Rajesh Kumar, Complainant (here-in-after referred to as complainant) has filed this complaint under section 12 of the Consumer Protection Act, (here-in-after referred to as 'Act') against the United India Ins. Co. Ltd, (here-in-after referred to as 'opposite parties).

2.       Briefly stated, the case of the complainant is that he got himself and his wife insured with the OP’s vide Family Medicare Policy 2014 bearing Policy No. 2002022817P109752294 dated 10.10.2017 for the period from 10.10.2017 to 9.10.2018 for Rs.2,00.000/-. The said policy covered the insurance of complainant and his wife namely Rajni Bhalla. It is alleged that suddenly he got heart problem and he got his Bye-Pass Surgery from IVY Hospital, Airport Road, Amritsar and remained in Hospital from 3.5.2018 to 9.5.2018 and spent Rs.1,86,000/- for the treatment including medicine expenses etc. It is further alleged that he submitted all the documents as demanded by the OP’s in the office of the OP’s for getting insurance claim which is covered under the insurance policy, but till today the OP’s have not paid any amount to him. It is further alleged that he visited many times to the offices of the OP’s but they are lingering on the matter on one pretext or the other. It is further alleged that he also served a notice dated 5.10.2018 to the OP’s but the OP’s did not bother and gave vague reply in response to said notice. Due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental harassment and inconvenience. So, there is a clear cut deficiency on the part of the opposite parties.

          On this backdrop of facts, the complainant has alleged deficiency in service and unfair trade practice on the part of the opposite parties and prayed that the opposite parties be directed to pay the amount of Rs.3,00,000/- i.e. Rs.1,86,000/- expenses for the treatment and Rs.1,14,000/- as damages by way of mental agony, interest and harassment and litigation expenses etc. along with future interest at the rate of 18% per annum from the date of filing of the complaint till actual realization of the amount to the applicant in the interest of justice.

3.       Notice of the complaint was issued to the opposite parties and appeared through their counsel and filed their written reply taking the preliminary objections that the present complaint against the replying respondents is not maintainable, as the same is hopelessly PRE-MATURE. The complainant has not lodged the claim with the replying respondent insurance company along with the requisite documents under the terms and conditions of the company. It is pleaded that the question of settlement of the claim under the provisions of law does not arise. Hence, the present complaint of the complainant is liable to be dismissed and no cause of action has accrued against the replying respondents, hence, the present complainant is liable to be dismissed on this score only.

          On merits, the opposite parties have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.

4.       Learned counsel for the complainant has filed documents as Ex.C-1 to Ex.C-15 alongwith complaint.

5.       Learned counsel for the opposite parties has tendered into evidence affidavit of Jai Kishan, Divisional-Manager, United India Ins. Co. Ltd, Pathankot, as Ex.OP-1/A along-with other documents as Ex.OP-1 to Ex.OP-4.

6.       Rejoinder not filed by the complainant.

7.       Written arguments not filed by both the parties.

8.       We have carefully gone through the pleadings of counsels for the parties; and heard counsel for the opposite parties, and since  none has appeared on behalf of complainant as such complaint is being disposed off after going through the pleadings of the complaint.                         

9.       Learned counsel for the complainant has pleaded that complainant got Family Medicare Policy 2014 from opposite party. Counsel for the complainant further pleaded that suddenly complainant got heart problem and got his Bye-pass Surgery from IVY Hospital from 03.05.2018 to 09.05.2018 and he spent all the money for the treatment and medical expenses. It is further pleaded by counsel for the complainant that for getting insurance claim under the insurance policy complainant visited many times at the offices of OP but they kept the matter pending on the matter on one pretext or other. It is further pleaded that complainant also served a legal notice on 05.10.2018 but the OP has failed to settle the claim.

10.     On the other hand counsel for opposite parties has argued that claim has not been lodged by the complainant and as complaint is pre-mature and liable to be dismissed.

11.     Learned counsel for the complainant has also placed on record copy of letter Ex.C12 with bear stamp of opposite parties with date of receipt as 19.11.2018 and while filing reply and during the course of arguments counsel for the opposite parties has not denied the receipt of letter Ex.C12. As such this Commission is of the view that inspite of receipt of letter Ex.C12 on 19.11.2018, the opposite parties have falsely alleged that the claim was never lodged with the opposite parties which definitely amounts to deficiency in service. Accordingly, the present complaints is partly allowed and opposite parties are directed to settle and pay the claim to the complainant on the basis of intimation letter Ex.C12 as per policy terms and conditions. Opposite parties are also directed to pay compensation of Rs.5,000/- for mental tension and cost of litigation alongwith interest @ 9% P.A. from the date of filing of the complaint till its realization within 30 days from the receipt of copy of this order. 

12.      The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

13.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record room. 

                               (Lalit Mohan Dogra)

                                                                       President   

Announced:                                          (B.S.Matharu)

Aug. 11, 2023                                               Member

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