Delhi

New Delhi

CC/734/2014

Hari Gopal - Complainant(s)

Versus

M/S. United India Insurance Company Ltd. - Opp.Party(s)

27 Jul 2022

ORDER

 

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, VI,

DISTT.NEW DELHI, M-BLOCK, VIKAS BHAWAN, NEW DELHI-110002.

 

CC/734/2014

 

IN THE MATTER OF:

 

SHRI HARI GOPAL

S/o LATE TARA CHAND GUPTA

R/o AHATA THAKUR DAS, SARAI ROHILLA,

NEW ROHTAK ROAD, DELHI 110005                         COMPLAINANT

VERSUS

1. M/S UNITED INDIA INSURANCE CO. LTD.

          THROUGH ITS REGIONAL MANAGER

        9^th FLOOR KANCHAN JANGA BUILDING,

         BARAKHAMBA ROAD, NEW DELHI

2. M/S UNITED INDIA INSURANCE CO. LTD.

         THROUGH ITS BRANCH INCHARGE,

       102, AGARWAL PLAZA CENTRAL MARKET,

         PLOT NO. 11, SECTOR-10, DWARKA, DELHI

3. M/S E-MEDITEK TPA LTD.

          THROUGH ITS CHIEF EXECUTIVE OFFICER,

         45, NATHUPURA ROAD, DLF,

          PHASE-III, GURGAON-122002 OPPOSITY PARTY

Quorum:

Ms. Poonam Chaudhry, President

          Shri Bariq Ahmad , Member

          Ms. Adarsh Nain, Member

                                                                   Dated of Institutio :   23.09.2014

                                                                   Date of Order          :  27.07.2022

O R D E R

POONAM CHAUDHRY, PRESIDENT

1. The present complaint has been filed under section 12 of the Consumer Protection Act. 1986 (in short CPA) against the OP (Opposite party in short) alleging deficiency in services. Briefly stated the facts of the case are that an individual health policy-2010 with prescribed schedule and a policy No. 040700/48/11/97/00001311 with previous policy No. 34070048109700001401  in continuation with the previous policies was issued by the opposite party no. 2 to the Complainant.
2. The Complainant was advised to convert the aforesaid individual health policy into family medicate policy and the Complainant considering the benefits of the aforesaid advised policy opted to obtain a family medicare policy and the Complainant was issued a policy no. 041381/48/12/06/00000015 with previous policy 040700/48/11/97/00001311 by the opposite party no. 2 where the period of insurance was from 12.40 hrs. of 14.08.2012 to midnight of 13.08.2013 and sum insured opted was Rs. 3,00,000/- (Rupees Three Lakh) and the Complainant also made a payment of Rs. 10,405/- in this connection vide receipt no. 041383/81/12/00000 dated 14.08.2012.
3. It is also stated the wife of Complainant Mrs. Komal Gupta was got admitted on 26.12.2012 in Jeewan Mala Hospital, 67/1, New Rohtak Road, New Delhi-110005, when she was suffering with different diseases like acute gastroenteritis, coronary artery disease post PTCA Status etc. and the Complainant submitted a claim with the opposite parte No. 3 and the opposite parte no. 3 approved initially a sum of Rs. 1,00,000/- as admissible limit, but finally the opposite party no. 3 wrongly made the admissible limit sum of Rs. 75,000/- and authorized limit was also shown as Rs. 75,000/-  vide PAC No. EMSL/PAC/UIIC/57733/2012, claim No. 122121204135 dated 09.01.2012 07:11 PM.
4. It is further alleged the claim of Complainant has been accepted only to the limit of Rs. 75,000/- (Rupees Seventy Five Thousand) whereas the Complainant was entitled for a claim of Rs. 3,00,000/- in view of the aforesaid policy as the Complainant made a total payment of Rs. 4,90,159/- to the aforesaid Jeewan Mala Hospital with regard to the treatment of the wife of Complainant namely Ms. Komal Gupta.
5. It is alleged the opposite parties were got served the legal notice dated 03.04.32014 by the Complainant. It is prayed to direct the OP to made payment of Rs. 2,11,000/-(Rupees Two Lakhs Eleven Thousand Only) on account of stress, pain, tension, torture, harassment and mental agony to the Complainant and his family members along with pendent lite and future interest @ 18% p.a. and also direct the OP to pay the litigation expenses.
6. OP-1 contested the case. The Written Statement was filed taking objection that claim was against the law as well facts on the record, and that the complainant had also not approached the Forum with clean hands.
7. It was further stated that the complainant was holding a family Medicare Policy Bearing no. 041382/48/12/06/00000015 issued by opposite party No. 1. It was further alleged the health insurance is a contract like other contracts and subject to terms and condition of the said contract. The complainant was bound by the terms and condition of the policy as the same is duly acknowledged and signed by him. The policy was issued for the sum insured of Rs. 3,00,000/- and entire amount of sum insured has been paid. No amount is balance to be paid.
8. It was also alleged that the claim was analyzed and recommended by the IRDA approved (TPA) agency known as E-Meditek TPA who is a professional agency and engaged for a fee or remuneration by the insurance companies for the provision of health services under an agreement and under the provision of IRDA Regulations (Third Party Administrator-Health Services) 2001. Even otherwise in the insurance policies of such nature as relates to the present case, the company relies upon professional recommendation and decisions of TPA which requires to be followed by the company under the provision as stated. On the basis of the recommendation of TPA, the entire amount of present claim has been paid. It was also alleged that the complaint is without any cause of action and hence the same is liable to be dismissed. OP No.-1 was company is not liable to pay claim.
9. On merits it was stated that the complaint was not maintainable because the policy was issued for the sum insured of Rs. 3,00,000/- (Rupees Three Lakh) and a sum of Rs. 75,000/- (Rupees Seventy Thousand) was approved as cashless by the respondent No.3 vide letter dated 13.01.2013 and same had been paid. Later on complainant also applied for reimbursement on 28.05.2014 for balance amount of expenses on treatment, since the policy was issued for the sum insured of Rs. 3,00,000/- (Rupees Three Lakh) and out of which Rs. 75,000/ - (Rupees Seventy Five Thousand) was already been paid as cashless, remaining amount of Rs. 2, 25,000/- (Two Lakh Twenty Five Thousand) was also paid to complainant 04.06.2014. The same had been admitted by complainant in complaint.
10. It was also stated the complainant had submitted his claim form for reimbursement on 28.05.2014 and balance amount of sum insured was paid only after in a week from filing of claim. As per policy, reimbursement amount was to be processed only after submitting of claim form and all other documents. It was alleged after the receiving of entire amount of claim the present complaint was not maintainable. It is prayed that complaint be dismissed.
11. OP-3 also filed the written statement taking objection that the complaint was not maintainable because the sum insured was Rs.3,00,000/- (Rupees Three Lakh) and a sum of Rs. 75,000/- (Rupees Seventy Five Thousand) was approved as cashless by the respondents vide letter dated 13.01.2013. The complainant applied for reimbursement of the claim on 28.05.2014. Since the total insured amount was of Rs.3,00,000/- (Rupees Three Lakh)  only, the remaining sum of Rs.2,25,000/- (Rupees Two Lakh Twenty Five Thousand) was paid to the complainant on 4.06.2014 vide cheque / UTR no. 1464720191T81W30. Since the full insured amount has been paid to the complainant, nothing is due or payable by the respondents.
12. It was further alleged Respondent no. 3 was only the agent of the insurance company and is only a third party administrator (TPA) licensed by the Insurance Regulatory. Development Authority to act as a facilitator between the ti Insurance Company and the insured / policy holder in return of a processing fee. The respondent no. 3 can process the claims and insurance company i.e. Respondent no. 1 has to make the payment only on the fulfillment of the terms and conditions of the insurance policy. The premium was also charged by the insurance company and is only small amount is paid and as processing fee to the respondent no. 3 and they are not liable to pay the claim.
13. It was also stated that the documents sent by the hospital were for the sum of Rs.75,000/- which was approved by the respondent no. 3 and in the letter dated 13.01.2013, it was specifically mentioned that if the hospitalization expenses exceeded the authorised limit the letter be sent to the respondent no. 3 for additional authorization. But no such letter or request was made by the complainant.
14. It was further alleged the complainant sent documents for reimbursement of the balance claims on 28.05.2014 and a sum of Rs. 2,25,000/- i.e. the balance insured amount as per the policy was paid on 4.06.2014. The original documents were required for reimbursement and the said documents were only filed on 28.05.2014.
15. Complainant filed its evidence by affidavit however OP did not filed his evidence. The complainant has reiterated the contents of his complaint in his affidavit and relied upon the policy.
16. Counsel for OP stated that the entire claim amount stands paid to the complainant and was acknowledged by him. Complainant led evidence in support of his claim but has not filed any documents to substantiate his case.
17. It was submitted by Ld. Counsel for OP No.-1 that complainant admitted in Para 9 of the complaint that OP had made payment of Rs. 2,22,500/- (Rupees Two Lakh Twenty Two Thousand Five Hundred). The same is as under:-

“That the opposite parties were got served the legal notice dated 03.04.2014 by the complainant through his counsel Shri BrijBrij Mohan Bharti, Advocate, where the complainant raised a demand of Rs. 4,25,000/- apart from Rs. 11,000/- towards the legal charges and the Opposite parties after receiving the aforesaid notice dated 03.04.2014 made a contact with the complainant and finally released a sum of rs. 2,25,000/- on 04.06.2014 and assured that in case any further amount would be considered then the complainant would be accordingly informed but till date the complainant has not received any call from the Opposite parties, therefore, by the acts and omissions of the

opposite parties it can be taken that the opposite parties is not ready to accept the genuine claim of the complainant therefore, the opposite parties jointly and severally have rendered themselves for a sum of Rs. 2,11,000/- as per demand made by the complainant through aforesaid notice dated 03.04.2014 along with further accrued interest thereof.”

18. We have heard the Ld. Counsel for parties and perused the record.
19. Complainant has file the present complaint alleging deficiency in service. The onus of proof that there was deficiency in service was on the complainant, after complainant was able to discharge its initial onus the burden would shift on OP.
20.  It has been held by Hon’ble Supreme Court in Indigo Airlines Vs. Kalpana Rani Debbarma and others (2020) 9 SCC 424 that the initial onus to substantiate the factum of deficiency in service committed by the opposite party was primarily on the compliant. The burden of proof would shift on the appellants only after the respondents/complainants had discharged their initial burden in establishing the factum of deficiency in service.”

Thus as complainant did not file documents to substantiate his case, we are of the view that complainant failed to prove that there was deficiency of service on part of OP. the complaint accordingly stands dismissed. No order as to costs. A copy of order be provided/sent to parties free of cost.

A copy of order be uploaded on the website of the Commission.

File be consigned to record room alongwith a copy of the order.

 

 

 

(POONAM CHAUDHRY)

President

 

 

 

        (BARIQ AHMAD)                                                        (ADARSH NAIN) 

​   MEMBER                                                                                             MEMBER