DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 146 of 27.4.2017
Decided on: 13.3.2018
Lachhman Singh aged 64 years , s/o Sh.Sher Singh, R/o House No.969-G, Azad Nagar, Gali No.38, Sirhind Road, Patiala.
…………...Complainant
Versus
1. Universal Sompo General Insurance, 7th Floor, Express Towers, 4ZA, Shakespeare Sarani, Kolkata-700017 through its Manager/M.D.
2. Allahabad Bank, Chhoti Baradari, Patiala through its Branch Manager.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.Lachhman Singh, complainant in person.
Sh. Amit Gupta, Advocate, counsel
for Opposite party No.1
Sh. Manjit Singh, Advocate, counsel
for opposite party No.2.
ORDER
SMT.NEENA SANDHU, PRESIDENT
Sh. Lachhman Singh, complainant has filed this complaint under Section 12 of the Consumer Protection Act,1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.) .
2. In brief the case of the complainant is that he was an employee of OP no.2 and retired on 31.1.2014. His PF number is 10400. It is stated that OP no.2 provided a scheme, which was launched by OP no.1, for Group Mediclaim Insurance Policy(Family Health Plan(TPA ltd.), Insurance coverage for officers, employees and retired employees alongwith their spouse. Accordingly the complainant got himself insured with Op no.1 who issued the policy bearing No.2816/51338480/04/000 for the period from 1.11.2015 to 31.10.2016. It is stated that the complainant felt problem in his left eye. On 16.10.2015 he got treatment from Patiala Eye Hospital & Lasik laser Centre, Leela Bhawan, Patiala and spent Rs.34530/- on the treatment. Thereafter, the complainant lodged the claim with the OPs and completed all the formalities as desired by them.The complainant time and again requested the OPs for the sanctioning and disbursement of the claim amount but they did not bother to hear his request. He also sent letters to the OPs for the said purpose but to no effect.The act and conduct of the OPs amounted to deficiency in service, which caused mental agony and physical harassment to the complainant. Hence this complaint with prayer for giving direction to the OPs to pay the claim amount of Rs.34530/- alongwith interest @18% per annum from the date of treatment till its realization; to pay Rs.50,000/-as compensation for causing mental agony and physical harassment. It is also prayed that any other relief which this Forum may deem fit may also be granted.
3. On being put to notice, the OPs appeared and filed their written versions.
In the written version, filed by Op no.1, it is admitted that the complainant being the retired employee of Allahabad Bank was covered under Group Health Insurance vide policy No.281651338480/04/000 with effect from 16.10.2015 to 15.10.2016, subject to terms and conditions of the policy i.e. “Benefits for insurance coverage of sublimit for each cataract operation ( for hospitalization) maximum permissible limit is Rs.18000/- or actual expenses incurred whichever is less”. It is stated that on receiving the intimation, the TPA vide letter dated 31.5.2016 put five queries but the complainant gave answer to one query given at Sr.No.1 and due to non giving of answers at Sr.No.2to5, the claim was pending.Even vide letter dated 23.9.2016, the complainant has not fulfilled the requirements. It is stated that the claim of the complainant could be processed only after the receipt of the complete information from the complainant. There is no deficiency of service on the part of the OP. After denying all other averments made in the complaint, it was prayed to dismiss the complaint.
In the written version filed by Op no.2 preliminary objections have been that the complainant is not the ‘consumer’of the OP and thus complaint filed against Op no.2 is not maintainable and is liable to be dismissed. On merits, it is admitted that the complainant was the employee of the OP and retired on 31.1.2014. It is also admitted that OP no.2 provided a scheme for Group Medical Insurance policy, when the complainant was employee. It is further admitted that the complainant got himself insured against the said policy which was issued by Op no.1. It is stated that no intimation with regard to the treatment taken by the complainant has been received by Op no.2 as the claim was directly submitted with OP no.1.Thus there is no deficiency of service on the part of OP no.2. After denying all other averments made in the complaint against OP no.2, it was prayed to dismiss the complaint.
4. On being called to do so, the complainant has tendered in evidence Ex.CA his own affidavit, alongwith documents Exs.C1 to C29 and closed the evidence.
The ld. counsel for OP no.1 has tendered in evidence Ex.OPB affidavit of Sh.Piyush Shankar, Asstt. General Manager-Legal Claims of OP no.1, alongwith documents Exs.OP1 to OP8 and closed evidence of OP no.1
The ld. counsel for OP no.2 has tendered in evidence Ex.OPA affidavit of Sh.Jagat Singh Rana, Chief Manager of OP and closed the evidence of OP no.2.
5. We have heard the complainant, the ld. counsel for OPs No.1&2 and have also gone through the record of the case, carefully.
6. The ld. counsel for the complainant has submitted that the complainant being the retd. Employee of OP no.2 was duly insured with OP no.1for the period from 1.4.2015 to 31.3.2016 vide policy No.2816/51338480/04/000. On 16.10.2015, the complainant got treatment for his left eye and incurred Rs.34530/. The complainant lodged the claim with the OP and thereafter he received a letter dated 8.6.2015 Ex.C25, vide which the OP no.1 asked him to submit certain documents .The complainant submitted the requisite documents vide letter Ex.C14. but the OP did not pay amount to him. The ld. counsel for the OP has submitted that as per the terms and conditions of the policy, the complainant was entitled to get maximum amount of Rs.18000/- for the operation of the cataract of his left eye but the said amount could not be paid for want of answers to the queries put to the complainant.
7. From the perusal of copy of the card, Ex.OP2, it is evident that the complainant being the retd. Employee of OP no.2 was duly insured with OP no.1for the period from 1.4.2015 to 31.3.2016 vide policy No.2816/51338480/04/000. On 16.10.2015, the complainant got treatment of his left eye and incurred Rs.34,530/- as is evident from the receipt and bill dated 16.10.2015,Exs.C7 & C9.On the policy schedule, Ex.OP1, against type of cover ‘Basic cover’ has been mentioned. In term no.21 printed on the backside of the said schedule, it is mentioned that basic cover for the employee is for Rs.1,50,000/-w.e.f.30th April 2013 to 28th February 2014.In term no.15, it is mentioned that, “Benefits for insurance coverage of sublimit for each cataract operation ( for hospitalization) maximum permissible limit is Rs.18000/- or actual expenses incurred whichever is less”. Thus as per terms and conditions of the policy, the complainant was entitled to get Rs.18,000/- for the operation of cataract of his left eye. The OP no.1, by not paying the said amount, has committed deficiency in service. Thus it is not only liable to pay the said amount of Rs.18000/- alongwith interest but is also liable to compensate the complainant for the mental agony and physical harassment caused to him alongwith litigation expenses. Since neither any specific allegation has been leveled by the complainant against OP no.2 nor proved, thus the complaint filed against OP no.2 is liable to be dismissed.
8. In view of the aforesaid discussion, we dismiss the complaint filed against OP No.2 and partly allow the same against OP no.1. The OP No.1 is directed in the following manner:
- To pay Rs.18000/- alongwith interest @7% per annum from the date of filing of the complaint i.e. 27.4.2017 till its realization;
- To pay Rs.7000/- as compensation for causing mental agony and physical harassment to the complainant;
- To pay Rs.5000/- as litigation expenses.
The OP No.1 is further directed to comply the aforesaid directions within a period of 45 days from the date of the receipt of the certified copy of this order. Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter, file be indexed and consigned to the Record Room.
ANNOUNCED
DATED:13.3.2018 NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
