| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 73 of 02-04-2019 Decided on : 28-07-2022 Savita Garg aged about 56 years W/o late Shri Janak Raj Garg, R/o #14307, Street No.2, Behind Dr. Kiran Sarwal, Ganesh Nagar, Bathinda. .......Complainant Versus United India Insurance Co. Ltd. Bangalore, BANCASSURANCE HUB, IFCI, BHAVAN No.2, CUBBONPET MAIN ROAD, NR SQUARE BANGALORE 560002 (Karnataka) through its Managing Director/ authorised person. MEDI Assist Insurance TPA Pvt Limited CIN UB 5199KA1999PTC025676 Tower 'D' 4th floor, IBC Knowledge Park, 4/1 Bannerghatta road, Bangalore-560029, through its authorised person/ competent person. Vijay Bank Goniana Road, Bathinda, through its authorised person. ( Deleted vide order dated 03.04.2019).
.........Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Kanwar Sandeep Singh, President Sh. Shivdev Singh, Member Smt. Paramjeet Kaur, Member Present For the complainant : Sh. S.K. Goyal, Advocate. For opposite parties : Sh. Rajan Singla, Advocate, for OP No.1 Opposite Party No. 2 ex-parte. Opposite party No. 3 deleted. ORDER Kanwar Sandeep Singh, President The Complainant Savita Garg (here-in-after referred to as Complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in-after referred to as 'Act') before this Forum (Now Commission) against United India Insurance and Others (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that her husband Sh. Janak Raj was insured with opposite parties No. 1 & 2 under policy No.0726002815P116921907 of United India Insurance Co. through Vijaya Bank, Bathinda. Janak Raj husband of the complainant died on 09.01.2018. It is alleged that the said health Insurance policy was covering all type of diseases and it was a cashless policy. Janak Raj was admitted in Delhi Heart Institute, Bathinda, first time on 16.10.2017 at 6.59 A.M and was discharged on 21.10.2017 at 4.00 a.m on request. The opposite parties denied cashless treatment on the ground that this hospital is not covered under cashless scheme. The opposite parties advised the complainant to continue the treatment and apply for reimbursement lateron. Husband of the complainant was shifted to Fortis Memorial Research Institute Gurgaon on 21.10.2017 at 10.36 a.m and was discharged on 24.10.2017. In this hospital stent was inserted and dialysis was done. The complainant submitted card for cashless treatment issued by the opposite parties but the opposite parties demanded previous medical policies of patient. At that time, the complainant was not able to produce the same. The complainant further alleged that her husband suffered from pneumonia and he was admitted on 05.01.2018 at Sidhu Hospital and Dialysis Centre Bathinda for lungs infection. During dialysis, husband of the complainant became serious and doctors put him on ventilator, but his condition did not improve and the doctors referred him to another hospital on 07.01.2018. The complainant shifted her husband to Max Super Specialty Hospital, Bathinda and he died on 09.01.2018 at 11.29 p.m. In Max Super Speciality Hospital also, the opposite parties did not allow cashless treatment. After the death of husband of the complainant, the condition of son of the complainant became more serious and he was admitted in AIMS hospitl Delhi and was discharged on 24.04.2018. The complainant and her son suffered mental agony and harassment due to refusal of cashless treatment of her husband. It is further alleged that complainant received a letter dated 24.04.2018 on 04.06.2018 and she sent all the documents sought by the opposite parties on 14.06.2018. The complainant also written letters to opposite parties on 13.06.2018 & 14.06.2018 requsting them to settle her claim. The complainant alleged that she sent details of claim vide letter dated 16.3.2018 which is as under:- Name | From | To | Amount | 1. Delhi heart Institute Bathinda | 16.10.2018 | 21.10.2018 | Rs. 98061/- | 2.Ambulance Bill | Bathinda | Gurgaon | Rs. 18500/- | 3.Forts Hospital Gurgaon | 21.10.2017 | 24.10.2018 | Rs. 2,95,405/- | 4.Medicine Bills | | | Rs. 28039/- | 5. Sidhu Hospital & Dialysis centre Bathinda | 01/05/18 | 01/07/18 | Rs. 20600/- | 6.Max Health Care, Bathinda | 01/07/18 | 01/09/18 | Rs. 1,22,747/- | Total Expenditure | | | Rs. 5,83,352/- |
It is further mentioned that some of the bills were left in total and total claim of the complainant comes to be Rs. 5,90,092/- and the same was conveyed to the opposite parties vide letter dated 13.06.2018. It is further alleged that the complainant sent a reminder dated 10.08.2018 for payment of claim amount, but with no effect. Thereafter the complainant approached opposite party No. 3 and opposite party No. 3 handed over a print out to the complainant on 25.01.2019 in which the amount of the claim has been mentioned as Rs. 1,47,400/- instead of Rs. 5,90,092/- but no amount has been paid by the opposite parties to the complainant, till today. Original bills have already been sent to opposite party No. 2. The complainant also alleged that she requested the opposite parties repeatedly to pay her claim, but to no effect. The complainant also got issued legal notice to the opposite parties in this regard, but no action has been taken by the opposite parties. On this backdrop of facts, complainant has prayed for directions to the opposite parties to pay claim amount of Rs. 5,90,092/- in addition to Rs. 4,00,000/- as damages on account of harassment and botheration caused to the complainant besides Rs.11000/- as costs of this forced litigation. and the complainant may also be awarded any other additional or alteranative relief. On the statement of learned counsel for the complainant, name of opposite party No. 3 was deleted from the array of the parties. Registered A.D. Notice of complaint was sent to opposite parties No. 1 & 2, but none appeared on behalf of opposite party No. 2, as such, exparte proceedings were taken against opposite party No. 2. The opposite party No. 1 put an appearance through counsel and contested the complaint by filing written reply. In written reply, the opposite party No. 1 raised legal objections that the complainant has not lodged any claim nor submitted any documents with the opposite party rather the complainant lodged the claim with opposite party No. 2 and opposite party No. 1 has not received any claim from opposite party No. 1 as well as the complainant as such the claim of the complainant has not been decided so far, hence the complaint is premature. That the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the 'Act'. That the complainant has concealed material facts and documents from this Commission as well as from the opposite party. It has been pleaded that the complainant has concealed the fact that the deceased insured was previously insured with New India Insurance Company since 10.07.2008 to 09.07.2016 for sum assured of Rs. 1,00,000/- but however the insured Janak Raj with malafide intention purchased policy of opposite party on 11.03.2016 i.e. prior to 4 month from the expiry date of above said previous policy knowing it fully well that he is suffering with chronic disease without disclosing material facts regarding his health & pevious diseases / aliments. Further the husband of complainant i.e. insured suffered from (DM-II) Diabetic Mallitus- II, Hypertension (HTN), Chronicle Kidney Disease, SEPSIS, RWMA in RCA & LCX (Heart disease) LVEF-33% (heart was working 33%) for the last many years and disease was pre existing which could get coverage for enhanced sum insured after waiting period 48 months of continuous coverage from opposite party, which has been issued by the New India Assurance Co. Ltd., with the opposite party under portability scheme as per clause 4.1 of Insurance Policy. Further as per clause 4.4 of the Insurance policy, if the diseases are pre-existing at the time of proposal, the company will not be covered even during subsequent period of renewal subject to the pre-existing disease exclusion clause. If the insured is aware of the existence of congenital internal disease before inception of the policy, the same will be treated as pre-existing. The complainants had got the sum assured enhanced from Rs. 1,00,000/- to Rs. 5,00,000/- only w.e.f. 11.03.2016 to 10.03.2017 and in policy in question w.e.f. 22.02.2017 to 21.02.2018. Since, less than 2 years had elapsed for enhanced coverage, the benefit of Rs. 5,00,000/- was not available and the benefit was available only up to sum insured under the previous policies i.e. Rs. 1,00,000/- and the said coverage was subject to terms and conditin of the policy. Further legal objections are that the complainant is not consumer and he has no locus standi or cause of action to file the complaint and that the complaint is not maintainable in the present form. On merits, the opposite party No. 1 denied all the averments of the complainant and reiterated its version as pleaded in legal objections and detailed above. In the end, the opposite party No. 1 prayed for dismissal of complaint. In support of his version, complainant has tendered into evidence her Affidavit dated 2-4-2019 (Ex. C-76) and the documents (Ex. C-1 to Ex. C-75 and Ex. C-77). In order to rebut the evidence of complainant, opposite party No. 1 tendered into evidence affidavit dated 2-7-2019 of Baldev Singh (Ex. OP-1/1) and the documents (Ex. OP-1/2 to Ex. OP-1/4). We have heard learned counsel for the parties and gone through the record. The learned counsel for the complainant submitted that Janak Raj husband of the complainant was got insured since 10-7-2008. by Vijay Bank, from New India Insurance Company being its account holder. Janak Raj was insured for Rs. 5,00,000/- vide Insurance Policy (Ex. C-9 & Ex. C-10) with opposite party No.1. Janak Raj suffered some health problem and first time he was admitted in Delhi Heart Institute on 16-10-2017. The opposite paties neither approved cashless treatment nor reimbursed the medical expenses incurred on the treatment of Janak Raj. Janak Raj has now expired. The opposite parties did not settle the claim of the complainant till date despite submission of all the documents. On the other hand, the submission of learned counsel for opposite party No. 1 is that complainant has not lodged any claim nor submitted any documents with the opposite party No. 1 till date rather complainant lodged claim with opposite party No. 2. As such, claim of the complainant has not been decided so far. The learned counsel for opposite party No. 1 further submitted that the insured/deceased was admitted with hospitals with pre-existing disease i.e. Type-II DM, HTN, CKD, Pulmonary acquired Infection and Septicemia and also died due to Anuria, Hypothention and Metabolic Acidosis. We have given thoughtful consideration to the rival contention of learned counsel for the parties. In the case in hand, the plea of opposite party No. 1 is that the complainant has not lodged any claim nor submitted any documents with opposite party No. 1 and submitted the documents with opposite party No.2. Ex.OP-1/4 is the Insurance Policy issued by opposite party No. 1 under which Janak Raj Garg was covered. It has been specifically mentioned on this policy “For ID Cards & Claim Intimation, please contract the TPA mentioned in the policy document.” This policy also shows that TPA name is mentioned as Medi Assist India TPA Pvt. Ltd., (opposite party No.2). Therefore, plea of the opposite party No. 1 that complainant has not lodged claim and submitted documents with them, is not tenable as complainant lodged claim and submitted documents with opposite party No. 2 (TPA) as per directions of opposite party No. 1. A perusal of file reveals that vide letter dated 14-6-2018 (Ex. C-3) complainant has furnished all the information required by opposite party No. 2 vide letter dated 10-4-2018 (Ex. C-2), which includes all original documents such as discharges summary, lab reports, IP bills, pharmacy bills etc., The complainant filed this complaint on 02-04-2019 and opposite party No. 2 did not appeal in this commission and was proceeded against exparte. Till this date, the opposite parties have not settled the claim of the complainant which amounts to deficiency in service on their part. In the result, this complaint stands disposed off with the directions to opposite parties No.1 &2 to settle/decide the claim of the complainant as per documents already submitted by complainant with opposite party No.2. The opposite parties No.1 & 2 are also directed to pay Rs.10,000/- as cost and compensation to the complainant. The compliance of this order be made by opposite parties No.1 & 2 jointly and severally within 45 days from the date of receipt of copy of this order. In case the complainant is not satisfied with the decision of opposite party No. 1 & 2, then the complainant will be at liberty to file fresh complaint on the same cause of action. The complaint could not be decided within statutory period due to Covid pandemic and heavy pendency of cases. Copy of order be supplied to parties free of cost as per law. File be consigned to record room.
Announced : 28-07-2022 (Kanwar Sandeep Singh) President
(Shivdev Singh) Member (Paramjeet Kaur) Member
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