Delhi

East Delhi

CC/17/2018

POONAM DHILLON - Complainant(s)

Versus

UNITED INDIA INS. - Opp.Party(s)

27 Apr 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 17/18

 

Smt. Poonam Dhillon

W/o Shri Amrit Pal Singh

R/o GH-5/7, Flat No. 262

Paschim Vihar, New Delhi                                           ….Complainant

 

Vs.    

 

1. United Health Insurance

Regd. & H. Off.:

24, Whites Road, Chennai – 600014

 

2. Smt. Harsh Mamotra (Customer Care Officer)

Assistant Manager, Uni Customer Care Deptt.,

Regional Office I, Stadium House, Floor No. 5

Veer Nariman Road, Church Gate

Mumbai – 400 020

 

3. Shri Lalit Kumar

Agent of Respondent No. 1

I/10813, Street No. 4, Subhash Park

Naveen Shahdara, Delhi – 110 052                                   …Opponents

 

Date of Institution: 17.01.2018

Date of Order: 02.05.2018

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Sh. Sukhdev Singh (President)

 

ORDER

            This complaint has been filed by Ms. Poonam Dhillon against United Health Insurance (OP-1), Smt. Harsh Mamotra, Asstt. Manager (OP-2) and Shri Lalit Kumar, Agent of OP-1 (OP-3)  under Section 12 of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service. 

2.         The facts in brief are that complainant Poonam Dhillon got a health insurance policy having no. 0216002816P107124412 and Certificate no. UI00067013 with cashless facility for a period of one year from 17.08.2016 to 17.08.2017 for a cover amount of Rs. 3,00,000/- from United Health Insurance at the instance of Shri Lalit Kumar, who is stated to be the agent of United Health Insurance Company (OP-1). 

            In the month of January 2017, complainant was having fever for which she was treated, however, in the month of May, 2017 her health deteriorated and in the month of July 2017, she was admitted in Ganga Ram Hospital where she was treated.  Since she was having the health insurance policy, she submitted all her documents with the TPA branch of the hospital for giving her cashless facility.  However, she came to know that her request was rejected on the ground that she was suffering from ‘Chronic Renal Failure’.    At the time of discharge, she paid an amount of Rs. 2,72,277/- as her cashless facility was declined. 

            She has filed the present complaint for reimbursement of amount of Rs. 2,72,277/- which she has spent on her treatment at Ganga Ram Hospital; Rs. 1,50,000/- compensation on account of mental pain and agony; Rs. 1,00,000/- for harassment and embarrassment and Rs. 15,457/- for insurance fees, paid by the complainant. 

3.         We have heard on admission.  During the course of arguments, it has been stated on behalf of complainant that they have filed the claim with insurance company in the month of February 2018 and they have not been informed as to whether their claim has been accepted or rejected.

            Since there is no averment in the petition/complaint as to whether the claim of the complainant have been rejected by the insurance company, maintainability of the complaint was in question as no cause of action have arisen in favour of the complainant to file the present complaint. 

            Counsel for complainant argued that complainant was maintainable in the absence of any cause of action as the insurance company denied the cashless facility as well as did not inform the complainant with regard to his final claim.

            To appreciate the arguments of Ld. Counsel for the complainant, a look has to be made to the complaint as such.  If the complaint as a whole is perused, it is noticed that in Para 10 of the complaint, the complainant have stated that respondents had rejected her claim on the ground that petitioner was suffering from Chronic Renal Failure.  To quote from her complaint “That came as utter shock and dismay to the petitioner when the petitioner got to know that the respondents had rejected her claim on the ground that petitioner was suffering from “Chronic Renal Failure”.

            Further, in Para 16 of the complaint, she has stated that a legal notice was given to the respondents.  There is nothing in the petition as to whether the complainant has submitted her final claim with the insurance company.  Not only that, no document has been placed on record to show that insurance company have rejected her claim.  In the absence of any documents on record for rejection of her final claim, no cause of action have arisen in favour of the complainant to file the present complaint.

            Not only that, counsel for the complainant is stated to have submitted the claim in the month of February 2018 and he has filed the complaint on 17.01.2018 which is prior in time.  Thus, when the complainant have filed the complaint, she did not submit her claim with the insurance company.  Therefore, no cause of action have arisen at the time of filing the complaint. 

            Further, complainant Smt. Poonam Dhillon have taken the treatment at Sir Ganga Ram Hospital under the policy which was issued by United Health Insurance having their registered and head office at Chennai.  It has been made as respondent no. 1, Assistant Manager – Customer Care Department of their regional office at Mumbai have been made as respondent no. 2 and Shri Lalit Kumar, agent of respondent no. 1 who has been staying at Naveen Shahdara has been made as respondent no. 3.  Shri Lalit Kumar, agent of respondent no. 1 who has been made as respondent no. 3 at whose instance the policy is stated to have been issued is not a necessary party.

            When he is not a necessary party, their remains only United Health Insurance of Chennai and Assistant Manager – Customer Care Department, Mumbai and they do not fall within the jurisdiction of this forum.  On this ground also, this forum has no territorial jurisdiction to entertain the complaint. 

            In view of the above, we are of the opinion that complaint of Smt. Poonam Dhillon cannot be admitted on the ground that no cause of action have arisen in favour of the complainant as well as on the ground of territorial jurisdiction, therefore, the same cannot be admitted and stands rejected.

            File be consigned to Record Room.        

 

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

       Member                                                                             Member    

 

            (SUKHDEV SINGH)

                   President