Punjab

Ludhiana

CC/22/184

Dilbagh Singh - Complainant(s)

Versus

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

Jishu Dhir

27 Nov 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  184 dated 04.05.2022.                                     Date of decision: 27.11.2024. 

 

Dilbagh Singh aged about 52 years son of Sh. Mohinder Singh, Resident of VPO Dalla Patti, Ramuwala Nawan, Tehsil & District Moga (Punjab)                                                                                                     ..…Complainant

                                                Versus

1. The United India Insurance Company Ltd., Reg. Office: #136, Floor No.1, Feroze Gandhi Market, Ludhiana-141001 (Punjab)        through its Managing Director/Manager/Authorized Signatory.
2. The Central Bank of India, Regional Branch Office at Ferojpur Road, Gurdev Nagar, Adjoining Hotel Park Plaza, Ludhiana-141001 (Punjab) through its Regional Manager/Authorized Signatory.                                                                                                        …..Opposite parties 

Complaint Under Section 36 of the Consumer Protect Act as amended up to date.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. Jishu Dhir, Advocate

For OP1                         :         Sh. R.K. Chand, Advocate.

For OP2                         :         Sh. Rajan Arora, Advocate.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant is an employee of OP2 Central Bank of India who obtained insurance from OP1  for its employees through agency of employee of Indian Bank Association/Central Bank of India. OP2 Bank purchased policy from OP1 vide policy No.MD15-0029791220 and covered under duly medical expenditure reimbursement scheme to its employee vide MDID:0029791220, which also covers the dependent family member of the employee for IBM Member Banks, parties to the Bipartite settlement/joint note dated 25.05.2015 in lieu of the existing hospitalization scheme.

                   The complainant further stated that father of the complainant namely Sh. Mohinder Singh was suffering from various old age ailments. On 20.04.2017, the medical condition of his father became sick and the complainant approached Mittal Hospital & Heart Centre, Opposite New Telephone Exchange, Dussehra Ground, Moga (Punjab). The medical incharge of the hospital, diagnoses his father but the problematical was still there and as such, his father was admitted on 20.04.2017 in the said hospital for further investigation and proper diagnose and thereafter, was discharged on 22.04.2017. The complainant incurred Rs.16,014/- on treatment of his father. However, on 30.03.2017, again medical condition of father of the complainant became  sick and he approached Mittal Hospital where his father was diagnosed and admitted for further investigation and proper diagnose and was discharged on 03.04.2017. The complainant spend Rs.25,198/- on treatment of his father and in all he spent Rs.41,212/- on treatment of his father. The complainant further stated that he approached OP2  who assured him to pay off the medical bill by OP1 on submission of hospital discharge slip and medicine bills to office of OP1. The complainant submitted the compete record along with bills, discharge summary and other documents in the office of OP1 and OP2 but their officials postponed the mater on one or the other pretext. However, the complainant kept awaiting for reimbursement and settlement of the claim for a long time but no reply was received. As such, he approached OPs but they did not give any reply nor they settled his legitimate claim and even they stopped responding to the complainant. The complainant claimed to have suffered mental torture, mental pain, agony and harassment due to deficiency in service on the part of the OPs. The complainant sent two legal notices dated 20.01.2022 and 05.04.2022 upon the OPs but no response was given. Hence this complaint whereby the complainant has prayed for issuing direction to the OPs to pay the claim amount of Rs.41,212/- along with compensation of Rs.50,000/- and litigation expenses of Rs.25,000/-.

2.                Upon notice, OP1 appeared and filed written statement and by taking preliminary objections assailed the complaint on the grounds of  maintainability; lack of jurisdiction; the complainant has not come with clean hands; suppression of material facts etc. OP1 stated that on receipt of the claim, it was duly entertained, registered and the complainant was called upon to submit the documents in support of his claim but he did not supply the same despite repeated requests. Further there was delay of intimation of the claim. OP1 requested the complainant to supply ECS detail and also requested to explain reason of delay in submission of claim but he did not respond and as such, his claim file was closed as “No Claim”. According to OP1, the claim was rightly closed due to non-submission of required documents by the complainant.

                   On merits, OP1 reiterated the crux of averments made in preliminary objections. OP1 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                OP2 filed separate written statement and by taking preliminary objections assailed the complaint on the grounds of maintainability; concealment of true and material fats; lack of cause of action etc. OP2 stated that the present complaint has been filed to extract money. Further the complainant has sought payment of some imaginary amount which is civil in nature and it also involves complicated questions of law and facts which can be decided by the civil court. Op2 further stated that the complainant sent the claim documents twice through two letters i.e. letter Ref. No. BO:MOGA/101 dated 03.05.2017 for claim amount of Rs.16,014/- and letter Ref. No. BO:MOGA dated 19.04.2017 for claim amount of Rs.24,393/- through Branch Manager, Central Bank of India, Moga Branch, Distt. Moga posted on 12.05.2017 and 20.04.2017. The same were forwarded to OP1 by them on 17.05.2017 and now OP1 is duty bound to deal with the claims of the complainant and OP2 has nothing to do with the claims of the complainant. According to OP2, it has sent number of reminders to OP1 to settle the claims of the complainant but  OP1 did not pay any heed to the said reminders. There is no lapse on the part of OP2.                  On merits, OP2 reiterated the crux of averments made in preliminary objections. OP2 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

4.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 to Ex. C60 and closed the evidence.

5.                On the other hand, the counsel for OP1 tendered affidavit Ex. RW1/A of Ms. Lipi Moitra, Assistant Manager of OP1 along with documents Ex. RW1/1 to Ex. RW1/27 and closed the evidence.

                   The counsel for OP2 also tendered affidavit Ex R2/A of Sh. Arun Kumar Singh, Chief Manager of Central Bank of India, Regional office, Ludhiana along with documents Ex. R2/1 to Ex. R2/5 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents as well as written statements, affidavits and documents produced on record by the parties.

6.                The complainant, an employee of OP2 Bank, having employee No.123960, was enrolled to Mediclaim Policy of OP1 insurance company vide MDID:0029791220 which also extended coverage to the family members of the employee. Sh. Mohinder Singh, father of the complainant, remained hospitalized at Mittal Hospital & Heart Centre, Opposite New Telephone Exchange, Dussehra Ground, Moga (Punjab) from 20.04.2017 to 22.04.2014 and incurred expenses of Rs.16,014/- and also from 30.03.2017  to 03.04.2017 for which the complainant incurred Rs.25,198/-. In all, the complainant spent Rs.41,212/- on treatment of his father for above said hospitalization. The complainant submitted his claim with OP2 Bank who in turn forwarded the claim of the complainant along with documents with OP1 insurance company vide letter dated 03.05.2017 Ex. C12 and letter dated 19.04.2017 Ex. C24 respectively. However, despite sending reminders through legal notices and also by OP2 bank, the claim of the complainant was not settled by OP1.

7.                Now by filing written version, OP1 has tried to justify its stand on the ground that there was a delay in submission of the documents and the claim file was closed as “No Claim”. OP1 while leading evidence, did not adduce any query/deficiency letter or repudiation letter to substantiate its version. The reason mentioned by OP1 appears to be an attempt to escape from the liability. Even otherwise, the said letters Ex. C12 and Ex. C24 were accompanied with documents such as claim form Part-A, ECS Form, Cancelled cheque, copy of MDID card, Original bills (11 bills), admission and discharge summary, investigation reports, X-ray, ECG and ultrasound. Moreover, non-submission of the documents cannot be made a sole ground to close the claim of the complainant. The insurance companies are required to be more liberal in their approach without being too technical.

8.                In this regard, reference can be made to 2022(2) Apex Court Judgment 281 (SC) in case title Gurmel Singh Vs Branch Manager National Insurance Company Ltd. whereby it has been held by the Hon’ble Supreme Court of India that the insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to procure and furnish. Once, there was a valid insurance on payment of huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non­submission of the duplicate certified copy of certificate of registration, which the appellant could not produce due to the circumstances beyond his control. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control.

                   So there is no iota justification on the part of OP1 in closing the otherwise genuine medical claim as “No Claim” which amounts to deficiency in service on the part of OP1.

9.                OP2 being bank has been rendering requisite services to the complainant and making efforts for expeditious settlement of his claims and as such, the complaint as against OP2 is liable to be dismissed. Keeping in view the above said facts and circumstances, it would be just and appropriate if OP1 is directed to settle and reimburse claim lodged by the complainant in respect of treatment of his father Sh. Mohinder Singh at Mittal Hospital & Heart Centre, Opposite New Telephone Exchange, Dussehra Ground, Moga (Punjab) from 20.04.2017 to 22.04.2014 and also from 30.03.2017  to 03.04.2017 along with composite costs of Rs.10,000/-.

10.              As a result of above discussion, the complaint is partly allowed with an order that OP1 shall settle and reimburse claim lodged by the complainant in respect of treatment of his father Sh. Mohinder Singh at Mittal Hospital & Heart Centre, Opposite New Telephone Exchange, Dussehra Ground, Moga (Punjab) from 20.04.2017 to 22.04.2014 and also from 30.03.2017  to 03.04.2017 as per terms and conditions of the policy along with interest @8% per annum on the settled amount w.e.f. 17.05.2017, when the claim along with documents were forwarded by OP2 with OP1, within period of 30 days from the date of receipt of copy of the order. OP1 shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Payment of costs shall be made within a period of 30 days from the date of the receipt of the copy of this order. However, the complaint as against OP2 is hereby dismissed. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.     

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:27.11.2024.

Gobind Ram.