

9.             Admittedly, complainant had purchased a family health insurance policy from the OP. It is also admitted that during the substance of the said policy, complainant suffering from Kidney disease has taken a treatment from the various hospitals.

10.           The claim of the complainant has been closed  by the OP, vide letter Ex.R3 dated 21.07.2018 on the ground of non-submission of documents.

11.           The OP has also taken a plea that the complaint filed against the Star Health & Allied Insurance Company has already been dismissed by this Commission on 02.05.2022 on the same cause of action. It is pertinent to mention here that the said policy was purchased by the OP on 19.01.2018 and complainant has taken treatment in the month of April, 2018 and spent Rs.3,50,000/- on his treatment. Complainant had taken a treatment within four months for purchasing the said policy and complaint was dismissed with the observation that complainant was having pre-existing disease at the time of purchasing of said policy. But said in the present complaint, the policy in question has been purchased by the complainant in the year of 2011 and that time complainant was not having any disease and same was renewed from time to time and was effective from 06.11.2017 to 07.11.2018 and same was in force at the time of taking the treatment. Hence, the plea taken by the OP has no force.

12.           The OP has sought various documents mentioned in the letter Ex.R1 dated 04.05.2018. But complainant submits that he has already supplied the required documents. The onus to prove his version was relied upon the complainant but complainant has miserably failed to prove the same by leading any cogent and convincing evidence. If the complainant had supplied the required documents, he would have placed on file the copies of the said documents. Moreover, complainant neither has placed on file treatment records nor medical bills to prove his case. Hence, in view of the above, at this stage, the present complaint is premature.

13.           In view of the above observation, the present complaint is disposed off with the liberty to the complainant to submit the documents as required by the OP as mentioned in the letters Ex.R1, and after submitting the same, OP is hereby directed to settle the claim of the complainant within 30 days. No order as to costs. This order shall be complied with accordingly. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:27.03.2023                                                                     

                                                                President,

                                                    District Consumer Disputes

                                                    Redressal Commission, Karnal.

 

 (Vineet Kaushik)       (Dr. Rekha Chaudhary)

  Member                   Member