BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 127 of 2011
Date of Institution : 27.5.2011
Date of Decision : 28.10.2015
Rajinder Kumar son of Sh.Gumani Ram, r/o Parmarth Colony, Gali no.2, Begu Road, Sirsa, District Sirsa.
….Complainant.
Versus
- Vipul Medcorp TPA Pvt. Ltd., 515, Udyog Vihar, Phase-V, Gurgaon (Hry.).
- National Insurance Company Ltd., near Sangwan Chowk, Sirsa through its Divisional Manager.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SMT.GURPREET KAUR GILL ………PRESIDING MEMBER.
SHRI RAJIV MEHTA ……MEMBER.
Present: Sh.A.K.Gupta, Advocate for the complainant.
Sh.Ravinder Goyal Advocate for the opposite parties.
ORDER
In brief, the complainant purchased a medi-claim policy no.
2FA0023508C w.e.f. 26.6.2010 to 25.6.2011 from Opposite party no.2.
He had been getting the policy for the last more than 6-7 years. The complainant and his family was insured to the extent of Rs.1 lac. Opposite party no.2-company appointed opposite party no.1 as Third party Administrator for settlement of the claim. On 13.8.2010, the wife of the complainant was admitted and her major operation was conducted in N.D.hospital, Hisar due to multiple Fibroids problem. She was discharged from the hospital on 17.8.2010. Intimation in this regard was also given to OP no.2 on 13.8.2010. After treatment, all the original bills amounting to Rs.25043/- and original medical papers were sent to OP no.1 on dt.14.9.2010 through Akash Ganga Courier Ltd. and also photocopies thereof were also submitted in the office of OP no.2 on 20.9.2010 for payment. On 7.10.2010, the complainant also sent form no.64 VB to OP no.1. Thereafter, a cheque bearing no.376907 dt. 20.11.2010 amounting to Rs.19276/- drawn in IDBI Bank was sent to the complainant by OP no.1 against claim of Rs.25043/-. The complainant contacted Mr.Neeraj, official of company on telephone and protested the said cheque. Said Neeraj told that original bills/file is not traceable and he further told to send a copy of said bills again. On 11.1.2011, the complainant again sent the required documents to OP no.1, but the claim has not been settled till date. Hence, this complaint for the direction to Ops to pay the balance amount of Rs.5767/- with interest thereon, besides compensation for harassment and litigation expenses etc.
2. Opposite parties, in their reply, have submitted that the complainant did not provide the original bills of treatment amounting to Rs.5367/- and Rs.400/-, rather provided duplicate bills and receipt of Rs.5367/- and Rs.400/- and even after intimation, he failed to provide such bills to Ops. Therefore, amount of Rs.5367/- and Rs.400/- was deducted and a cheque of Rs.19.276/- was issued in his favour as full and final settlement, which was accepted by the complainant without any protest. Other averments have also been denied.
3. Both the parties have led their evidence in the form of affidavits and documents. The complainant has tendered in evidence Ex.C1-his own affidavit; Ex.C2-legal notice; Ex.C3& Ex.C4-postal receipts; Ex.C5-insurance policy; Ex.C6- reply to legal notice; Ex.C7 to Ex.C9, Ex.C14 & Ex.C15-courier receipts; Ex.C10, Ex.C12 and Ex.C13-representation for finalization of claim; Ex.C16-request for sanction of medical bills; Ex.C17-copy of detail of bills; Ex.C18-copy of claim form; Ex.C19 to Ex.C39-copies of medical certificates and receipts, whereas respondents have tendered Ex.R1- affidavit of Inder Singh, Divisional Manager; Ex.R2-copy of request for sanction of claim; Ex.R3-copy of information for sanction of amount Rs.19276/-; Ex.R4-copy of forwarding letter for sending cheque; Ex.R5-copy of claim form; Ex.R6-copy of insurance policy.
4. We have heard learned counsel for the parties and have gone through the record carefully.
5. It is admitted fact that complainant Rajender Kumar insured his family with Ops for medi-claim policy Ex.C5. Complainant is consumer of Ops i.e. insurance company since last 7-8 years and had paid premium to Ops regularly. The wife of Complainant has suffered with multiple fibroids problem and remained admitted in N.D.Hospital, Hisar from 13.8.2010 to 17.8.2010. Complainant submitted his claim of Rs.25043/- to Op no.1 through Akash Ganga Courier Ltd. vide receipt no. 76487162 dt.14.9.2010 Ex.C15. Complainant also submitted the photo copies of above bills to Op no.2 on dt. 20.9.2010 for payment. Complainant contacted with Op no.1 on telephone to know the progress of his case. It was told by Mr.Santosh one official of Op no.1 that Form no.64VB is not attached with the case, which be sent immediately. Complainant also sent the same to Op no.1 on 7.10.2010 through Akash Ganga Courier vide receipt no. 76489403 Ex.C14. Complainant has incurred total Rs.25043/- on the treatment of his wife. It is not disputed that complainant sent his all the bills i.e. Rs.25043/- to Op no.1, but the Ops have passed/verified Rs.19276/- only out of claimed amount and sent a cheque of Rs.19276/- bearing cheque no. 376907 dt. 20.11.2010 drawn in IDBI Bank. Complainant got encashed the cheque amount and immediately lodged his grievance with Op no.2 in their local office on telephone to Sh.Neeraj Gupta, he has assured to complainant for payment of remaining amount, and complainant sent photo copies of required documents/medical bills to Op no.1 third party TPA Vipul Medcorp TPA Pvt. Ltd. through courier vide dt.11.1.2011 for remaining amount. The receipt of courier is Ex.C7 on the file. Even complainant sent his representation through e.mail dt.30.11.2010 in which he has explained entire details of bills Ex.C16 and C17 are copy of covering letter and detail of medicine/treatment on the file which are sent by the complainant to Op no.1. It is transpired from the claim form Ex.C18 claimant claimed the amount of Rs.25043/-.
6. Ops stated in their written statement that it is correct that complainant has sent his all medical bills of Rs.25043/- to Vipul Medcorp TPA Pvt. Ltd. As the Ops has passed/verified Rs.19276/-, whereas the remaining bill of Rs.5767/- was duplicate one. Duplicate bill are not admissible as per rule.
7. We have to decide that whether the Ops have hold the amount Rs.5767/- alleging that these bills are duplicate one, is a legal manner or not?
8. First of all, we have to examine the documents to conclude the matter. After receiving the cheque the complainant lodged his complaint with the local office of Op no.2 on telephone to their official Mr. Neeraj Gupta and sent photo copies of bills to Op no.1 and his protest to Vipul Medcorp TPA Pvt. Ltd. through courier Ex.C7. In the reply of legal notice, Op no.2-National Insurance Company admitted the version of complainant and stated that Vipul Medcorp TPA Pvt. Ltd. had intimated to complainant about the duplicate bills. There is no copy of any such letter etc. is available on the file to support the case of Ops.
9. It was primary duty of Op no.1 to immediately sent the intimation to the complainant about the discrepancies in the bills. No such intimation was ever sent by the Op no.1 to the complainant prior to replied by the Op no.2 of the legal notice of the complainant. Even, complainant lodged his complaint/protest with the Op no.2-National Insurance Company immediately and sent the required document through courier receipt Ex.C7, prior to issuance of cheque Rs.19276/-.
10. Both the Ops have kept mum for long time, not replied the representation of complainant. Silence on the part of Ops is a admission. It was incumbent on the part of Ops to have intimated the complainant in pursuance of his protest application.
11. Arguments sake, if we presumed that complainant have not submitted original bill of Rs.5767/- with Ops inadvertently. It was duty of Ops before decline the bills essential mandatory notice was required to Ops for clarification of complainant view. When no opportunity being heard was afforded to the complainant, the Ops violated the principle of natural justice and as such, the action of Ops to left the abovesaid bills, fully illegal and cannot be sustained in the eyes of law.
12. Before left the disputed bill, no one OP explained as to why they have left these amounts from the total bills submitted by the complainant. If an opportunity would have been given to complainant, the complainant could have represented his case. Thus, the action of Ops is totally arbitrarily and illegal and the complainant is deprived from his legal relief.
13. It is pertinent to mention here that complainant has categorically stated in his complaint as well as in his affidavit, after received the cheque of Rs.19276.- from the Op no.1. He has immediately lodged his complaint with Op no.2 in their local office on telephone through their one official Mr.Neeraj Gupta. Ops have not been specifically denied this fact in their written statement as well as other allied documents. It seems that the protest/complaint of complainant is in the knowledge of Ops since day one. They have been unnecessarily harassed to complainant from long time for his bonafide claim.
14. The consumer and insurance company are supplement to each other. IRDA issued the licence to insurance companies for welfare and financial support to the consumers in hard days.
15. A gentleman could not be kept the partly bills with him, when he has known very well that these bills are essential for the settlement of his claim. Even he has no purpose/business to withhold the original bills in question with him. There are so many lapses on the part of Ops. Vipul Medcorp TPA Pvt. Ltd. appointed and under the control of insurance company i.e. National Insurance company. But, there is no coordination between each other, even their version have not been tallied on the file. At the time of insurance, Op no.2 introduced to complainant with Raksha TPA for handle their case. During the course of policy, Op no.2 suomoto changed the third party TPA i.e. Vipul Medcorp TPA Pvt. Ltd. without any intimation to complainant. So, op no.2 is harassing the complainant from the date of purchase of policy to till now.
16. Insurance company is a large entity, there are so many officials, surveyor and investigator under their control. The branches of insurance company are in throughout India. If the company have desire/Will to settle the claim of complainant, then they could have got verified the matter from N.D.hospital, Hisar through their personnel. Ops have not been adopted this practice and deprived the complainant from his legal right.
17. It is true fact that at the time of policy the official/agent of Ops motivated the people and assure them for better service and return, but at the time of settling the claim, imposed unnecessary condition to prolonging the matter to one pretext to other. In view of factual position the complainant is entitled for relief.
18. For the reasons and findings recorded above, we accept the complaint of the complainant with cost of Rs.1000/-. Ops are directed to pay the amount of Rs.5767/- with interest @ 9% from the date of filing of complaint i.e. 27.5.2011 till the actual payment. Compliance of this order be made within a period of one month, failing which the complainant is entitled for legal proceedings u/s 25& 27 of C.P.Act. A copy of this order be supplied to the parties free of costs. File be consigned to record room after due compliance.
Announced in open Forum. Presiding Member,
Dated:28.10.2015. Member. District Consumer Disputes
Redressal Forum, Sirsa.
Rajender Kumar Vs. Vipul Medcrop
Present: Sh.A.K.Gupta, Advocate for the complainant.
Sh.Ravinder Goyal, Advocate for the opposite parties.
Arguments heard. For order to come up on 28.10.2015.
Presiding Member,
D.C.D.R.F,Sirsa.
Member. 20.10.15
Present: Sh.A.K.Gupta, Advocate for the complainant.
Sh.Ravinder Goyal Advocate for the opposite party.
Order announced. Vide separate order of even date, complaint has been allowed with costs. File be consigned to record room after due compliance.
Announced in open Forum. Presiding Member,
Dated:28.10.2015. Member. District Consumer Disputes
Redressal Forum, Sirsa.
