Punjab

Ludhiana

CC/21/424

Maninder Singh - Complainant(s)

Versus

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

complaint in person

13 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 424 dated 15.09.2021.                                                        Date of decision: 13.10.2023.

 

Maninder Singh Bhatia aged 63 years son of S. Jagjit Singh Bhatia, resident of House No.10513, Haqiqat Nagar, Haibowal Kalan, Ludhiana-141001.                                                                                                        ..…Complainant

                                                Versus

1. United India Insurance Co. Ltd., Local Office at 136, Feroze Gandhi Market, Ludhiana-141001 through its Manager/authorized person.
2. United India Insurance Co. Ltd., having its Registered office at I.B.A. Vulcan Insurance  Building, Ground floor, 77, V.N. Road, Church Gate, Mumbai-400020, through its Manager/authorized person.     
3. Health Insurance TPA of India Ltd., Majestic Omnia Building, A-110, 2^nd Floor, Sector 4, Noida, U.P.-201301 through its authorized person.                                                                                     …..Opposite parties  

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Maninder Singh Bhatia in person.

For OP1 and OP2          :         Sh. D.R. Rampal, Advocate.

For OP3                         :         Exparte.

ORDER

PER SANJEEV BATRA, PRESIDENT

 

1.                Briefly stated, the facts of the complaint are that the complainant was retired as Special Assistant from Central Bank of India, Civil Lines, Ludhiana in April 2018 and he was hale and hearty and was not suffering from any serious ailment. The complainant got group insurance scheme from opposite party No.1 and 2 for himself and for his wife Smt. Rajinder Kaur Bhatia vide policy No.1118000041449001 w.e.f. 01.11.2018 to 31.10.2019 having coverage of Rs.3,00,000/-. The complainant stated that his wife Smt. Rajinder Kaur Bhatia was feeling difficulty in moving and standing properly due to knee problem and as such, he along with Smt. Rajinder Kaur Bhatia visited Dr. Sanjeev Mahajan of Fortis Hospital, Chandigarh Road, who after checkup recommended for admission. Smt. Rajinder Kaur Bhatia was admitted in the said hospital on 12.06.2019 and after her knees replacement, she was discharged on 17.06.2019. Fortis Hospital raised a bill of Rs.2,48,600/- which was paid by opposite parties No.1 and 2 as the policy was cashless one. The complainant further stated that after her discharge, Smt. Rajinder Kaur Bhatia had to undergo physiotherapy, tests, medication and treatment of UTI dated 03.08.2019 from Dr. Deepak  Mahajan of Kidney Kare Surgical Centre, Kitchlu Nagar, Ludhiana and spent Rs.46,765/- from his own pocket. On 26.08.2019, the complainant lodged claim of Rs.46,765/- for post hospitalization and consequent medicines with the opposite parties along with relevant documents with request to process and sanction the claim.  However, the opposite parties kept on lingering the matter. According to the complainant, he sent various emails and reminders including reminder dated 14.08.2020 to the opposite parties to sanction the claim but no reply was received at the end of the opposite parties. As such, the complainant moved an application to the Insurance Ombudsman, Chandigarh on 20.11.2020 and the Insurance Ombudsman passed an award on 05.01.2021 holding entitled the complainant to the tune of Rs.15,000/- on account of physiotherapy and also ordered to disburse the balance amount of claim to the complainant subject to submission of documents by the complainant. Thereafter, the complainant sent email dated 02.03.2021 with request to make payment of Rs.21,444/- out of Rs.46,765/-. On 25.02.2021, the opposite parties transferred an amount of Rs.15,000/- only to the pension account of the complainant bearing account No.3500090370 maintained with Central Bank of India, Civil Lines, Ludhiana, which was accepted by the complainant under protest by reserving his right to claim the balance amount. The complainant further stated that under the head of Pre and Post hospitalization in the schedule of the policy, it has been specified that Pre and Post Hospitalization expenses payable in respect of each hospitalization shall be actual expenses incurred subject to 30 days prior to hospitalization and 90 days after discharge. The complainant sent final reminder dated 14.08.2020, in which the complainant stated that:

                   i) “TPA is not permitted to settle/reject/repudiate claims” as per                 Section 33(c) of HIR 2016.

                   ii) The claims settlement (rejection letter should mention ‘ground                for denial/rejection of claims’ as per Section 33(d) of HIR 2016.

iii) Consumer will ‘get interest of 2% over the prevailing bank rates on claims payment delayed beyond 30 days’ and have to be mentioned in the policy document as per Section 28 (v) of HIR 2016.

However,  no response was received from the opposite parties. The complainant further stated that after receiving amount of Rs.15,000/- still an amount of Rs.31,765/- is payable to him by the opposite parties which they have failed to pay despite his repeated requests and demands. As such, the complainant has suffered mental pain, agony, harassment due to deficiency in service and unfair trade practice on the part of the opposite parties for which he is entitled to compensation of Rs.50,000/-. In the end, the complainant prayed for issuing direction to the opposite parties to make payment of Rs.31,765/- along with interest and compensation of Rs.50,000/-.

2.                Notice was issued to opposite party No.3 through regist4red post on 23.09.2021 but none turned up for opposite party No.3 despite this service and as such, opposite party No.3 was proceeded against exparte vide order dated 11.01.2022.

3.                Upon notice, opposite parties No.1 and 2 appeared and filed written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint; suppression of material facts; bad for non-joinder and mis-joinder of necessary parties; the complainant has no locus standi to file the present complaint; the complaint is barred by the principle of resjudicata etc. Opposite party No.1 and 2 stated that the complainant has filed one complaint before Insurance Ombudsman, Chandigarh, which was decided vide order dated 06.01.2021. Opposite parties No.1 and 2 paid Rs.15,000/- for physiotherapy of Mrs. Rajinder Kaur Bhatia after passing of order dated 06.01.2021 but the complainant had not complied with said order. In order dated 06.02.2021 it was held that the complainant is not entitled to bill of Rs.18,000/- as same is not payable and it was also held that treatment taken for Urinary Tract Infection is not on account of replacement of knees and same was held to be non-payable. However, qua other amounts, the Insurance Ombudsman directed to settle the balance amount as per terms and conditions of the policy subject to submission of requisite documents by the complainant within30 days from the receipt of award copy but the complainant did not supply the requisite documents to the opposite parties.

                   On merits, opposite parties No.1 and 2 reiterated the crux of averments made in the preliminary objections. The opposite parties No.1 and 2 have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of insurance policy w.e.f. 01.11.2018 to 31.10.2019, Ex. C2 is the copy of inpatient  summary bill, Ex. C3 is the copy of discharge summary, Ex. C4 is the copy of post hospitalization expenses, Ex. C5 to Ex. C8, Ex. C20, Ex. C26 to Ex. C28, Ex. C30, Ex. C35 are the copies of bills/receipts, Ex. C9 to Ex. C19, Ex. C21 to Ex. C25 are the copies of test/investigation reports, Ex. C29 is the copy of certificate of treating doctor, Ex. C31 to Ex. C33 is the copy of award dated 06.01.2021 of Insurance Ombudsman, Ex. C34 is the copy of account statement of the complainant and closed the evidence.

5.                On the other hand, opposite parties No.1 and 2 tendered affidavit Ex. RA of Sh. Maneesh Kumar Singh, Divisional Manager, United India Insurance Co., DO I, Near Nehru Sidhant Kender, Pakhowal Road, Ludhiana and submitted documents Ex. RA is the copy of award dated 06.01.2021 of Insurance Ombudsman and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and affidavit produced on record by both the parties.

7.                It is the admitted case of the complainant that his wife Smt. Rajinder Kaur Bhatia got her knee replacement done at Fortis Hospital, Chandigarh Road, Ludhiana and she remained admitted from 12.06.2019 to 17.06.2019. She was advised physiotherapy and this fact also finds corroboration in discharge summary Ex. C3. The complainant claimed to had spent Rs.2,48,600/- on knee replacement treatment which was disbursed by the opposite parties being cashless one. The only grievance of the complainant is that with regard to non-payment of post hospitalization charges as well as medicine charges by the opposite parties. The complainant preferred to move a complaint before Insurance Ombudsman, who vide orders award dated 06.01.2021 pleased to pass an order with following terms:-

“Taking into account the facts & circumstances of the case and the submission made by both the parties during the course of personal hearing, Rs.15,000/- on account of physiotherapy and balance amount subject to submission of documents by complainant, is hereby awarded to be paid by the insurer to the insured, towards full and final settlement of the claim.”

8.                Admittedly, after passing of the award, the opposite parties paid a sum of Rs.15,000/- to the complainant on account of physiotherapy. The complainant who appeared in person contended that he had already supplied the documents before lodging the claim with Insurance Ombudsman but he candidly admitted that he has not supplied the documents after passing of the award. Moreover, non-submission of the documents cannot be made a sole ground to non-settlement of the claim of the complainant. The insurance companies are required to be more liberal in their approach without being too technical.

9.                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.

As such, it will be in the interest of justice, if another opportunity is afforded to the complainant for furnishing the documents as mentioned in the order of Insurance Ombudsman. In the given circumstances, it will be just and appropriate of the complainant is directed to submit the requisite documents with the opposite parties within 15 days from the date of receipt of copy of order and further the opposite parties will settle and reimburse the claim of the complainant strictly in accordance with terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. 

10.              As a result of above discussion, the complaint is partly allowed with direction to submit the requisite documents with the opposite parties within 15 days from the date of receipt of copy of order and further the opposite parties will settle and reimburse the balance claim of the complainant strictly in accordance with terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. However, there shall be no order as to costs.  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)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:13.10.2023.

Gobind Ram.