DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.    103

                                                Instituted on:      01.03.2018

                                                Decided on:       28.11.2018

Jarnail Singh aged 62 years son of Pritam Singh, resident of Village Badla, PO Gowara, Tehsil Malerkotla, District Sangrur.

                                                        …Complainant

                                Versus

1. United India Insurance Co. Ltd. Divisional Office, LCB, Mumbai, Vulcan Insurance Building 77, Floor No.0, Veer Nariman Road, Church Gate, Mumbai Maharashtra-400020 through its Manager.

2.  M.D. Heritage Health TPA Pvt. Ltd. Nicco House, 5^th Floor, 2 Hare Street Kolkata through its MD.

3.State Bank of India (Previously known as State Bank of Patiala) Old Mandi Ahemdgarh, District Sangrur through Branch Manager.

4.United India Insurance Co. Ltd. Divisional Office, Railway Road, Sangrur through its Divisional Manager.

                                                        ..Opposite parties

For the complainant            :       Shri S.S.Ratol, Adv.

For Opp.partyNo.1&4         :       Shri Bhushan Garg, Adv.

For Opp.party No.3            :       Shri Ashi Goyal, Ad.

For OP No.2                      :       Exparte.

Quorum:    Inderjeet Kaur, Presiding Member

                Vinod Kumar Gulati, Member

Order by : Inderjeet Kaur/Vinod Kumar Gulati, Members.

1.             Shri Jarnail Singh, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant retired as Deputy Manager, State Bank of Patiala, Old Mandi, Ahemdgarh on 31.3.2015 and he along with his family members was insured under Group Employee Medical policy of the bank and the bank deducted a premium of Rs.7526/- on 17.11.2015 and the insurance cover was for one year and the complainant was issued membership number M-2431 and the policy was issued by the OP number 4. The group employee mediclaim policy bearing number 500100/48/15/41/00000515 was issued for the purpose and the OP number 2 is the TPA. It is further stated that the complainant was not issued any terms and conditions of the policy separately. 

2.             The grievance of the complainant is that wife of the complainant Baljinder Kaur suffered from Hepatitis C, as such she took treatment from Dr. Ajit Sood of DMC Hospital, Ludhiana for the period from 26.10.2015 to 23.5.2016, where she spent an amount of Rs.1,10,837/- on her treatment. Thereafter the complainant submitted all the original bills to the Ops, but the claim was not settled, despite issuance of legal notice dated 20.6.2017 and in the reply to that it was wrongly alleged that the domiciliary treatments are not covered.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant the insurance claim amount of Rs.1,10,837/-  along with interest @ 18% per annum from the date of treatment till realisation and further claimed compensation and litigation expenses.

3.             In reply filed by Ops number 1 and 4, objections are taken up on the grounds that claim of the complainant does not fall under the purview of the policy as the expenses claimed by complainant are incurred on domiciliary treatment, which are not covered under the policy, therefore, the complainant is not entitle for the same from this opposite party as per mentioned in the policy at page 3 in Part-1 policy schedule. 

4.             That India Bank’s Association account state bank of Patiala, head office, the mall Patiala has obtained Group Mediclaim Policy for retirees plus their spouse or widow/widower from replying opposite party which was valid for the period 06/11/2015 to 31/10/2016 having policy No. 00100/48/15/41/00000515. Under the said policy, the expenses of domiciliary/OPD treatment are not payable. The policy was issued subject to terms, conditions, exclusions and definitions contained therein or endorse or otherwise express their.

5.             That as per the version of the complainant, his wife Baljinder Kaur started his treatment from 26/10/2015 i.e before the start of the period of insurance policy (Medical Certificate ExC8). As per the complaint, the premium under the mediclaim policy was deducted on 17/11/2015 by the Bank. It is pertinent to here that the company undertakes under the policy that if during the period stated in the schedule or during the continuance of this policy by renewal and insured person shall contract any disease or suffer from any illness, the company will pay through TPA, the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person but not exceeding the sum assured in aggregate in any one period of insurance stated in the schedule. Meaning thereby, if any, person contract disease before the start of the insurance policy, he is not entitled for the reimbursement of medical expenses incurred by him. In this case the wife of complainant suffers from disease prior to the commencement of policy in question, so complainant is not entitled to get the claim amount. The complaint therefore is liable to be dismissed.

6.             The complainant has failed to disclose that Baljinder Kaur wife of the complainant ever hospitalized for the treatment of the disease. Even the complainant has not disclosed knowingly the name of the disease in this para. It is pertinent to note here that as per record submitted by complainant, Baljinder Kaur was suffering from hepatitis C and she was given domiciliary/OPD treatment only. She never remained admitted in the hospital for the treatment of the said disease.

7.             That present complaint filed by the complainant is gross abuse of process of law, and is absolutely false, frivolous and vexatious thereby making it illegal and not tenable thus as the said application is filed without any cause of action, the same is liable to be dismissed in limini.

8.             That there is neither any negligence nor deficiency in service nor any unfair trade practice on the part of the this opposite party. Non payment of the claim, if the same is not payable as per terms and conditions of the insurance policy does not amount to any negligence of deficiency in service or unfair trade practice on the part of the insurance company.

9.             That complainant does not fall under the definition of consumer under the consumer protection act and therefore the present complaint is not maintainable. The contract of the replying opposite party is with the Indian Bank Association account state bank of Patiala. Only the civil court has jurisdiction to try and hear the present dispute.

10.            That this Hon’ble forum has got no jurisdiction to try and hear the present complaint as the policy is issued from Mumbai and the treatment of patients was done from Ludhiana and thinking claim has been laws at Patiala with the state bank of Patiala. Further the Ops have quoted case law S.G. Radha Krishnan V. T.T.K. Health case Services (T.N.S.C.D.R.C.) (Chennai) : Law Finder Doc Id #589491 + F.A. No. 781 of 2008 D/d. 16.5.2011. 2016(4) CPJ 159 New India Assurance Co. Ltd. V. Rajendra Kapoor, (NC). 2015(2) C.P.J. 26 : New India Assurance Co. Ltd., Versus M/s Global Poultry. Further It has been therefore prayed that complaint may kindly dismissed with cost of rupees 20,000/-.

11.            In reply filed by OP number 3, preliminary objections are taken up on the ground that the complainant has not come to the Forum with clean hands, that there is no occasion for the complainant to file the present complaint, that the complaint is not maintainable, that the complaint is false, frivolous, misconceived and vexatious in nature. On merits, the allegations levelled in the complaint have been denied in toto.

12.            Record shows that the Op number 2 was proceeded against exparte.

13.            The learned counsel for the complainant has produced Ex.C-1 to Ex.C-31 copies of documents and closed evidence. On the other hand, the learned counsel for the OP number 1 and 4 has produced Ex.OP/1&4/1 to Ex.OP&4/5 copies of documents and affidavit and closed evidence. The learned counsel for OP number 3 has produced Ex.OP3/1 affidavit and closed evidence.

14.            We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

15.            It is an admitted fact that the complainant retired as Deputy Manager from State Bank of Patiala Ahemdgarh on 31.3.2015 and he along with his family members was insured under Group Employee Medical policy of the bank by paying the requisite premium of Rs.7526/- on 17.11.2015 under policy number 500100/48/15/41/00000515.  In the present case, the grievance of the complainant is that his wife Baljinder Kaur suffered from Hepatitis C, as such, she took treatment from Dr. Ajit Sood of DMC Hospital, Ludhiana from 26.10.2015 to 23.5.2016, where she spent an amount of Rs.1,10,837/- on her treatment and after getting the treatment, the complainant submitted all the bills to the OPs for settlement of the claim, but the OPs refused to pay the claim on flimsy grounds, which is said to be deficiency in service on the part of the OPs.  On the other hand, the learned counsel for the OPs has contended vehemently that the claim of the complainant does not fall under the purview of the policy as the expenses claimed by the complainant are incurred on domiciliary treatment, which are not covered under the policy. It is on record that the complainant spent an amount of Rs.1,10,837/- on the treatment of her wife during the subsistence of the insurance policy and has also produced on record the copies of various medical bills as well as treatment record, but the Ops number 1,2 and 4 have wrongly denied the rightful claim to the complainant. Under the circumstances, we feel that there is deficiency in service on the part of the OPs.   

16.            In view of our above discussion, we allow the complaint and direct OPs number 1, 2 and 4 to pay to the complainant an amount of Rs.1,10,837/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 1.3.2018 till realisation. OPs number 1, 2 and 4 are further directed to pay to the complainant an amount of Rs.5000/- on account of compensation for mental tension, agony as well as harassment. This order of ours be complied with within a  period of thirty days of receipt of copy of this order. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        November 28, 2018.

                                                            (Inderjeet Kaur)

                                                          Presiding   Member

                                                        (Vinod Kumar Gulati)

                                                                     Member