Punjab

Ludhiana

CC/19/173

Sohan Singh - Complainant(s)

Versus

Medi Assist Insurance - Opp.Party(s)

Manish Kumar

02 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:173 dated 04.04.2019.                                                        Date of decision: 02.03.2023.

 

Sohan Singh S/o. Chand Singh, aged 48 years R/o. Village Rajewal, Tehsil Samrala, District Ludhiana (Punjab)                                                                                                                                                        ..…Complainant

                                                Versus

1. M/s. Medi Assist Insurance TPA Private Limited, Tower D, 4^th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, K.M. Layout, Bengaluru, Karnataka-560029.
2. Branch Manager, Medi Assist Insurance TPA Private Limited, S.C.O. 37, 2^nd Floor, Sector 31-D, Chandigarh.                                                      
3. Chairman, United India Insurance Company Ltd., 24, Whites Road, Chennai-600014.                                                                                                                                                                  …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. Munish Kumar Goyal, Advocate.

For OP1 and OP2          :         Exparte.

For OP3                         :         Sh. R.K. Chand, Advocate.

 

 

 

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant is an employee of Vijaya Bank having employee id no.21183, got insurance policy No.5030868156 along with his family. The complainant submitted that he slipped on road from motor bike due to stray dog and was admitted with multiple fractures on 28.02.2018 in Krishna Hospital, Backside Dawat Sweets, Khanna and was discharged on 03.03.2018. He was readmitted on 13.03.2018 for surgery of left leg and ORIF with lateral Buttress plate and lag screws was done on 14.03.2018 and discharged on 16.03.2018. The complainant had spent Rs.71,670/-,  Rs.38,500/- for post hospitalization charges, Rs.4800/- as ambulance charges, Rs.3900/- as health check cost and Rs.24,701/-0 as other expenses. On 02.07.2018, the complainant submitted his al original bills and reports with opposite party No.1 and claimed reimbursement through insurance claim No.5001002818C324255001. As per query of opposite party No.1, the complainant had provided each and every documents in original through courier delivered on 31.07.2018 but opposite party No.1 informed that his claim has been closed on 28.02.2019 without any reason and without any explanation resulting deficiency in service and unfair trade practice. The complainant further submitted that the inspecting officer of the opposite parties personally visited all the hospitals, chemist shops, laboratories, X-ray departments and also checked the bills and records. The complainant also lodged a complainant but al in vein and no claim had been provided by the opposite parties, which amounts to deficiency in service on the part of the complainant due to which the complainant has suffered a huge monetary loss and mental agony.  In the end, a prayer has been made to direct the opposite parties to pay back the amount of bills of Rs.71,670/- along with compensation of Rs.2,00,000/- and litigation expenses of Rs.22,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections that this Commission has no jurisdiction to try and decide the present complaint. The opposite parties alleged that immediately on receipt of claim, it was duly entertained, registered and referred to M/s. Medi Assist Insurance TPA Pvt. Ltd.  and the complainant was called upon to submit the documents in support of his claim. M/s. Medi Assist Insurance TPA Pvt. Ltd. duly processed the claim file in terms of the insurance policy and requested the complainant to supply relevant documents which the complainant has not supply despite several reminders and letters dated 25.07.2018 and 03.08.2018, as per which following documents were required:-

• Please provide the circumstances lead to injury, if it is RTA please provide a copy of MLC/FIR and also provide a letter from the hospital confirming the time of admission and discharge.
• Please provide original discharge summary towards hospitalization dated 13.03.2018 to 16.03.2018 (provided discharge summary only dated 28.02.2018 to 03.03.2018.)
• Please provide original prenumbered cash paid receipt Rs.10,300/- and Rs.21,900/- towards both the final bills.
•  Please provide all original lab reports and xray reports for the claimed amount (xray report mandatory for process)
• Pease check with the hospital and provide a copy of hospital registration certificate with no. of beds available in hospital.

As per letter dated 03.08.2018, the complainant was informed to supply the said documents within 7 days from the date of said letter failing which file shall be closed. The complainant failed to supply the documents despite receipt of said letter and as such, the opposite parties left with no other option except to close the file as ‘No claim’. The opposite parties further alleged the complainant has not come to the court with clean hands and has  suppressed the material facts from the court. The complaint is not maintainable since complicated question of aw and facts are involved which require elaborate evidence both oral and documentary and can be decided only by the civil court of competent jurisdiction and not by this Commission in a summary manner. Moreover, the insurance policy is a contract between the insured and insurer which is based on utmost good faith and the terms and conditions of the policy are binding on the parties.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties admitted the fact of obtaining insurance policy by the complainant. The opposite parties further alleged that M/s. Medi Assist Insurance TPA Pvt. Ltd. vide letter dated 25.07.2018, 22.07.2018, 13.07.2018 and 03.08.2018 requested the complainant to supply the documents but he has failed to supply the same and the file was closed as ‘No Claim’. The opposite parties denied any deficiency in service on their part and in the end, a prayer for dismissal of the complaint has been made.

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 reimbursement claim form, Ex. C2 is the copy of case summary of Krishna Hospital, Ex. C3, Ex. C8 to Ex. C21 are the copies of bills/receipts of medicine etc., Ex. C4 to Ex. C7 are the copies of prescription slips, Ex. C22 is the copy of courier receipt, Ex. C23 is the copy of track record of consignment, Ex. C24 is the copies of identity cards issued by the opposite parties and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RW1/A of  Sh. Prem Pahuja, Divisional Manager of the opposite parties, affidavit Ex. RW2/A of Sh. Gurbachan Singh, Manager of M/s. Medi Assist Insurance TPA Pvt. Ltd. along with documents Ex. OP3/1 is the copy of letter dated 25.07.2018, Ex. OP3/2 is the copy of letter dated 03.03.2019, Ex. OP3/3 is the copy of letter dated 20.02.2019, Ex. OP3/4 is the copy of letter dated 08.03.2018, Ex. OP3/5 is the copy of reimbursement claim form, Ex. OP3/6 is the copy of PAN card of the complainant, Ex. OP3/7, Ex. OP3/48 are the copies of Aadhar card of the complainant, Ex. OP3/8 is the copy of certificate issued by Dr. Neeraj Kumar of Krishna Hospital, Ex. OP3/9 is the copy of indoor patient admission record, Ex. OP3/10 to Ex. OP3/14,  Ex. OP3/31 to Ex. OP3/34, Ex. OP3/115, Ex. OP3/116, Ex. OP3/136 to Ex. OP3/138 are the copies of medical treatment record, Ex. OP3/15 to Ex. OP/18 are the copies of laboratory reports, Ex. OP3/19, Ex. OP3/28, Ex. OP3/29 are the copies of  x-ray report, Ex. OP3/20, Ex. OP3/113, Ex. OP3/114 are the copies of  case summary, Ex. OP3/21, Ex. OP2/22, Ex. OP3/24, Ex. OP3/25, Ex. OP3/27  are the copies of certificates issued by Dr. Neeraj Kumar of Krishna Hospital, Ex. OP3/23, Ex. OP3/26, Ex. OP3/30, Ex. OP3/129 are the copies of case summary, Ex. OP3/35 is the copy of investigation report dated 15.02.2019 of Lawman Associates, Ex. OP3/36 to Ex. OP3/46 are the photographs of medical stores, san centre and bills etc., Ex. OP3/47 is the copy of certificate dated 09.02.2019, Ex. OP3/48 is the copy of statement of Sohan Singh, Ex. OP3/49 is the copy of Aadhar card of Harsimratpal Kaur, Ex. OP3/50 to Ex. OP3/53 are the copies of photographs of the complainant, Ex. OP3/54 to Ex. OP3/59, Ex. OP3/131 to Ex. OP3/134 are the copies of x-ray reports, Ex. OP3/60 to Ex. OP3/63, Ex. OP3/67 to Ex. OP3/87, Ex. OP3/89 to Ex. OP3/112, Ex. OP3/117 to Ex. OP3/125, Ex. OP3/127  are the copies of bills/receipts, Ex. OP3/64 to Ex. OP3/66 are the copies of attendance register of Vijaya Bank, Ex. 68 to Ex. OP3/88 is the copy of statement of account of the complainant,  Ex. OP3/126  copy of letter issued to the complainant for supplying documents, Ex. OP3/128, Ex. OP3/130 are the copies of certificates issued by Dr. Neeraj Kumar of Krishna Hospital, Ex. OP3/135 is the copy of letter dated 28.12.2018 issued by Vijaya Bank  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. We have also gone through the written arguments submitted by the complainant.

6.                It can be borne from the record that the complainant remained admitted in Krishna Hospital, Khanna from 28.02.2018 to 03.03.2018 on account of road side accidental injuries and again he was readmitted on 13.03.2018 for surgery and remained hospitalized till 16.03.2018. He preferred a claim with regard to the expenses incurred by him on account of aforesaid hospitalization along with its incidental charges of ambulance and health checkup. The grievance of the complainant is that his claim was not settled.

7.                On the other hand, the opposite parties have very specifically  and consistently have taken a defence that certain documents were repeatedly demanded from the complainant who failed to provide the same and as such, his claim could not be settled. Perusal of reminders dated 08.03.2018 Ex. OP3/1 and 25.07.2018 Ex. OP3/4 shows that the following documents were demanded again and again from the complainant:-

• Please provide the circumstances lead to injury, if it is RTA please provide a copy of MLC/FIR and also provide a letter from the hospital confirming the time of admission and discharge.
• Please provide original discharge summary towards hospitalization dated 13.03.2018 to 16.03.2018 (provided discharge summary only dated 28.02.2018 to 03.03.2018.)
• Please provide original prenumbered cash paid receipt Rs.10,300/- and Rs.21,900/- towards both the final bills.
•  Please provide all original lab reports and xray reports for the claimed amount (xray report mandatory for process)
• Pease check with the hospital and provide a copy of hospital registration certificate with no. of beds available in hospital.

However, subsequently, the opposite parties vide letters Ex. OP3/3 dated 20.02.2019 and Ex. OP3/2 dated 03.03.2019 demanded the following documents from the complainant:

• Please provide all original reports with film for confirmatory diagnosis (provided duplicate without film)
• Please confirm as per discharge summary DOD – 16/03/2018 but ICPs dates till 17/03/2018.
• Please clarify difference in receipts: amount previously provided receipt Rs/21900, and IR provided receipt rs/-20900.

The insurance companies are required to be more liberal in their approach without being too technical. This Commission is of the considered view that in the light of the guidelines issued vide IRDA circular 20.09.2011, it can be safely held that the insurance company cannot be allowed to reject the claim on technical grounds. Rather the rejection by the insurance company must be based on sound logic and valid grounds.

8.                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. In the given set of circumstances, it would be just and appropriate if the complainant is directed to submit the above said documents as per Ex. OP3/2 to opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. 

9.                As a result of above discussion, the complaint is partly allowed with an order that the complainant is directed to submit the documents as per Ex. OP3/2 dated 03.03.2019 to the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse the claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant.  However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.   

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

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:02.03.2023.

Gobind Ram.

 

 

Sohan Singh Vs M/s. Medi Assist Insurance TPA                            CC/19/173

Present:       Sh. Munish Kumar Goyal, Advocate for complainant.

                   OP1 and OP2 exparte.

                   Sh. R.K. Chand, Advocate for OP3.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with an order that the complainant is directed to submit the documents as per Ex. OP3/2 dated 03.03.2019 to the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse the claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant.  However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.       

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:02.03.2023.

Gobind Ram.