BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.273 of 2016
Date of Instt. 04.07.2016
Date of Decision: 28.03.2018
Suresh Kumar S/o Sh. Kartar Chand, R/o H. No.1233/1, Mohalla Sufi Railway Road, Nakodar, District Jalandhar, Punjab, Mobile: 94176-90062.
..........Complainant
Versus
1. Universal Sompo General Insurance Co. Ltd., Unit No.401, 4th Floor, Sangam Complex, 127 Andheri Kurla Road, Andheri (East) Mumbai-400 059 (Maharashtra).
2. Universal Sompo General Insurance Co. Ltd., SCO-4, 2nd Floor, Puda Complex, Ladowali Road, Jalandhar 144001, Through its authorized Signatory.
3. Indian Overseas Bank, Shankar Road, Nakodar, District Jalandhar, Punjab, Through its Branch Manager.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Harvimal Dogra (Member)
Present: Sh. GS Saini, Adv Counsel for the Complainant.
Sh. VK Gupta, Adv Counsel for OP No.1 and 2.
Sh. IS Bhatia, Adv Counsel for the OP No.3.
Order
Karnail Singh (President)
1. The instant complaint is presented by the complainant, wherein alleged that he purchased a health insurance policy No.2817/546554125/00/000, covering period from 19.12.2014 to 18.12.2015 for Rs.1,00,000/- and again the said policy was got renewed, covering period 19.12.2015 to 18.12.2016 and it was enchanced from Rs.1,00,000/- to Rs.4,00,000/-, bearing No.2817/546554125/01/000 from the OP No.1 and 2. The said policy was cashless, issued at Jalandhar Branch through Indian Overseas Bank i.e. OP No.3, for 4 lacs for himself and his spouse.
2. That on 15.02.2016, the complainant felt chest pain and got medically checked from Sandhu Clinics Heart Specialist Nakodar, who also conducted ECG from which it was found that a minor heart attack had occurred and on the advice of the said doctor, the complainant with his family members consulted the doctor at Joshi Hospital Shri Ram Cardiac Centre, Jalandhar, who conducted the Angiography and wherein found 100% blockage of arteries and accordingly, the complainant informed the company's Head Office i.e. OP No.1 as well as Branch Office of OP No.2 regarding his critical condition through email and thereupon the OP demanded expected expenditure of the hospitalization and other charges from the concerned hospital and further advised the complainant not to inquire anything. The OPs shall talk to the hospital authorities each and everything regarding this matter. The hospital authorities provided estimated expenses on the whole process Rs.1,81,000/- approximately. As the policy was cashless covers the terms and condition, the complainant informed to the OPs No.1 and 2 about his critical condition. During the correspondence, the OP No.1 permitted the complainant to get operated as early as possible. As it was getting late and the complainant got himself operated from Shri Ram Cardiac Centre and made himself safe and a stent was put for the proper functioning of the heart. OP No.1 after examining the expected expenditure, allowed to pay Rs.1,00,000/- to the hospital directly. The rest of the expenditure was neither paid nor refused by the OPs. The hospital authorities gave net expenditure of the hospital was Rs.1,75,000/- and Rs.1,00,000/- was paid to the hospital directly by the OP and remaining Rs.75,000/- was paid by the complainant himself to the hospital in cash, vide receipt No.5233 dated 21.02.2016 and got discharged from the hospital, but the said amount of Rs.75,000/- was not refunded/reimbursed by the OP No.1 and 2 to the complainant till date. The complainant made his grievances to the concerned authority of the OPs, but all in vain and then complainant served a notice to the OP, but no action was taken and as such, there was a deficiency in service on the part of the OP No.1 and 2 and accordingly, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the remaining amount of medical expenditure i.e. Rs.75,000/- and also pay litigation expenses of Rs.25,000/- and compensation of Rs.2,00,000/- for mental harassment.
3. Notice of the complaint was given to the OPs and accordingly, OP No.1 and 2 appeared through its counsel and filed reply and contested the complaint by taking preliminary objections that the present complaint is not maintainable under any provision of law against OP and the same is liable to be dismissed with heavy cost and further submitted that there is no negligence and unfair trade practice on the part of the answering OP and further submitted that the claim of the complainant was closed on account of non-submission of documents by the complainant. It is further submitted that the answering OP many times demanded the documents from the complainant, but the complainant himself failed to provide the said documents and ultimately, the claim case of the complainant was closed and intimation to this effect was given to the complainant, vide letter dated 05.08.2016. From the above narrated facts, it is clear that there is no deficiency in service or negligence on the part of the answering OP and the present complaint of the complainant is pre mature, therefore, the same is liable to be dismissed with heavy costs. On merits, the purchase of the policy by the complainant and submission of insurance claim and part payment of Rs.1,00,000/- made by the OP No.1 and 2 is not denied, but the other averments as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
4. OP No.3 filed its separate reply, whereby contested the complaint by taking preliminary objections that the complaint of the complainant is not maintainable against the answering OP as there is no deficiency on the part of the answering OP. The answering OP is carrying on the business of Banking and is not carrying on the business of insurance nor has issued the Insurance Policy to the complainant. The answering OP is not liable to settle/pay any claim against the Insurance Policy issued by the OP No.1 and 2 in favour of the complainant. On merits, the averments as made in the complaint are categorically denied except the factum that the complainant purchased the insurance policy from OP No.1 and 2 through answering OP, who is agent of the OP No.1 and 2 and lastly prayed that the complaint of the complainant is without merits and the same may be dismissed.
5. In order to prove the case of the complainant, the complainant himself tendered into evidence his own affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-13 and closed the evidence.
6. Similarly, counsel for OP No.1 and 2 tendered into evidence two affidavits Ex.OP1/A and Ex.OP1/B alongwith some documents Ex.OP-1/1 to Ex.OP-1/3 and closed the evidence and similarly, counsel for the OP No.3 also tendered into evidence affidavit Ex.OP3/A and one document Ex.OP3/1 and closed the evidence.
7. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
8. From the over all circumstances, it is clear that the complainant purchased an insurance policy for a covering period from 19.12.2015 to 18.12.2016 for insured amount of Rs.4,00,000/- to this effect and the copy of insurance policy is produced on the file by the complainant, which is Ex.C-1 and moreover, these facts are not denied by the OPs. The said policy was obtained by the complainant through OP No.3 i.e. Indian Overseas bank being an agent of the OP No.1 and 2 and as such, we find that the claim of the complainant in regard to insurance policy is not against the OP No.3 rather it is against the insurance company i.e. OP No.1 and 2 and therefore the complaint of the complainant against OP No.3 is not maintainable and the same is dismissed against OP No.3, rather the OP No.3 is impleaded by the complainant only as a performa OP.
9. Now, we considered the medical claim of the complainant regarding treatment obtained by the complainant from Joshi Hospital Shri Ram Cardiac Centre, Jalandhar and where he remained admitted for surgery of the heart and accordingly, stent was inserted by the doctor and issued a bill Ex.C-3 and Ex.C-4 for total amounting to Rs.1,75,000/-, out of which Rs.1,00,000/- is admittedly paid by the insurance company i.e. OP No.1 and 2, but remaining amount of Rs.75,000/- has yet not been paid by the OP No.1 and 2 on one pretext or the other, despite serving notices dated 12.03.2016 Ex.C-7 and Ex.C-8. It is not denied by the OP No.1 and 2 that the policy of the complainant was cashless and moreover, if the policy of the complainant was not cashless, then there was no occasion on the part of the OP No.1 and 2 to make part payment of the medical expenses i.e. Rs.1,00,000/-, to this effect is also itself established. Further, we find that the OP No.1 and 2 had already paid a part payment of Rs.1,00,000/-, after considering the case of the complainant that he required a medical treatment from the Cardiac Centre and if the policy of the complainant was cashless, then why the entire payment of Rs.1,75,000/- was not paid by the OP No.1 and 2 directly to the said hospital prior to discharge of the complainant from that hospital, simply non payment of the entire medical expenses by OP No.1 and 2 is itself a deficiency in service on its part, not so the OP No.1 and 2 further lingering the matter for a long time, since 2016 and the case of the complainant is putting off on one way or the other just for a pretext that the complainant had not submitted the document, whereas the OP No.1 and 2 can get directly copy of the final bill from the said hospital and then make the payment directly to the hospital, but the OP No.1 and 2 itself not made any efforts to indemnify the claim of the complainant well within time, itself show that the intention of the OP No.1 and 2 is not to pay the said amount rather harassing the complainant on one way or the other.
10. We find that there is no occasion for demanding the document when the factum in regard to admission of the complainant in Joshi Hospital Shri Ram Cardiac Centre, Jalandhar has come to notice of the OP No.1 and 2, then they make any inquiry or any document directly from that hospital, but OP No.1 and 2 did not to do so intentionally. So, from the over all circumstances, it is clearly established that there is negligence on the part of the OP No.1 and 2 and as such, we are of the considered opinion that the complainant is entitled for the relief claimed.
11. In the light of above detailed discussion, the complaint of the complainant succeeds and accordingly, the same is partly accepted and OP No.1 and 2 are directed to pay the remaining medical expenses of Rs.75,000/- with interest @ 9% per annum from the date of discharge from the hospital i.e. 21.02.2016, till realization and further OP No.1 and 2 are directed to pay compensation to the complainant for mental agony and mental harassment, to the tune of Rs.30,000/- and further directed to pay litigation expenses of Rs.7000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Harvimal Dogra Karnail Singh
28.03.2018 Member President
