Haryana

Yamunanagar

CC/19/2012

Jitender Gupta S/o Murari Lal - Complainant(s)

Versus

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

S.S.Panjetha

09 Mar 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

Complaint No. 19 of 2012.

Date of institution: 04.01.2012

Date of decision: 09.03.2017

Jitender Gupta aged about 53 son of Murari Lal Gupta, resident of Jitender Udyog, near Railway out Agency, Jagadhri 135003.                                              

       …Complainant.

                        Versus

1.  United India Insurance Company Limited, Branch near Telephone Exchange, Jagadhri Road, Yamuna Nagar

2.  Meditek Solution Ltd., resident of 45, Nathupura Road, DLF Phase-III, Gurgaon 12202 throu`gh its authorized signatory.                                                                                                                                       

                                                                                                               …Respondents.

 

BEFORE:       SH. ASHOK KUMAR GARG…………….. PRESIDENT.

                        SH. S.C.SHARMA………………………….MEMBER.

 

Present:          Shri Sher Singh Panjetha, Advocate for complainant.

                        Sh. V.K. Sharma, Advocate for respondent No.1.

                        Respondent No.2 already ex-parte.

 

ORDER  (ASHOK KUMAR GARG, PRESIDENT)

 

1                          The present complaint has been filed under section 12 of the Consumer Protection Act. 1986.

2.                Brief facts of the present complaint, as alleged by the complainant, are that complainant lodged a medical claim for reimbursement of medical expenses to the tune of Rs. 37,481/- with the OPs Insurance Company on 10.07.2011 on account of hospitalization and treatment in respect of kidney problem of his son Yatul Gupta which was against the policy bearing No. 110101/48/11/97/00000004 valid from 10.04.2011 to 09.04.2012 which was repudiated vide letter dated 31.12.2011 by the OPs Insurance Company on the flimsy ground which constitute the deficiency in service and unfair trade practice on the part of the OPs.

3.                     Upon notice OP No.1 appeared and filed its written statement whereas OP No.2 failed to appear despite service, hence he was proceeded ex-parte vide order dated 30.06.2015. OP No.1 filed its written statement by taking some preliminary objections such as complaint is not maintainable; complainant has no locus standi to file the present complaint; there is no cause of action in favour of the complainant; complainant has not approached this Forum with clean hands and on merit it has been admitted that complainant has taken a mediclaim policy bearing No. 110101/48/11/97/00000004 valid from 10.04.2011 to 09.04.2012 vide which the OP No.1 Insurance Company had under-taken to indemnify the complainant for the treatment of his son Mr. Yatul Gupta for a sum of Rs. 50,000/- only.  Further, it has also been admitted that complainant has lodged the claim with the answering OP Insurance Company on 04.08.2011 on the claim form. However, it has been specifically denied that complainant has lodged the claim on 10.07.2011 and on that day claim form was not available. Further, it has also been admitted that OP Insurance Company has received letter dated 26.08.2011 from the complainant. In fact, the OP Insurance Company has sent the claim papers to M/s E.maditek (TPA) Service Ltd vide letter dated 05.08.2011 for scrutiny and processing the claim as the final decision was to be taken by (TPA) Service Ltd. In fact M/s E. Meditek (TPA) Service Ltd. has written letter dated 13.12.2011 and 28.12.2011 to the complainant requiring some documents/ information, which is re-produced as under:

1.         Kindly provide reason for delay intimation and submission of documents.

2.         Kindly provide original receipts of final hospital bill.

3.         Kindly provide your bank account details for facilitation of claims payment through Electronic Fund Transfer (EFT),

However, the complainant has not sent the aforesaid information to the OP No.2, therefore, the OP No.2 has closed the claim of the complainant as No Claim vide letter dated 31.12.2011 addressed to the complainant. Rest contents of the complaint were denied being wrong and incorrect and lastly prayed for dismissal of the complaint as there was no deficiency in service or unfair trade practice on the part of OPs.

4.                     In support of the case, counsel for the complainant tendered into evidence affidavit of complainant as Annexure CW/A and documents such as photo copy of insurance policy as Annexure C-1, Photo copy of hospital treatment card as Annexure C-2, Photo copy of claim intimation letter as Annexure C-3, Photo copy of detail of bill amounting to Rs. 37481/- as Annexure C-4, Photo copy of letter dated 26.08.2011 as Annexure C-5, Photo copy of another letter dated 30.08.2011 as Annexure C-6, Photo copy of letter issued by the OP No.1 to Op No.2 dated 05.09.2011 as Annexure C-7, Photo copy of Urography report as Annexure C-8, Photo copy of lab report and bill as Annexure C-9, Photo copy of hospital medicine bills as Annexure C-10 to C-13, Photo copy of discharge summary of hospital as Annexure C-14, Photo copy of certificate issued by the hospital as Annexure C-15 and closed the evidence on behalf of complainant.

5.                     On the other hand, counsel for the OP No.1 tendered into evidence affidavit of Dr. Karan Mehta C/o M/s E-Meditec (TPA) as Annexure RW/A and affidavit of Ajay Sareen Assistant Divisional Manager UIIC as Annexure RW/B and documents such as photo copy of quarry letter dated 13.11.2012 as Annexure R-1, Photo copy of repudiation letter dated 31.12.2011 as Annexure R-2, Photo copy of insurance policy as Annexure R-3 and closed the evidence on behalf of OP No.1.

6.                     We have heard the counsel of both the parties and have gone through the pleadings as well as documents placed on the file very carefully and minutely.

7.                     It is not disputed that complainant obtained mediclaim insurance policy bearing No. 110101/48/11/97/00000004 valid from 10.04.2011 to 09.04.2012  for a sum of Rs. 50,000/- to indemnify the expenses of treatment of his son Mr. Yatul Gupta which is duly evident from the copy of insurance policy Annexure R-3. It is also not disputed that son of the complainant remained admitted in the hospital i.e. Kidney Centre, at Chandigarh from 02.07.2011 to 03.07.2011 which is duly evident from the copy of discharge summary issued by the Hospital Annexure C-14 and obtained the treatment for Hydro Uretero Nephrosis right side due to right lower ureteric calculus which is evident from the Urography Report Annexure C-8. Further, it is also not disputed that complainant spent Rs. 37,481/- on the treatment of his son Yatul Gupta which is also duly evident from the copy of bills Annexure C-4, C-8 to C-13.

8.                     The only version of the OP No.1 Insurance Company is that the claim of the complainant has been rightly repudiated by the OPs Insurance Company vide its repudiation letter dated 31.12.2011 (Annexure R-2) on the ground that despite so many letters dated 13.12.2011 and 28.12.2011, the complainant failed to reply the quarry letters in which the reason for delay intimation and submission of documents was asked and further the complainant was asked to provide original receipts and final hospital bills and also was asked to provide bank account but this plea of the OPs Insurance Company is not tenable as the OPs Insurance Company has totally failed to convince this Forum that which condition of the terms and conditions of the insurance policy has been violated by the complainant. From the perusal of letter issued by the OPs Insurance Company on dated 13.12.2011 (Annexure R-1), it is duly evident that OPs Insurance Company has received the claim papers on 12.08.2011 from the complainant whereas complainant was discharged from the hospital on 03.07.2011, meaning thereby that complainant submitted the documents with the OPs Insurance Company within a period of 39 days which cannot be treated as a belated stage. It is not the case of the Ops Insurance Company that a forged and false claim has been lodged by the complainant as no investigation report or any cogent evidence has been placed on file to rebut the version of the complainant whereas, the case of the complainant is duly supported with the medical treatment papers of the hospital Annexure C-8 to C-15. Although, the complainant has failed to file any such document vide which he replied the quarry put by the OP Insurance Company vide letter dated 13.12.2011 and 28.11.2011 even then the genuine claim of the complainant cannot be repudiated by the OPs Insurance Company only on the ground of some delay for lodging the same. Generally the terms and conditions of the insurance policy were never supplied to the insured.

9.                     In the circumstances noted above, we are of the considered view that the OP Insurance Company has wrongly and illegally repudiated the claim of the complainant vide letter dated 31.12.2011 Annexure R-2 and the same is hereby set aside. Hence, the complainant is entitled for relief.

 10.                  Resultantly, we partly allow the complaint of complainant and direct the OPs Insurance Company to pay Rs. 37,481/- alongwith interest at the rate of 6% per annum from the date of filing of complaint till its realization and further to pay Rs. 2000/- as litigation expenses. Order be complied within a period of 30 days after preparation of copy of this order failing which the complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be supplied to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Pronounced in open court: 09.03.2017.

                                                                              (ASHOK KUMAR GARG)

                                                                               PRESIDENT

                                                                               DCDRF Yamuna Nagar

 

 

                                                                              (S.C.SHARMA)

                                                                               MEMBER