DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT
C.C. No. : 138 of 2018
Date of Institution: 16.08.2018
Date of Decision : 11.06.2019
Krishan Kant Garg aged about 61 years son of Ramji Dass Garg r/o Dr Harpal Street, Jaitu Road, Kotkapura.
...Complainant
Versus
- United India Insurance Co. Ltd. 24, White Road Chennai having one of its Branch Office at Kotkapura, through its Branch Manager, Kotkapura.
- Dedicated Healthcare Services TPA (India ) Pvt Ltd Cambata Building (Eros Theatre Building) East Wing, 2nd Floor 42, Maharishi Karve Road, Mumbai-400 020.
- Bank of India, Zonal Office, Surya Kiran Building, Opp. Rakh Bagh, Ludhiana.
.......Ops
Complaint under Section 12 of the
Consumer Protection Act, 1986.
* * * * * *
Quorum: Sh. Ajit Aggarwal, President,
Smt Param Pal Kaur, Member.
Present: Sh Anil Chawla, Ld Counsel for complainant,
Sh Ashok Kumar Monga, Ld Counsel for OP-1,
Sh Ranjit Singh Kakkar, Ld Counsel for OP-3,
OP-2 Exparte.
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ORDER
(Ajit Aggarwal, President)
Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of insurance claim and for further directing OPs to pay Rs.50,000/- as compensation for harassment, inconvenience, mental agony and Rs.10,000/- as litigation expenses.
2 Briefly stated, the case of the complainant is that complainant was employed in bank and during his service, as per policy of bank mediclaim policy for the bank employees was purchased, which also covered the complainant. Complainant retired on 30.09.2017 and premium for the October, 2017 was deducted by bank authorities from the account of complainant and was submitted to OP-1 as per terms of policy. It is submitted that on 7.09.2016, complainant met with an accident. His bike suddenly slipped and he got injuries for which he remained under treatment at Anil Baghi Hospital, Ferozepur and thereafter, he submitted his claim for Rs.8213/-to OP-1 and 2, vide e-mail, OPs declined the claim of complainant on the ground of non submission of requisite documents. Though he has already submitted all requisite documents with them. it is further submitted that claim of complainant was approved for Rs.7613/-, but despite approval of claim, they did not pay any amount to him. After that complainant sent domiciliary claim for Rs.8262/-for three months and Ops passed the
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same only for Rs.5,508/-and have declined the remaining claim for Rs.2654/-+Rs.100/- i.e Rs.2754/-. Complainant made several requests to them to make payment of remaining claim amount, but all in vain. All this amounts to deficiency in service and trade mal practice on the part of OPs and has caused harassment and mental agony to him. He has prayed for directions to OPs to pay the remaining insurance claim alongwith compensation and litigation expenses. Hence, the present complaint.
3 The counsel for complainant was heard with regard to admission of the complaint and vide order dated 4.09.2018, complaint was admitted and notice was ordered to be issued to the opposite party.
4 On receipt of the notice, OP-1 filed reply taking preliminary objections wherein they have denied all the allegations of complainant being wrong and incorrect and asserted that complaint is without any cause of action as there is no deficiency in service on the part of answering OP. Complainant never submitted any documents and complaint is barred as per conditions of the policy. It involves complicated questions of law and facts requiring lengthy evidence, which is not possible in summary procedure of this Forum. Complainant has concealed the material facts from this Forum and he has not disclosed that how he calculated the alleged amount of Rs.8213/-, Rs.2754/-. It is further averred that complaint filed by
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complainant is premature due to non submission of claim papers as claim has neither been processed nor declined and thus, complaint is liable to be dismissed. Moreover, this Forum has no jurisdiction to hear and try the present complaint. It is further averred the Rs.5508/-have already been received by complainant in full and final settlement of his claim and said claim cannot be reopened again. However, on merits OPs have reiterated that there is no deficiency in service on the part of answering OP and asserted that no intimation regarding alleged accident was ever given by complainant to them thereby preventing them to gather first hand information. It is in violation of terms and conditions of the policy. Complainant neither gave any intimation regarding his accident nor submitted requisite documents with them. claim of Rs.5508/-has already been settled by them and complainant duly received the same with his own free ill without any protest, it cannot be reopened and nothing is due to be paid. All the other allegations are denied being wrong and incorrect and prayer for dismissal of complaint with costs is made.
5 OP-3 filed written statement wherein they have also denied all the allegations of complainant being wrong and incorrect and asserted that this Forum has no jurisdiction to hear and try the present complaint and averred that they have been wrongly impleaded as party in present complaint because as per policy, claim is to be settled by Insurance Company and bank would not be involved in any such process and would only act as intermediary in providing data
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to IBA/Insurance Company. All the other allegations are denied being wrong and prayer for dismissal of complaint with costs is made.
6 Notice of complaint was issued to OP-2 alongwith copy of complaint and relevant documents through registered cover, but it did not receive back undelivered and presumed to be served. Despite repeated calls, no body appeared in the Forum on date fixed on behalf of OP-2 either in person or through counsel, therefore, vide order dated 14.11.2018, OP-2 was proceeded against exparte.
7 Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to C-26 and then, closed his evidence.
8 In order to rebut the evidence of the complainant, the opposite party no. 1 tendered in evidence, affidavit of R N Bansal as Ex OP-1/1, document Ex OP-1/2 and then, closed the evidence on behalf of OP-1. Ld Counsel for OP-3 did not tender any evidence on behalf of OP-3 though it availed several opportunities and therefore, vide order dated 27.05.2019, evidence of OP-3 was closed by order of this Forum.
9 We have heard the arguments addressed by all the parties and have also gone through the evidence and documents placed on record by respective parties.
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10 From the careful perusal of record and going through the affidavits, evidence and pleadings of the parties and from the above discussion, it is observed that case of the complainant is that as per policy of bank, he was insured under mediclaim policy for the bank employees . On 7.09.2016, complainant met with an accident by falling from his bike that slipped suddenly and he got injuries for which he remained under treatment at Anil Baghi Hospital, Ferozepur. He lodged claim for Rs.8213/-to OP-1 and 2, vide e-mail, but OPs declined the claim of complainant on the ground of non submission of requisite documents. Claim of complainant was approved for Rs.7613/-, but despite approval of claim, they did not pay claim amount to him. After that complainant sent domiciliary claim for Rs.8262/-for three months and Ops passed the same for Rs.5,508/- only and declined the remaining claim for Rs.2754/-. Grievance of the complainant is that despite repeated requests, OPs have not cleared his claim amount, which amounts to deficiency in service. He has prayed for accepting the complaint. In reply, OP-1 have denied all the allegations of complainant being incorrect and stressed mainly on the point that complaint filed by complainant is premature due to non submission of claim papers as claim has neither been processed nor declined and thus, complaint is liable to be dismissed being premature. Moreover, Rs.5508/-have already been received by complainant in full and final settlement of his claim and said claim cannot be reopened again. There is no deficiency in service on the part of OP-1 as no intimation regarding alleged accident
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was ever given by complainant to them thereby preventing them to gather first hand information. He has violated terms and conditions of the policy. Complainant neither gave any intimation regarding his accident nor submitted requisite documents with them. On the other hand, OP-3 brought before the Forum that they have already furnished the claim documents submitted by complainant to Insurance Company and there is no deficiency in service on their part. They have been wrongly impleaded as party because as per policy, claim is to be settled by Insurance Company and bank would not be involved in any such process and would only act as intermediary in providing data to IBA/Insurance Company. Prayer for dismissal of complaint is made.
11 To prove his pleadings, ld counsel for complainant has brought our attention towards document Ex C-4 that clearly depicts that complainant was insured with OP-1 against policy in question and was entitled for reimbursement of amount spent by him on his treatment for injuries caused due to accident dated 7.09.2016. Ex C-5 is the discharge summary issued by Anil Baghi Hospital, Ferozepur wherein it is clearly stated complainant was admitted in their hospital on 17.09.2016 and was discharged therefrom on 18.09.2016. Ex C-6 to Ex C-14 are copies of bills for the amount paid by complainant for his treatment to hospital authorities. ExC-15 is a vital and cogent document that proves the pleadings of complainant that all requisite documents for processing the insurance claim were sent to Insurance Company by OP-3. Plea taken by OPs that claim of complainant is not payable due to non
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submission of requisite documents, has no legs to stand upon in the light of document ExC-15 vide which all the required documents were already submitted by OP-3 to OP-1. Ex C-18 to Ex C-24 are copies of e-mails sent by Bank of India to Insurance Company for processing the claim of complainant. It reveals the correspondence occurred between Insurance Company and Bank which clears that bank forwarded all claim relating documents to Insurance Company. Ex C-2 is closure letter dated 14.10.2016 vide which OPs refused to reimburse the expenses incurred by complainant on his treatment. We come to the conclusion that there is no dispute about the insurance of complainant under policy in question. Plea taken by OP-1 that complainant has not submitted requisite documents to them, has no legs to stand upon in the light of their own version in which they have stated that they have settled the claim of complainant for Rs.5508/-, but they have not put forward any plausible reason to justify the point that why they have deducted the remaining claim from claim amount sought by complainant.
12 From the above discussion and keeping in view the evidence produced by complainant, it is observed that there is no deficiency in service on the part of OP-3 as they have furnished all the claim documents received from complainant to Insurance Company. There is no iota of doubt that all documents required for processing the genuine claim of complainant have already been submitted to OP-1 and 2 and action of OP-1 and 2 in not processing and clearing the claim of complainant amounts to deficiency in service. Complainant has
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succeeded in proving his case. Therefore, complaint in hand is hereby allowed against OP-1 and OP-2 and stands dismissed against OP-3/Bank of India. OP-1 and 2 are directed to pay Rs.8,213/- and Rs.2,754/- for the claim of October, 2017 alongwith interest at the rate of 7% per anum from the date of filing the present complaint till final realization. OPs are further directed to pay Rs.5000/-to complainant as consolidated compensation for harassment and mental agony suffered by him and for litigation expenses. Compliance of this order be made within one month of receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Copy of the order be supplied to parties free of costs. File be consigned to record room.
Announced in Open Forum
Dated : 11.06.2019
(Param Pal Kaur) (Ajit Aggarwal)
Member President
