DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Complaint Case No : 1132/2015
Date of Institution : 30.10.2015
Date of Decision : 24.10.2016
Vipan Singla S/o Sh. Raj Kumar resident of House No. B-XI-985, K.C Road, Street No. 4, Barnala, District Barnala.
…Complainant
Versus
1. The New India Assurance Company Ltd., Near Police Station, Sadar Bazar, Barnala, through its Branch Manager.
2. The New India Assurance Company Ltd., Old Katchery Road, Near Allahabad Bank, Mansa, through its Branch Manager.
…Opposite Parties
Complaint Under Section 12 of Consumer Protection Act, 1986.
Present: Sh. R.K. Singla counsel for the complainant.
Sh. Vinay Kumar Jindal counsel for the opposite parties.
Quorum.-
1. Shri S.K. Goel : President.
2. Sh. Karnail Singh : Member.
3. Ms. Vandna Sidhu : Member.
ORDER
(SHRI S.K. GOEL PRESIDENT):
The complainant namely Vipan Singla has filed the present complaint under Consumer Protection Act, 1986 (hereinafter called as Act) against The New India Assurance Company Ltd., Barnala and The New India Assurance Company Ltd., Mansa (hereinafter called as opposite parties).
2. The facts leading to the present complaint are that the complainant purchased insurance policies named New India Floater Mediclaim Policy from the opposite parties for the period from 21.8.2014 to 20.8.2015 and thereafter from 21.8.2015 to 20.8.2016 for his family and paid the premium. It is averred that the premium was paid at Barnala and policies were received at Barnala. As per the terms and conditions of the policy, the policy holder can claim the amount of bills spent for the treatment for a period of one month prior to the admission to the hospital and a period of two months after the discharge from the hospital.
3. It is further averred that the wife of the complainant named Neena Singla suffered with acute pains on 16.7.2015, as such the complainant approached Dr. Pankaj Khanna at Civil Hospital, Barnala, who thoroughly checked-up his wife and advised some tests, which were conducted by Dr. Grover's Hi-Tech Labs, Barnala. The complainant paid a sum of Rs. 420/- against the fee of the tests. The wife of the complainant did not get any relief. As such on 17.7.2015 the complainant approached Dr. Bobby John of C.M.C & H, Ludhiana and paid a sum of Rs. 500/- as OPD fee. The doctor prescribed some medicines but there was no relief to the wife of the complainant. The said doctor referred the said case to Dr. Ankush Bansal for further management. At that time the complainant paid a sum of Rs. 200/- as OPD fee on 25.7.2015. The said doctor checked the wife of the complainant and prescribed some medicines. It is further averred that again on 29.7.2015 the complainant paid a sum of Rs. 500/- as OPD fee at C.M.C & H, Ludhiana. The wife of the complainant checked by Dr. John Mary and advised some tests. The said tests were conducted on 30.9.2015. In this way, the complainant spent a sum of Rs. 5,630/-. On 5.8.2015 the wife of the complainant was again checked by Dr. Bobby John, Ortho specialist and for the said appointment the complainant paid a sum of Rs. 500/- as OPD fee. The complainant also paid a sum of Rs. 190/- for X-ray fee on the advice of Dr. Bobby John.
4. It is further averred that the wife of the complainant was got admitted by doctors of C.M.C. & H, Ludhiana on 5.8.2015. The complainant immediately informed the opposite parties. The wife of the complainant was discharged on 7.8.2015. During this period, number of tests were conducted, X-ray was taken, medicines were prescribed, MRI was also conducted, Echo etc., were conducted and for the same the complainant paid a sum of Rs. 30,500/- i.e. Rs. 4,980/- as admission fee and Rs. 25,520/- for other above said purposes. The complainant also incurred expenses of Rs. 120/- on medicines. The MRI report was given on 11.8.2015, as such the complainant again paid a sum of Rs. 500/- as OPD fee for the check-up of his wife. The complainant also incurred an expenses of Rs. 598/- for the medicines. The complainant submitted his claim form with the opposite parties to settle the claim alongwith original copies of treatment and expenses. In this way, the complainant incurred expenses to the tune of Rs. 39,975/-. The complainant visited the opposite parties to settle the claim, but all in vain.
5. It is further averred that the wife of the complainant did not get any relief with the treatment given by the doctors of C.M.C. & H Ludhiana. The complainant approached Dr. Naresh Goel a specialist to get the treatment for his wife. The said doctor referred his wife to Dr. Parshant Aggarwal at Ludhiana for further management. The complainant thought to get a specialist treatment from a multi-specialist hospital for his wife, as such on 17.8.2015 the complainant approached Medanta, the Medicity Hospital at Gurgaon. The complainant paid a sum of Rs. 900/- as OPD fee. The doctor of the said hospital thoroughly checked the wife of the complainant and tests and X-ray were conducted. The complainant incurred Rs. 820/- on the tests and Rs. 275/- on X-ray. It is further averred that the doctor of the said hospital told the complainant that it is a rare disease and further tests are required. On 18.8.2015 CT Scan and TB tests were conducted by the said hospital and charged Rs. 5,175/- for CT Scan and Rs. 280/- for TB tests and medicines were given. On 27.8.2015 the complainant again approached the hospital for further management and doctors gone through all the reports and prescribed medicines. The complainant paid a sum of Rs. 1,000/- as OPD fee and Rs. 100/- for the injection and Rs. 150/- for medicines. In this way, the complainant spent Rs. 9,966/-. The complainant immediately lodged his claim with the opposite parties indicating his earlier claim of Rs. 39,975/- and present claim of Rs. 9,966/- totaling Rs. 49,941/-. All the original bills and other requisite documents were submitted with the opposite parties. Thereafter, the complainant visited the office of the opposite parties to settle the claim of the complainant, but they avoided the complainant on one pretext or the other and did not settle the claim. Thus, the act of the opposite parties is not only deficiency in service but also an unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.
To pay Rs. 49,941/- for the expenses incurred for treatment of the wife of the complainant alongwith interest @ 18% per annum from the date of payment till realization.
To pay Rs. 40,000/- on account of mental tension, agony and harassment.
To pay Rs. 6,000/- as litigation expenses.
6. Upon notice of this complaint, the opposite parties appeared and filed joint written version taking preliminary objections interalia on the grounds of maintainability, cause of action and locus-standi to file the present complaint, concealment of material facts, complaint is bad for non-joinder of necessary party, jurisdiction and the complaint is premature because the opposite parties has repudiated the claim of the complainant on 11.1.2016, rather the complainant has filed the present complaint before the decision of claim. On merits, it averred that the complainant and his wife are insured vide policy No. 3606023414280000034, which is valid from 21.8.2014 to 20.8.2015 by New India Floater Medi Claim Policy. The terms and conditions of the policy were immediately supplied to the complainant and the above said policy was issued by the Mansa Branch of the opposite parties. It is denied that the premium was paid by the complainant at Barnala or policies were received at Barnala. It is submitted that the wife of the complainant has taken almost OPD treatment of joint pain and paid all the expenses and charges only for tests, X-ray and prescription fee of doctors and on going through the documents and discharge summary of wife of complainant it is clearly established that admission of the wife of the complainant is only for the purpose of investigation and no active treatment was given to her. It is further averred that the wife of the complainant primarily admitted with complaint of multiple joint pain for 20 days prior to admission and diagnosed with a case of evaluation of joint pain with Rheumatic fever.
7. It is further submitted that the wife of the complainant Neena Singla was admitted on 5.8.2015 and discharged on 7.8.2015 from CMC Ludhiana as per summary produced by the complainant and on going through the discharge summary, it is also established that admission of wife of the complainant is only for the purpose of investigation and no active treatment was given during hospitalization. The wife of the complainant could have been treated on OPD basis. The complainant has intentionally got admitted his wife in hospital just to get the claim by wrong way and means. The treatment and expenses alleged in the complaint does not fall in the terms and conditions of the policy. The complainant just tried to convert the OPD treatment into the hospitalized treatment to get the claim with malafide intention. It is further submitted that the opposite parties sent all the claim documents alongwith claim form submitted by the complainant to Raksha TPA Pvt. Ltd., for the approval of claim, who repudiated the claim of complainant after scrutinization of documents after taking opinion of their expert. The Raksha TPA Pvt. Ltd., intimated the opposite parties on 11.1.2016 that the claim of the complainant has been repudiated as per clause 4.4.11 of terms and conditions. The opposite parties also issued repudiation letter dated 11.1.2016 to the complainant vide which the complainant was informed that his claim has been repudiated. Clause 4.4.11 of terms and conditions is as under:-
“Charges incurred at hospital primarily for diagnosis, X- ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or any illness or injury for which confinement is required at a hospital”
8. It is further submitted that the above mentioned amount is not payable to the complainant as per terms and conditions of the policy. There is violation of terms and conditions of insurance policy. The complainant has not produced insurance policies related to previous years. As per terms and conditions of the policy, the complainant cannot get medi-claim upto four years from taking the policy. It is further submitted that policy in question is issued from Branch Mansa and treatment has taken by the wife of the complainant from Ludhiana and Gurgaon. It is denied that the complainant has paid premium at Barnala and policies were received by the complainant at Barnala, therefore, this Forum has got no territorial jurisdiction to try and decide the present complaint and finally prayed for the dismissal of complaint.
9. In order to prove his case, the complainant tendered in evidence his affidavit Ex.C-1, copy of insurance policy Ex.C-2 & Ex.C-3, copy of claim form Ex.C-4, copy of bill Ex.C-5, copy of survey report Ex.C-6, copy of bill Ex.C-7, copy of treatment report Ex.C-8 & Ex.C-9, copy of bill Ex.C-10, copy of report Ex.C-11, copies of bills Ex.C-12 & Ex.C-13, copy of examination report Ex.C-14, copies of bills Ex.C-15 to Ex.C-18, copy of examination report Ex.C-19 to Ex.C-23, copy of bill Ex.C-24, copies of examination report Ex.C-25 to Ex.C-27, copy of bill Ex.C-28, copy of examination report Ex.C-29, copy of claim form Ex.C-30, copy of request letter Ex.C-31, copy of bill Ex.C-32, copy of examination report Ex.C-33 & Ex.C-34, copy of bills Ex.C-35 & Ex.C-36, copy of report Ex.C-37 to Ex.C-39, copy of bill Ex.C-40, copy of report Ex.C-41, copy of bills Ex.C-42 & Ex.C-43, copy of report Ex.C-44, copy of bill Ex.C-45, copy of report Ex.C-46, copy of report Ex.C-47 & Ex.C-48, copy of report Ex.C-49, copy of letter dated 7.9.2015 Ex.C-50, copy of bank statement Ex.C-51 & Ex.C-52, copy of order dated 27.2.2012 Ex.C-53 and closed the evidence.
10. In order to rebut the case of complainant, the opposite parties tendered in evidence affidavit of M. Dhawan Ex.O.P1, affidavit of Dr. Rakesh Kalra Ex.O.P-2, copy of repudiation letter dated 11.1.2016 Ex.O.P-3, copy of letter dated 11.1.2016 Ex.O.P-4, copy of insurance policy Ex.O.P-5 & Ex.O.P-6, copy of terms and conditions Ex.O.P-7 and closed the evidence.
11. We have heard the Ld. Counsel for the parties and have gone through the record.
12. At the outset the learned counsel for the opposite party has contended that this Forum at Barnala has no territorial jurisdiction. He submitted that the policy in question in which treatment of the wife of the complainant falls i.e. Ex.OP-5 issued from Branch Mansa and treatment was also taken from Ludhiana and Gurgaon. In his support he has cited 2012 (1) CLT-26 Surinder Goyal Versus National Insurance Company Limited, 2010 CTJ-2 (SC) Sonic Surgical Versus National Insurance Company Limited and Tata Motors and others Versus Dharam Singh and Goyal Motors First Appeal No. 187 of 2010 decided on 22.8.2013 by the Hon'ble Punjab State Commission, Chandigarh.
13. On the other hand the learned counsel for the complainant contended that apart from alleged policy Ex.OP-5 another policy Ex.C-2 was issued from Barnala Branch and since the complainant had received the treatment fallen in both the policies, therefore, being a continuous cause of action the Forum at Barnala have the necessary jurisdiction.
14. Now coming to the present case, Ex.C-3/Ex.OP-5 is the insurance policy issued by the opposite parties showing issuing office at Mansa Branch. This policy pertains to the period from 21.8.2014 to 20.8.2015 in favour of Vipan Singla complainant. Ex.C-5 is the OPD slip of the Civil Hospital, Barnala showing the prescription and it is of 16.7.2015. It also shows the chemist bill of Rs. 480/-. Ex.C-6 is the report of the test. Ex.C-7 is the OPD Cash Memo of CMC, Ludhiana showing payment of Rs. 500/- dated 17.7.2015. Ex.C-8 is the OPD slip and Cash memo dated 17.7.2015 of Ludhiana. Again Ex.C-10 is the OPD Cash Memo showing payment of Rs. 500/- dated 29.7.2015. Ex.C-12 to Ex.C-28 are the prescription and medicines slips of Ludhiana showing the date from 22.7.2015 to 11.8.2015. Ex.C-32 to Ex.C-48 are the bill cum receipts, test reports from Medanta Hospital, New Delhi and Gurgaon. The most important document showing the admission of the patient in CMC, Ludhiana as Ex.C-19 which is discharge summary showing that the patient Neena was admitted on 5.8.2015 and was discharged on 7.8.2015. Perusal of the various bills placed on record shows that the same are before 20.8.2015. There is no dispute that the patient was admitted in CMC, Ludhiana and there is nothing on record to show that the patient was admitted at Barnala and has exhibited only OPD slip Ex.C-5 and test report Ex.C-7. It is also on the record that the patient has also got treatment from Medanta Hospital New Delhi and Gurgaon prior to 20.8.2015 i.e expiry of policy Ex.C-3 issued from Mansa Branch.
15. Facing this situation the learned counsel for the complainant contended that with the purchase of the policy Ex.C-2 at Barnala Branch, the continuous cause of action has arisen in favour of the complainant. This argument is untenable.
16. Perusal of the policy Ex.C-2 issued from Barnala Branch shows that it was for the period 21.8.2015 to 20.8.2016 and therefore it can at the most cover the expenses borne by the complainant within the period of the said policy. However, by stretch of any imagination the expenses borne by the complainant for the period pertaining to policy Ex.C-3/Ex.OP-5 cannot be said to be fallen in the policy Ex.C-2 issued at Barnala considering it to be a continuous cause of action.
17. In Surinder Goyal Versus National Insurance Company Limited (Supra) wherein the insurance policy was issued at Faridabad. No cause of action or part of cause of action arose at Bathinda. Mere existence of Branch Office of the opposite party at Bathinda is not sufficient to confer the jurisdiction of the District Consumer Forum Bathinda when no cause of action has accrued at Bathinda.
18. In Sonic Surgical Versus National Insurance Company Limited (Supra) wherein in paras No. 9 and 10 as follows.-
“9. Moreover, even if it had application, in our opinion, that will not help the case of the appellant. Learned counsel for the appellant submitted that the respondent- insurance company has a branch office at Chandigarh and hence under the amended Section 17 (2) the complaint could have been filed in Chandigarh. We regret, we cannot agree with the learned counsel for the appellant. In our opinion, an interpretation has to be give to the amended Section 17 (2) (b) of the Act, which does not lead to an absurd consequence. If the contention of the learned counsel for the appellant is accepted, it will mean that even if a cause of action has arisen in Ambala, then too the complainant can file a claim petition in Tamil Nadu or Guwahati or anywhere in India where a branch office of the insurance company is situated. We cannot agree with this contention. It will lead to absurd consequences and lead to bench hunting. In our opinion, the expression 'branch office' is amended Section 17(2) would mean the branch office where the cause of action has arisen. No doubt this would be departing from the plain and literal words of Section 17 (2) (b) of the Act but such departure is sometimes necessary (as it is in this case) to avoid absurdity.
10. In the present case, since the cause of action arose at Ambala, the State Consumer Disputes Redressal Commission, Haryana alone will have jurisdiction to entertain the complaint.”
19. In Tata Motors and others Versus Dharam Singh (Supra) of our Hon'ble Commission held in para No. 8 as.-
“The car was purchased by the complainant from the dealer at Patiala and the same was got serviced and repaired by him at Ludhiana, Moga and Ferozepur. His main grievance is that the vehicle was suffering from manufacturing defect and as such he is entitled to the replacement thereof and in the alternative to receive the price thereof alongwith amount which he spent on the repairs of the car. If it is so, then it cannot be said that any part of cause of action had arisen at Ludhiana, Moga or Ferozepur.”
20. As a result of the above discussion and in view of the above citations as referred to above we are of the opinion that the complainant has miserably failed to prove the territorial jurisdiction of this Forum to try and decide the present complaint. Therefore, present complaint is ordered to be returned to the complainant against proper receipt with the liberty to present the same in the appropriate Forum, which shall exclude the time spent by the complainant for prosecuting the complaint in this Forum at Barnala while computing the period of limitation for filing the complaint. No order as to costs. Copy of this order be supplied to the parties free of costs. The file be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
24st Day of October 2016
(S.K. Goel)
President
(Karnail Singh)
Member
(Vandna Sidhu)
Member
