DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT, AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/41.

Date of Institution   : 17.01.2018/29.11.2021.

Date of Decision    : 20.07.2022.

Hardish Sandhu wife of Sh. Surinderjit Singh Sandhu resident of 33-E, Ranjit Avenue, Amritsar.    

                …Complainant Versus

New India Assurance Co. Ltd. Lawrence Road, Branch Amritsar through its Manager.    

                 …Opposite Party

 

Complaint Under Section 12 and 13 of the Consumer Protection Act, 1986. 

 

Present: Sh. Pardeep Mahajan Adv counsel for complainant.

Sh. Sanjay Kapoor Adv counsel for opposite party. 

Quorum:-

1. Sh. Ashish Kumar Grover : President

2.Smt. Urmila Kumari : Member

 

(ORDER BY ASHISH KUMAR GROVER, PRESIDENT):

1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant has filed the present complaint Under Section 12 and 13 of the Consumer Protection Act, 1986 against New India Assurance Co. Ltd. (hereinafter referred as opposite party).

2. Brief facts of the case are that the complainant had to travel to England and she took the mediclaim Overseas Policy from the opposite party vide Insurance Policy No. 36050034150900000019 which started from 12.7.2015 to 8.11.2015 for a period of 120 days and as per schedule the complainant was to stay uptill 30.10.2015 in England and was to return on 2.11.2015 but due to the medical problem, she had to stay upto 22.11.2015 as the doctors did not issue the relevant certificate to the complainant for traveling. It is further alleged that the complainant left India on 12.7.2015 and on 30.10.2015, the complainant was seriously unwell and was admitted in Norfolk and Norwich University Hospital Norwich and due to the illness she remained admitted in Hospital. On 7.11.2015 the complainant was discharged but before discharging thorough investigation alongwith chest X-ray was done on 6.11.2015. Thereafter, on 12.11.2015 the Chest C.T. Scan of the complainant was taken as the complainant was unwell and she was again hospitalized on 18.11.2015 for one day and Atypical chest infection was diagnosed and the doctors studied the X-ray done on 6.11.2015 and Specialist respiratory Physician doctor De Silva analyzed both the above said reports and found that the complainant was suffering from Lobar Pneumonia and thereafter the Chest X-ray of the complainant was done on 20.11.2015 and doctor C.F. Ramsay confirmed Pneumonia and Mr. Mark Davies the Chief Executive of the Hospital also gave his report that the complainant spent 8385 pounds for both the admission and for her ailments. Although the policy was upto 8.11.2015, the disease was detected on 30.10.2015 which is well within the period of policy. Thereafter, the matter was brought to the knowledge of the opposite party but the opposite party repudiated the claim on 13.2.2016. After this matter was referred with grievances Cell of opposite party vide representation dated 16.5.2016 but the grievance cell did not apply its mind to the comprehensive issues raised before it but arbitrarily rejected the representation by referring to the earlier rejection vide letter dated 13.2.2016. It is further alleged that thereafter the matter was taken up before Insurance Ombudsman where Ombudsman only allowed the claim for the first admission upto 7.11.2015 regarding 3966 pounds and wrongfully denied the claim of the remaining treatment whereas the doctor's opinion shows that the treatment given after 7.11.2015 was relating to the infection which came to the knowledge of doctors on 30.10.2015. It is further alleged that the complainant was not satisfied with the partial award of the Ombudsman, whereas the complainant is fully entitled to the remaining amount of her treatment after 7.11.2015 as it was well covered with the policy. Due to the above said act and conduct of the opposite party the complainant suffered mental agony and harassment and the same amounts to deficiency in service and unfair trade practice on the part of opposite party. Hence, the present complaint is filed for seeking the following reliefs.- 

i)To pay the remaining amount 4419 Great Britain Pounds (Rs. 3,88,872/-) to the complainant.

ii)To pay Rs. 1,00,000/- as compensation alongwith Rs. 5,000/- as litigation expenses.  

3. Upon notice of this complaint, the opposite party appeared and filed written version by taking preliminary objections interalia on the grounds of complainant has no locus-standi to file present complaint or cause of action, time barred, not come with clean hands etc. It is further alleged that against the repudiation the complainant approached the Insurance Ombudsman and vide award dated 6.7.2017 the insurance ombudsman partly allowed the claim of the complainant on account of her first admission from 30.10.2015 to 7.11.2015 against the bill submitted for GBP 3966 subject to policy terms and conditions including deductible of US$ 100 on each claim. However, reimbursement on account of admission dated 18.11.2015 held to be not payable by the insurance ombudsman as it was held to be beyond the policy period. The complainant has received a sum of Rs. 3,92,640/- towards full and final settlement in respect of the entire claim vide cheque No. 224616 dated 16.8.2017 and the complainant gave consent letter dated 25.7.2017 in this regard and gave unconditional acceptance of the award in full and final settlement in respect of her claim. On merits, the opposite party denied the case of the complainant and prayed for the dismissal of complaint. 

4. In order to prove her case the complainant tendered into evidence her own affidavit Ex.CW1/A alongwith documents Ex.C-1 to C-25 and closed the evidence. 

5. To rebut the case of the complainant the opposite party tendered into evidence affidavit of Sh. S.K. Sharma Divisional Manager Ex.O.P1 alongwith documents Ex.O.P2 to Ex.O.P8 and closed the evidence. 

6. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties. 

7. It is admitted fact between the parties that the complainant took the mediclaim Overseas Policy from the opposite party vide Insurance Policy No. 36050034150900000019 Ex.C-13 & Ex.O.P8 which was valid from 12.7.2015 to 8.11.2015 for a period of 120 days. Ld. Counsel for the complainant argued that the complainant left India on 12.7.2015 and on 30.10.2015, the complainant was seriously unwell and was admitted in Norfolk and Norwich University Hospital Norwich and due to the illness she remained admitted in Hospital and on 7.11.2015 the complainant was discharged but before discharging thorough investigation alongwith chest X-ray was done on 6.11.2015. It is further argued that the complainant was again hospitalized on 18.11.2015 for one day and Atypical chest infection was diagnosed and it was found that the complainant was suffering from Lobar Pneumonia and thereafter the Chest X-ray of the complainant was done on 20.11.2015 and the complainant spent 8385 pounds for her ailments. Ld. Counsel for the complainant further argued that the policy was upto 8.11.2015 but the disease was detected on 30.10.2015 which is well within the period of policy and the matter was brought to the knowledge of the opposite party but the opposite party repudiated the claim on 13.2.2016.

8. On the other hand, Ld. Counsel for opposite party argued that against the repudiation the complainant approached the Insurance Ombudsman and vide award dated 6.7.2017 Ex.O.P2 the Insurance Ombudsman partly allowed the claim of the complainant on account of her first admission from 30.10.2015 to 7.11.2015 against the bill submitted for GBP 3966 subject to policy terms and conditions including deductible of US$ 100 on each claim and reimbursement on account of admission dated 18.11.2015 held to be not payable by the insurance ombudsman as it was held to be beyond the policy period. Ld. Counsel for the opposite party further argued that the complainant has received a sum of Rs. 3,92,640/- towards full and final settlement in respect of the entire claim vide cheque No. 224616 dated 16.8.2017 Ex.O.P6 and the complainant gave consent letter dated 25.7.2017 Ex.O.P3 in this regard and gave unconditional acceptance of the award in full and final settlement in respect of her claim. Ld. Counsel for the opposite party also argued that there is no deficiency in service on its part.

9. From the perusal of the record it is proved that the complainant has herself approached the Insurance Ombudsman against the repudiation of the claim and the Insurance Ombudsman vide its award dated 6.7.2017 partly allowed the claim of the complainant on account of her first admission from 30.10.2015 to 7.11.2015 against the bill submitted for GBP 3966 subject to policy terms and conditions including deductible of US$ 100 on each claim and her complaint. However, Insurance Ombudsman further held that the reimbursement on account of admission dated 18.11.2015 is not payable as the same is 

 

beyond the policy period (as the policy was valid from 12.7.2015 to 8.11.2015 for a period of 120 days). Mr. Ajesh Kumar, The Insurance Ombudsman had decided the matter on 6.7.2017. The complainant has not challenged the orders of Insurance Ombudsman before the Appropriate Court or Authority. The complainant has filed the present complaint on 17.1.2018 i.e. approximately after the period of more than 6 months. The complainant herself opted to file the claim case before the Insurance Ombudsman and the matter has already been decided by the Insurance Ombudsman. Moreover, after agreed from the judgment/award passed by the Insurance Ombudsman, the complainant signed the full and final voucher Ex.O.P6. Even, the complainant has gave her consent letter dated 25.7.2017 Ex.O.P13 vide which it is mentioned that “I hereby give my unconditional acceptance of the Award in full and final settlement in respect of my above complaint”. Therefore, it is established that there is no deficiency in service on the part of opposite party. 

10. In view of the above discussion, the present complaint has no merits and the same is dismissed. However, there is no order as to costs. Copy of the order will be supplied to the parties free of costs by the District Consumer Commission, Amritsar as per rules. 

 

File be sent back to District Consumer Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

       20th Day of July, 2022

 

 

            (Ashish Kumar Grover)

            President             

 

(Urmila Kumari)

Member