Punjab

Ludhiana

CC/20/164

Sunil Kumar Kainth - Complainant(s)

Versus

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

Subhash Lal

01 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:164 dated 01.09.2020.                                                        Date of decision: 01.03.2023.

 

Sunil Kumar Kainth aged 37 years S/o. Sh Shri Pal, R/o. House No.1023/2, St. No.1, Baldev Nagar, Rahon Road, Ludhiana.                                                                                                                                     ..…Complainant

                                                Versus

1. United India Insurance Company, having its Head Office at 24, Whites Road, Chennai-600014.
2. United India Insurance Company, Regional Office at Feroze Gandhi Market, Ludhiana.
3. M/s. Vidal Health TPA Pvt. Ltd., Ist Floor, Tower 2, SJR 1 Park, EPIP, Whitefield, Bengaluru-560066.                                                                                                                                            …..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. Subhash Lal, Advocate.

For OP1 and OP2          :         Sh. R.K. Chand, Advocate.

For OP3                         :         Exparte.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the employer of the complainant Syndicate Bank had obtained Medicaim Policy from opposite party No.1 and 2 for its employees including the complainant. The complainant and his parents were also insured under the said policy having card No.BLR-UI-I-580-001-0003375-A issued by the opposite parties. The complainant submitted that during the validity of the said policy his father Sh. Shri Pal suffered Enteric Fever and Septicemia and was hospitalized in Shri Ram Chand Uppal Memorial Hospital, North Avenue, Opp. Krishna Colony, St. No.7, Rahon Road, near Basti Jodhewal, Ludhiana. The complainant intimated the opposite parties regarding his admission in the hospital and also lodged claim by supplying the documents provided by the hospital and bills etc. to the opposite parties. Respondent No.3 processed the claim but the opposite parties repudiated the claim vide letter dated 22.11.2019 on the ground of fraud. The opposite parties have not explained in the said letter dated 22.11.2019 how the claim is fraudulent and how fraud has been committed by the complainant. The complainant further submitted that he reserves right to initiate separate proceedings under Section 500 IPC for leveling defamatory allegations of fraud etc. The complainant has never submitted any false documents rather submitted the documents received from the concerned hospital which can be verified by the opposite parties from the hospital record by deputing investigator. The complainant also issued legal notices dated 23.12.2019 and 23.12.2019 upon the opposite parties to which opposite party No.3 sent a false and frivolous reply. There is clear cut deficiency in service and unfair trade practice on the part of the opposite party which has caused financial loss and mental pain and agony to the complainant for which the opposite parties are liable to pay compensation  of Rs.50,000/- to the complainant. In the end, the complainant has prayed for directing the opposite parties to pay the amount of Rs.19,311/- and Rs.50,000/- for compensation besides litigation expenses of Rs.22,000/-.

2.                Notice to opposite party No.3 was sent through registered post on 05.12.2020 but none turned up for opposite party No.3 and as such, opposite party No.3 was proceeded against exparte vide order dated 09.03.2021.

3.                Upon notice, opposite party No.1 and 2 appeared and filed joint written statement and assailed the complaint on the ground of lack of jurisdiction, the complaint is not maintainable, there is no deficiency in service on their part and suppression of material facts by the complainant etc. The opposite parties alleged that on receipt of claim, it was duly entertained, registered and referred to M/s. Vidal Health TPA Pvt. Ltd. and the complainant was called upon to submit the documents in support of his claim. M/s. Vidal Health TPA Pvt. Ltd. duly processed the claim file in terms of insurance policy and after adopting the procedure and completing the formalities on obtaining documents, found that the claim is not payable and accordingly they returned the file to opposite party No.2. After receipt of file from M/s. Vidal Health TPA Pvt. Ltd. and after going through the documents of claim file and scrutinizing the file by officials of the opposite parties, the claim of the complainant was repudiated vide letter dated 22.11.2019 as per  condition No.6.4 of the term and conditions of the policy which is reproduced as under:-

“If Claim is found to be fraudulent, or if any false declaration is made, or if any fraudulent devices are used by you or the insured person or anyone acting on their behalf to obtain any benefit under this policy then this policy shall be void in respect of such insured person and all claims being processed shall be forfeited for all insured persons within the family. All sums paid under this policy shall be repaid to us by you on behalf of all insured persons who shall be jointly liable for such repayment.” 

Opposite party No.1 and 2 further alleged that the documents submitted by the insured are found to be fictitious as per the documentary evidence available and as such, the claim of the complainant was found to be not payable as per policy clause No.6.4 and the claim was repudiated vide letter dated 22.11.2019. The complainant was informed regarding repudiation of claim vide letter dated 08.01.2020.

                   On merits, opposite party No.1 and 2 reiterated the crux of averments made in the preliminary objections. The opposite parties denied any deficiency in service on their part and in the end, they 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 repudiation letter dated 22.11.2019, Ex. C2 is the copy of identity card of the complainant issued by opposite parties, Ex. C3 is the copy of report of M/s. Vidal Health TPA Pvt. Ltd. dated 08.08.2019, Ex. C4 is the copy of medical certificate issued by Sh. Ramchand Uppal Memorial Hospital, Ex. C5 is the copy of claim form-Part A, Ex. C6 is the copy of declaration by the insured, Ex. C7 is the copy of claim form-Part B, Ex. C8 to Ex. C11 are the copies of investigation reports, Ex. C12 is the copy of bill issued by Sh. Ramchand Uppal Memorial Hospital, Ex. C13 to Ex. C33 are the copies of medicine slips of Sh. Ramchand Uppal Memorial Hospital, Ex. C34 to Ex. C39 are the copies of bills/receipts of medicine of Shree Ram Medicos, Ex. C40 is the copy of Aadhar card of the complainant, Ex. C41 is copy of letter dated 26.08.2019 written by the complainant to M/s. Vidal Health TPA Pvt. Ltd., Ex. C42 is the legal notice dated 23.12.2019, Ex. C43 to Ex. C45 are the postal receipts, Ex. C46 is the reply to legal notice dated 09.01.2020, Ex. C47, Ex. C51 and Ex. C53 are the copies of investigation reports, Ex. C48 is the copy of repudiation letter dated 08.01.2020, Ex. C49 is the legal notice dated 15.02.2020, Ex. C50 is the postal receipt, Ex. C52 is the reply to legal notice dated 24.02.2020 and closed the evidence.

5.                On the other hand, counsel for opposite party No.1 and 2 tendered affidavit Ex. RW1/A of Sh. Ashok Paul, Sr. Div. Manager of the opposite parties along with documents Ex. R1 is the copy of repudiation letter dated 22.11.2019, Ex. R2 is the copy of medical certificate issued by Sh. Ramchand Uppal Memorial Hospital, Ex. R3 is the copy of Claim Form- Part A, Ex. R4 is the copy of Claim Form-Part B, Ex. R5 to Ex. R8 are the copies of investigation reports, Ex. R9 is the copy of repudiation letter dated 08.01.2020 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 written reply along with affidavit and documents produced on record by both the parties.     

7.                Perusal of medical record relied upon by both the parties shows that the complainant remained admitted in Shri Ram Chand Uppal Memorial Hospital, Ludhiana from 22.07.2019 onwards and he incurred an amount of Rs.19,311/- as medical expenses. The complainant submitted his claim vide letter Ex. C3 along with claim form, identity proof, discharge summary, investigation reports and prescription and medical bills. The claim was repudiated vide letter Ex. C1 dated 22.11.2019 by invoking clause 6.4 of the policy, operative part of which is reproduced as under:-

“6.4 Fraudulent Claims

If Claim is found to be fraudulent, or if any false declaration is made, or if any fraudulent devices are used by you or the insured person or anyone acting on their behalf to obtain any benefit under this policy then this policy shall be void in respect of such insured person and all claims being processed shall be forfeited for all insured persons within the family. All sums paid under this policy shall be repaid to us by you on behalf of all insured persons who shall be jointly liable for such repayment. 

Detailed Narration

The hospitalization <b> documents submitted are found to be factious</b> as per the documentary evidence available. Hence, the claim is not admissible.”

The reason assigned by the opposite parties in the repudiation is that the hospitalization documents submitted are found to be fictitious and as such, the claim is inadmissible. The contents of the repudiation letter by itself are vague, sketchy and does not reveal how and which of the documents were found to be fictitious. It is also not clear that some independent investigation was ever conducted by the opposite parties before repudiating the claim. The opposite parties have also not shown whether any show cause notice/deficiency letter was ever issued to the complainant calling upon him to explain the alleged discrepancy. However, in response to the legal notice Ex. C44, opposite party No.3 Third Party Administrator responded vide letter Ex. C46 stating therein that the complainant has submitted medical report Annexure-A that does not contain signature of pathologist and it is not a valid medical report. Perusal of Annexure-A Ex. C47 shows that it is a serology report issued by the in-house laboratory of the hospital and it is a computer generated statement which does not require signatures. So the opposite parties were not justified in repudiating the claim of the complainant. The complainant has submitted his claim for reimbursement of medical expenses of Rs.19,311/-. In the given facts and circumstances, it would be just and appropriate if the opposite parties are directed to consider and reimburse the claim of the complainant within 30 days from the date of receipt of copy of order along with composite cost of Rs.5000/-.

8.                As a result of above discussion, the complaint is allowed with direction to the opposite parties to consider and reimburse the claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of copy of the order. The opposite parties shall further pay a composite costs of Rs.5000/- (Rupees Five Thousand only) to the complainant within 30 days from the date of receipt of copy of order. Liability of the opposite parties shall be joint and several. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

10.              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:01.03.2023.

Gobind Ram.

 

 

Sunil Kumar Kainth Vs United India Insurance Co. Ltd.                 CC/20/164

Present:       Sh. Subhash Lal, Advocate for complainant.

                   Sh. R.K. Chand, Advocate for OP1 and OP2.

                   OP3 exparte.       

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with direction to the opposite parties to consider and reimburse the claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of copy of the order. The opposite parties shall further pay a composite costs of Rs.5000/- (Rupees Five Thousand only) to the complainant within 30 days from the date of receipt of copy of order. Liability of the opposite parties shall be joint and several. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:01.03.2023.

Gobind Ram.