Punjab

Faridkot

CC/19/264

kaka Singh - Complainant(s)

Versus

Directorate of Health and family welfare - Opp.Party(s)

Sangeeta Sharma

26 Jul 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FARIDKOT

C. C. No. :             264 of 2019

Date of Institution:     23.10.019

Date of Decision :    26.07.2022

Kaka Singh aged about 48 years, son of Balvir Singh resident of Village Gondara, Tehsil Jaitu, District Faridkot.

...Complainant

Versus

1. Directorate of Health & Family Welfare, Punjab, Parivar Kalyan Bhavan, Sector 34-A, Chandigarh through Director.
2. Director, Bhagat Puran Singh Sehat Beema Yojna, c/o Directorate of Health & Family Welfare, Punjab, Parivar Kalyan Bhavan, Sector 34-A, Chandigarh through Director.
3. Deputy Medical Commissioner, (Designated Under Bhagat Puran Singh Health Insurance Scheme) Office of Civil Surgeon, Faridkot, Tehsil and District Faridkot.                                         
4. United India Insurance Company Ltd, Registered Divisional Office : SCO 72, Phase 9, Mohali-160055 through its Regional Manager.
5. Reliance General Insurance Company through its authorized signatory, Office at SCO 145-146, 2^nd Floor, Sector 9 (C), Madhya Marg, Chandigarh.

 .....Opposite Parties

 

Complaint under Section 12 of the

Consumer Protection Act, 1986.

(Now, Section 35 of the Consumer Protection Act, 2019)

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Quorum:     Smt Param Pal Kaur, Member.

                     Sh Vishav Kant Garg, Member.

 

Present:      Ms Sangeeta Sharma, Ld Counsel for complainant,    

                  Sh Manpreet Singh, Ld Counsel for OP-1 to 3,

         Sh Ashok Monga, Ld Counsel for OP-4,

                   Sh Manohar Lal Chugh, Ld Counsel for OP-5.

 

(ORDER) 

( Param Pal Kaur, Member)

                                                  Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs for deficiency in service in not making payment of Rs. 5,00,000/-of insurance claim on account of his treatment and for further directing OPs to pay Rs.1,00,000/- as compensation for harassment, inconvenience, mental agony and Rs.15,000/-as litigation expenses.

2                                    Briefly stated, the case of the complainant is that complainant was insured under Bhagat Puran Singh Scheme vide card no. 03045000178035604 and policy was issued to him. It is submitted that during the subsistence of said policy on 28.04.2016, complainant met with an accident and in said accident he lost his vision of right eye due to head injury and got

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fracture in both legs and right thigh. DDR No.020 dated 04.05.2016 to this effect was got registered in Police Station City, Bajakhana. Complainant got conducted his treatment from Civil Hospital, Bajajkhana and was then, referred to Guru Gobind Singh Medical College and Hospital, Faridkot and thereafter, he continued his treatment in Badayal Multispecialty Hospital and Trauma Centre, Bathinda. Complainant could not recover from his injuries and his family spent more than Rs. 5 lakhs on his treatment. Complainant lodged online claim with OPs on their customer care no.104 for his disability and OPs assured to appoint a surveyor and said that claim would be passes after surveyor report, but despite repeated requests, OPs have neither appointed any surveyor nor have released the claim amount on account of disability being suffered by him. Act of Ops in not making payment of claim amount amounts to deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for accepting the complaint alongwith compensation and litigation expenses. Hence, the present complaint.

3                                                          The counsel for complainant was heard with regard to admission of the complaint and vide order dated 30.10.2019,

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complaint was admitted and notice was ordered to be issued to the opposite parties.

4                                              OP-1 to 3 appeared in this Commission through counsel and filed written reply  taking preliminary objections that as per Section 10 (3) of the Policy, if grievance of beneficiary is not satisfied, then he was required to approach DGRC and DGRC was required to take appropriate decision within 30 days from the receipt of complaint, but complainant has not got registered his complaint with DGRC. Moreover, if beneficiary is not satisfied with the decision of DGRC, then he may make appeal to SCRC, who would decide the matter within 30 days, but complainant has not file any appeal.  On merits, they have denied all the allegations being wrong  and incorrect and stressed mainly on the point that no consideration or any amount is ever paid by complainant to OP-1 to Op-3 for insurance and he is not their consumer and answering OPs have nothing to do with this matter and matter is between complainant and Insurance Company. All the other allegations are denied being wrong and incorrect and made prayer for dismissal of complaint with costs.

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5              On receipt of the notice, OP-4 filed written statement wherein  they have denied all the allegations of complainant being wrong and incorrect and asserted that complainant is not their consumer and there is no relationship of consumer and service provider between them. It is averred that complainant did not give them requisite immediate intimation preventing them to gather first hand information and to inspect the spot, which is violation of terms and conditions of the policy in question. Complaint involves complicated questions of law and facts requiring lengthy evidence, which is not possible in summary procedure of this Forum. No cause of action arises  against answering Ops and present complaint is vague and is based on wrong facts and complainant has no locus standi to file the present complaint. It is further averred that complainant was not insured with them at the relevant time, rather he was insured under Reliance Insurance. Neither complainant nor other  respondents provided them proper insurance particulars and therefore, they are not liable to make payment of any insurance claim. There are several regional offices, divisional offices and branch and micro offices and it is not possible to locate the insurance particulars without supply of the same by complainant or by other OPs. All the other allegations are

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denied being wrong and incorrect and asserted that there is no deficiency in service on the part of answering Ops and prayed for dismissal of complaint with costs.

6                                   OP-5 filed written statement taking preliminary objections that complaint filed by complainant is false, frivolous and vexatious and it involves complication questions of law and facts requiring cross examination and therefore, it should be referred to Civil Court. It is averred that Insurance Policy is a bilateral contract and parties to the contract are bound by its terms and conditions. Complainant did not lodge any claim with answering OP. Moreover, complaint filed by complainant is premature as no claim is lodged by complainant and therefore, answering OPs have not rejected the same. As per letter dated 12.01.20217, answering OP will entertain the PA claims that are intimated up to 31.01.20217. Alleged accident took place on 28.04.2016 and complainant filed the present complaint on 23.10.2019 and they have been served on 15.06.2020  and thus, it is time barred. However, on merits OP-5 has denied all the allegations being wrong and incorrect and reiterated the same pleadings as taken in preliminary objections and asserted that there is no

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deficiency in service on their part as complainant has never lodged any claim with them.                       

7                                                        Parties were given proper opportunities to prove their respective case. Ld Counsel for complainant tendered in evidence affidavits of complainant as Ex C-1/A and Ex C-1/B and documents Ex C-1 to 65 and then, closed his evidence.

8                                                          In order to rebut the evidence given by complainant, the ld Counsel for OP-1 to 3 tendered in evidence affidavit of Dr. Rohini Goyal, Deputy Medical Commissioner, Faridkot as ExOP-1 to 3/A and closed the same on behalf of OP-1 to 3. Ld counsel for OP-4 tendered in evidence affidavit of Vinod Kumar, Deputy Manager of United India Insurance Co. Ltd Ex OP-4/1 and document Ex OP-4/2 to OP-4/3 and closed the same on behalf of OP-4. Ld Counsel for OP-5 tendered in evidence affidavit of Suryadeep Singh Thakur, Manager, Reliance General Insurance Company Ltd as Ex OP-5/1 ad documents Ex OP-5/2 to Ex OP-5/3 and then, also closed the evidence.

 

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9                                                        We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents placed on the file.

10                                                         After careful perusal of the record available on file and going through the evidence led by parties, it is observed that case of the complainant is that he was insured under Bhagat Puran Singh Scheme and during the subsistence of said policy, he met with an accident on 28.04.2016 and sustained head injury and got fracture in both legs and right thigh. DDR to this effect was also registered in Police Station City, Bajakhana. Complainant got conducted his treatment from Civil Hospital, Bajajkhana, Guru Gobind Singh Medical College and Hospital, Faridkot and then from Badayal Multispecialty Hospital and Trauma Centre, Bathinda, but he could not recover from his injuries. He spent more than Rs. 5 lakhs on his treatment. Complainant lodged online claim with OPs and they assured to appoint a surveyor, but till now OPs have neither appointed any surveyor nor have released the claim amount on account of disability being suffered by him. Act of Ops in not making payment of claim amounts to deficiency in service. Grievance of the complainant is that despite submission of claim and completion of all

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formalities, Ops have not made payment of insurance claim. Repeated requests made by complainant for passing his genuine insurance claim, served no purpose. It amounts to deficiency in service on the part of OPs. In reply, OP-1 to 3 stressed mainly on the point that no consideration or any amount is ever paid by complainant to them  and he is not their consumer  and they have no role in making payment of insurance claim. Plea taken by OP-4 is that complainant did not give them requisite immediate intimation preventing them to gather first hand information and to inspect the spot, which is violation of terms and conditions of the policy in question and even complainant was not insured with them at the relevant time, rather he was insured under Reliance Insurance. Neither complainant nor other  respondents provided them proper insurance particulars and therefore, they are not liable to make payment of any insurance claim. As per OP-5 complainant did not lodge any claim with them. Thus, complaint filed by complainant is premature as no claim is lodged by complainant and they have not rejected the same. As per letter dated 12.01.20217, answering OP is will entertain the PA claims that are intimated up to 31.01.20217. Alleged accident took place on 28.04.2016 and complainant filed the present complaint on 23.10.2019 and they have been served on

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15.06.2020  and thus, it is time barred. All the OPs asserted that there is no deficiency in service on their part and prayed for dismissal of complaint with costs.

11                                   In order to prove his pleadings, complainant has stressed on document Ex C-1 i.e copy of  card issued by Bhagat Puran Singh Health Insurance Scheme that clearly depicts that policy in question was issued in the name of complainant and he was insured under said scheme. This document is self explanatory and proves that complainant was insured under said scheme and he sustained injuries and undertook treatment during the subsistence of said policy. There is no denial that complainant was insured under policy in question. Document Ex C-2 is copy of Daily Diary Report No. 20 dated 04.05.2016 that proves the pleadings of complainant that complainant  met with an accident on 28.04.2016 by colliding with a car and in said road accident he got fractures in his both legs and also suffered huge head injury. It says that he was taken to Civil Hospital, Bajakhana and then was referred to Guru Gobind Singh Medical College and Hospital, Faridkot and then, was shifted to Badyal Hospital, Bathinda. Ex C-3 to Ex C-58 are the copies of payment slips and certificate

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issued by Badyal Hospital, Bathinda and reveal the fact that complainant spent expenditure on his treatment and paid this amount to hospital authorities. Ex C-59 is an important document that proves the pleading of complainant that he suffered 70% disability due to that accident. Photographs Ex C-62 to 65 also leave no doubt about the disability of complainant.

 12                                             Document Ex C-1 showing membership and card number issued to complainant Kaka Singh under Bhagat Puran Singh Sehat Bima Yojna is beyond any doubt. Complainant has placed on record sufficient and cogent evidence to prove his pleadings. There is no reason to doubt that complainant has suffered huge harassment and mental agony by action of OPs in not making payment of insurance claim on account of expenses incurred by him on his treatment.

13                                      Ld Counsel for complainant placed reliance on judgment given by Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Life Insurance Corporation of India Vs Devi Das Sirsode Revision Petition Nos. 2517 & 2518 of 2005 decided on 20.10.2005 “ Consumer Protection Act, 1986-Section 21(b)- Life Insurance- Accident Claim-

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Disability – legs amputated due to accident on railway track – Accident benefit denied on ground that disability not permanent – Complaint allowed by Forum -  Order upheld by State Commission – Accidental injuries resulted in irrecoverable loss – Assured suffered permanent disability as defined under policy clause – Insured if continuing service on ex gratia or on compassionate ground, no benefit can be given to Company – Benefit under policy cannot be denied – Company liable – Policy terms, if vague, should be interpreted for benefit of assured – Company liable.” In present case, it is admitted that disability occurred during the subsistence of policy in question. Plea taken by OP-5 that complainant is debarred from filing the complaint on the ground that accident took place on 28.04.2016 and complaint is filed on 23.10.2019 and OP-5 is served on 15.06.2020, but this plea has no legs to stand upon as filing the complaint late or delay due to some other reason which was beyond the control of complainant, does not make the claim of complainant ingunuine. Being insured, complainant is entitled to get relief as per terms and conditions of the policy. Insurance Company OP-5 cannot escape its liability on the ground of technical delay.

 

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14                                                 From the above discussion and in the light of evidence produced by the respective parties, we are of considered opinion that complainant has succeeded in proving his case. However, from the careful perusal of bills and other hospital record placed on file, it is made out that complainant has suffered 70% permanent disability and being member of Insurance Scheme, he is entitled for benefit of Rs.3,00,000/-under policy in question as claimed by complainant vide Ex C-60. Complaint filed by complainant is hereby accepted against OP-5 Reliance General Insurance Company with direction to them to pay Rs.3,00,000/- (Three Lacs only) alongwith interest at the rate of 4 % per anum from the date of filing the present complaint till final realization to complainant who was insured with OP-5 against policy in question. OP-5 is further directed to pay Rs.10,000/- to complainant as consolidated compensation for harassment and mental agony suffered by him as well as for litigation expenses incurred on present complaint. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to initiate proceedings under Section 71 and 72 of the Consumer Protection Act 2019. Complaint against OP-1, OP-2, OP-3 and OP-4 stands hereby dismissed as they have no

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role in making payment of insurance claim. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced on

Dated : 26.07.2022

(Vishav Kant Garg)       (Param Pal Kaur)                        

Member                          Member