Punjab

Ludhiana

CC/21/254

Raman Kumar - Complainant(s)

Versus

Chola Mandlam General Insurance Company Limited - Opp.Party(s)

Harvinder Pal

09 May 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 254 dated 06.05.2021.                                                        Date of decision: 09.05.2023.

 

Raman Kumar, aged about 38 years son of Late Sh. Rajinder Kumar, Resident of House No.B-33-902, Street No.3, New Ashok Nagar-C, Ludhiana-141001.                                                                                       ..…Complainant

                                                Versus

1. The General Manager, Chola Mandlam General Insurance Company Ltd., 2^nd Floor, Dare House, 2, N.S.C. Bose Road, Chennai-600001 through its director/partners/M.D./authorized signatory etc.
2. Cholamandlam MS General Insurance Company Ltd., SCO No.2463-64, First Floor, Sector 22-C, Chandigarh through its Area Head/General Manager.
3. Cholamandlam MS General Insurance Company Ltd., 417, Rani Jhansi Road, Mall Enclave, Civil Lines, Ludhiana-141001 through its Branch Manager.                                                                                                                                                                    …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Harvinder Pal Singh, Advocate.

For OPs                          :         Sh. Vyom Bansal, Advocate.

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the complaint are that the complainant had purchase Family Floater/Arogya medical insurance policy No.2876/00035245/000014/000/00 on 03.09.2018 having validity8 up to 02.11.2019 by paying a premium of Rs.7866/- including GST etc. which was paid through RTGS from his bank account with OBC Bank, GMT Branch, Ludhiana. The policy covers the complainant himself, his wife Rajni, daughter Bhavika and sons Aryan and Vaibhav. The complainant renewed the said policy on payment of Rs.7866/-  on 02.12.2019 through RTGS from his account with PNB, GMT Public School branch, Ludhiana and a policy No.2876/00035245/000014/000/01 was issued which was valid up to 07.12.2020. The complainant stated that only policy number was informed to him whereas the policy has not been sent. However, after lapse of the said policy, he again renewed the policy by making payment of premium of Rs.7866/- from his bank account. The complainant further stated that unfortunately his son Aryan was hospitalized from 26.08.2020 to 27.09.2020 for fever at Dayanand Medical Hospital, Ludhiana during the subsistence of policy No.2876/00035245/000014/000/01. The complainant lodged the claim of Rs.1,55,836/- with local agent of the opposite parties namely Deepak vide claim form and also submitted relevant documents which was sent through DTDC courier company. The claim form was duly received by the opposite parties and Damanpreet Kaur Dhawan, official of opposite party No.2 also confirmed the receipt of claim of the complainant and she had processed the claim and forwarded to opposite party No.1 but the opposite parties have not paid the claim amount till today. According to the complainant, one official namely Jatinder Kumar also talked with complainant and assured that in near future the claim amount would be paid to him without any delay but the amount was not paid till today. The complainant issued a legal notice dated 01.04.2021 upon the opposite parties through registered post through his counsel Sh. Harvinder Pal Silngh, Advocate but the opposite parties had not responded to the legal notice of the complainant. The complainant has suffered monetary loss as well as mental tension and agony due to negligent, arbitrary, unjust and unfair practice adopted by the opposite parties for which the complainant is entitled to compensation of Rs.2,00,000/- and litigation expanses of Rs.33,000/-. In the end, the complainant has prayed for issuing direction to the opposite parties to make the payment of Rs.1,55,836/- along with interest spent by the complainant on the treatment of his son and also to pay compensation of Rs.2,00,000/- and litigation expenses of Rs.33,000/-.

2.                Upon notice to the opposite parties filed written statement by taking preliminary objections that the complaint is not maintainable being pre-mature and the complainant has suppressed the material facts.  It has been stated by the opposite parties that Raman Kumar and his family were firstly insured for the period of 03.11.2018 to 02.11.2019 vide certificate No.2842/00154425/0005/000/00 and thereafter, renewed for the period from 07.12.2020 to 06.12.2021 vide certificate No.2876/00035245/000014/000/02 under the Group Health Insurance Policy issued to Punjab National Bank by the opposite parties for maximum sum insured of Rs.3 Lacs as detailed in Coverage details of the policy subject to conditions and exclusions of the policy wordings. The benefits under the policy are governed by the terms and conditions of the policy and the liability of the opposite parties is limited to the insured perils occurring within the policy period subject to conditions and exceptions as mentioned in the terms and condition of the policy. The opposite parties further stated that a claim was received from the insured for his son named Aryan who suffered from Dengue fever with compensated shock with respiratory distress with right side pleural effusion and admitted in Dayanand Medical College and Hospital on 26.08.2020 and discharged on 07.09.2020. The insured submitted the claim form along with treatment and medical expenses documents which was duly registered vide claim No.2876020677. The opposite parties  further stated that they issued deficiency letter dated 24.11.2020 demanding documents for processing the claim and after receiving the documents from the complainant, the authorized officials of the insurance company applied their mind and in terms of the policy coverage found the claim payable to the extent as permissible under the policy. The complainant was asked to submit his NEFT details for payment of the claim amount and he submitted a cancelled cheque for erstwhile Oriental Bank of Commerce, GMT School, Ludhiana now merged with Punjab National Bank and its branch code, IFSC code etc. had changed to merge with Punjab National Bank. Thereafter, the insurance company intimated the insured to provide fresh NEFT details of his bank which he failed to submit till date and as such, the claim is still pending for want of documents from the complainant/insured. The opposite parties further stated that they have provided completed services to the complainant but the complainant has miserably failed to show any reason as to whey any of the reliefs prayed by him in the complaint should be granted to him.

                   On merits, the opposite parties reiterated the crux mentioned in the preliminary objections. The opposite parties have denied any deficiency in service on their part and in the end, have prayed for dismissed the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of Group Health Insurance from 03.11.2018 to 02.011.2019, Ex. C2 is the copy of account statement of the complainant, Ex. C3 is the copy of Group Health Insurance from 07.12.2020 to 06.12.2021, Ex. C4 is the copy of discharge summary, Ex. C5 is the copy of claim form, Ex. C6 is the copy of courier receipt, Ex. C7 is the copy of legal notice dated 01.04.2021, Ex. C8 and Ex. C9 are the copies of postal receipts, Ex. C10 is the copy of acknowledgement and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Ms. Vidhi Passi, Legal-TP Claims of the opposite parties along with document Ex. R1 is the copy of Group Health Insurance from 03.11.2018 to 02.12.2019, Ex. R2 is the copy of claim form, Ex. R3 is the copy of discharge summary, Ex. R4 is the copy of health claim query reminder cum closure letter dated 24.11.2020, Ex. R5 is the copy of cancelled cheque and closed the evidence.  

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.      

6.                Admittedly, the complainant is a holder of a medical insurance policy namely Family Floater/Arogya medical insurance since its inception on 03.09.2018 and it was renewed twice. The policy was having an insurance cover for his wife, daughter and both sons. During the subsistence of policy Ex. R1, the son of the complainant remained hospitalized w.e.f 26.08.2020 to 07.09.2020. As per discharge summary Ex. R3, he was diagnosed for having severe Dengue fever with compensated shock with respiratory distress with right side pleural effusion. The complainant incurred the medical expenses and lodged the claim of Rs.1,55,836/- along with relevant documents. The claim was duly registered by the opposite parties and during the cause of settlement process, the opposite parties issued deficiency letter dated 24.11.2020 Ex. R4  calling upon the complainant to submit discharge summary, final bills and receipts, indoor case papers so that admissibility of the claim could be decided. 7.                   However, in para no.3 of the written statement, the opposite parties  admitted that upon receiving the documents from the complainant, the authorized officials of the insurance company applied their mind and in terms of the policy coverage found the claim payable to the extent as permissible under the policy. The complainant was asked to submit his NEFT details for payment of the claim amount and he submitted a cancelled cheque for erstwhile Oriental Bank of Commerce, GMT School, Ludhiana now merged with Punjab National Bank and its branch code, IFSC code etc. had changed to merge with Punjab National Bank. Thereafter, the insurance company intimated the insured to provide fresh NEFT details of his bank which he failed to submit till date.

8.                From the above said chronology of events, it is evident that only fresh NEFT details of the bank of the complainant was left to be submitted. Further when the officials of the opposite parties were of the opinion that the claim is genuine and payable to the extent as permissible under the policy, they could have easily intimated the extent of payable claim to the complainant. It was well within the rights of the opposite parties to send an account payee cheque to the complainant via post but the opposite parties did not act swiftly in settling the claim and redressing the grievance of the complainant. The insurance companies are required to be more liberal in their approach without being too technical.

9.                In this regard, reference can be made to 2022(2) Apex Court Judgment 281 (SC) in case title Gurmel Singh Vs Branch Manager National Insurance Company Ltd. whereby it has been held by the Hon’ble Supreme Court of India that the insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to procure and furnish. Once, there was a valid insurance on payment of huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non­submission of the duplicate certified copy of certificate of registration, which the appellant could not produce due to the circumstances beyond his control. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control.

As such, there is deficiency in service on the part of the opposite parties to reimburse the claim payable to the extent as permissible under the policy. In the given facts and circumstances, it would be just and appropriate if the complainant is directed to furnish fresh NEFT details with the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties, as per terms and conditions of the insurance policy, shall settle and reimburse the claim of the complainant regarding medical expenses of Rs.1,55,836/- incurred on hospitalization of his son Aryan from 26.08.2020 to 07.09.2020 within 30 days from the date of receipt of NEFT details from the complainant along with interest @8% per annum on the settled amount from the date of filing of the complaint till actual payment.  The opposite parties are also burdened to composite compensation of Rs.10,000/- to the complainant.

10.              As a result of above discussion, the complaint is partly allowed with direction to the complainant to furnish fresh NEFT details with the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties, as per terms and conditions of the insurance policy, shall settle and reimburse the claim of the complainant regarding medical expenses of Rs.1,55,836/- incurred on hospitalization of his son Aryan from 26.08.2020 to 07.09.2020 within 30 days from the date of receipt of NEFT details from the complainant along with interest @8% per annum on the settled amount from the date of filing of the complaint till actual payment. The opposite parties shall also pay a composite compensation of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made  within 30 days from the date of receipt of copy of the order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                                       (Sanjeev Batra)                      Member                                                         President   

 

Announced in Open Commission.

Dated:09.05.2023.

Gobind Ram.

 

 

Raman Kumar Vs Cholamandalam                        CC/21/254

Present:       Sh. Harvinder Pal Singh, Advocate for complainant.

                   Sh. Vyom Bansal, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to the complainant to furnish fresh NEFT details with the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties, as per terms and conditions of the insurance policy, shall settle and reimburse the claim of the complainant regarding medical expenses of Rs.1,55,836/- incurred on hospitalization of his son Aryan from 26.08.2020 to 07.09.2020 within 30 days from the date of receipt of NEFT details from the complainant along with interest @8% per annum on the settled amount from the date of filing of the complaint till actual payment. The opposite parties shall also pay a composite compensation of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made  within 30 days from the date of receipt of copy of the order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

                

(Monika Bhagat)                                       (Sanjeev Batra)                      Member                                                         President   

 

Announced in Open Commission.

Dated:09.05.2023.

Gobind Ram.