BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.172 of 2019

      Date of Instt. 17.05.2019

      Date of Decision: 16.11.2022

Manav Batra age 24 years son of Sh. Raj Kumar, resident of House No.112, Basti Nau, Opp. PNB, Jalandhar.

..........Complainant

Versus

1.       The Oriental Insurance Co. Ltd., Divisional Office, Jalandhar, through its Sr. Divisional Manager.

2.       The Oriental Insurance Co. Ltd., B-I-90, Opposite Central Jail,          The Mall, Ferozepur City.

3.       M/s Park Mediclaim TPA Pvt. Ltd. 702, Vikrant Tower,          Rajindera Palace, Delhi, 110008 Through its Manager.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)                                

Present:       Sh. Anuj Mehta, Adv. Counsel for the Complainant.

                   Sh. A. K. Arora, Adv. Counsel for OPs No.1 and 2.

                   OP No.3 exparte.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the OPs proclaimed themselves as one of the best insurance company in their field for providing medical and health insurance to all public in general and the complainant hired the services through his father Raj Kumar from the OPs for the last so many years by obtaining the Health Companion policy for their family, which includes he himself, his father Raj Kumar, mother Rajni and Brother Ashu. The complainant and his father paid a last premium of Rs.15,595/- against the medical policy i.e. Happy Family Floater, vide policy bearing No.233704/48/2016/2215, which is effective from the date 06.02.2016 to 05.02.2017. As per the terms and conditions of the said policy, OPs assured complainant to give all the medical benefits to complainant and her family members upto Rs.5,00,000/-. During the period of above said policy, complainant Manav Batra due to his medical problem/ill-health got admitted in Vedanta Multispecialty Hospital on 12.09.2016 and discharged on 14.09.2016. During that period, complainant was diagnosed by the doctors of the said hospital. The complainant had paid an amount of Rs.20,415/- on his treatment which includes hospital bills, medical bills and other expenses. Thereafter, complainant applied for the reimbursement of the said amount by filing the insurance claim form and handed over the same to the office of OPs alongwith necessary documents as they are liable to pay the said amount to complainant as per the terms and conditions of their policy. At that time their representatives assured complainant to pay the said amount and the same will be reimbursed to them within few days. The OPs No.1 & 2, thereafter further referred the claim of the complainant to OP No.3 i.e. M/s Park Mediclaim TPA Pvt. Ltd. and they also seeks other documents, which were also handed over to them by complainant and the employees of the OP No.3 assured complainant that claim will be passed within few days. Thereafter, the OPs started harassing the complainant for one reason to the other and giving unreasonable excuse to delay the matter and no reasonable answer has been given by them and they harassed the complainant and his family members a lot and till date they have not settled the claim of complainant even after so many visit and reminder of complainant for about last more than one year. The act and conduct of the OPs clearly shows unfair trade practice on their part. Complainant also issued legal notice through his father Raj Kumar to the OP, but no action was taken by them. Earlier father of the complainant Raj Kumar filed a complaint before this Commission but the same was not entertained by the Commission with the observation that the same is to be filed by the complainant himself in his individually capacity as such, the present complaint has been filed. The non-settlement of the claim amount of the claim is without any justification, hence the OPs has shown their negligence in service and unfair trade practice on their part. OPs has also unnecessarily harassed and caused mental agony and financial harassment to complainant, which complainant is entitled to claim damages for such inconvenience and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay a claim amount of Rs.20,415/- alongwith interest @ 18% per annum from the date of filing of the claim form alongwith the damages to the tune of Rs.30,000/- for harassment, mental agony and on account of unfair trade practice on the part of the OPs.

2.                Notice of the complaint was given to the OPs, but despite service OP No.3 failed to appear and ultimately OP No.3 was proceeded against exparte, whereas OPs No.1 and 2 appeared through its counsel and filed written reply and contested the complaint by taking preliminary objections that the Commission has got no jurisdiction to entertain and try the present complaint in view of the fact that the policy of insurance was issued by Ferozepur office of the company, the claim was also lodged at Ferozepur, the claim settling agency of the policy issuing office is at Delhi. OP No.1 which is a Divisional Office of the Company at Jalandhar has nothing to do with the present claim of the complainant. Thus, the complaint is liable to be dismissed. It is further averred that the complaint filed by the complainant is barred by time as                       per the provisions of Consumer Protection Act, being after a period of more than two years after the settlement of claim by the OPs. It is further averred that there is no deficiency in service or unfair trade practice on the part of the answering OPs and that being so the present complaint is not maintainable. It is further averred that the complainant lodged a claim for the reimbursement of medical expenses of Rs.20,415/- for the treatment taken by him from Vedanta Multispeciality Hospital, Jalandhar from 12.09.2016 to 14.09.2016 with OP No.2 which was sent to OP No.3 for settling as per terms and conditions of policy of insurance. OP No.3, the claim settling agency of OP No.2 wrote letter dated 26.10.2016 to Sh. Raj Kumar S/o Sh. Som Nath, who has lodged the claim and has taken policy of insurance for the benefit of the complainant asking for the reason for delay in submission of the claim documents after 15 days of discharge from the hospital. Thereafter reminder dated 11.11.2016 was sent to said Raj Kumar by OP No.3 to submit the reasons for delayed submission of claim documents within 15 days from the date of letter, but the complainant failed to give any justification or reply to the letter in question. Thereafter, the final reminder cum closure letter dated 09.12.2016 was written by OP No.3 again asking for the reason for delay in non-submission of claim documents after 15 days of discharge from the hospital and vide this letter last opportunity was given to the complainant to supply the desired information within 15 days from the date of this letter and it was mentioned in the said letter that in the event of non-supplying of the desired information within 15 days from the date of this letter the claim file shall be filed as ‘No Claim’. As per condition no. 5.5 of policy of insurance immediate written notice of the claim with particulars relating to policy number, ID Card Number, Name of the Insured Person in respect of whom, the claim is made, nature of disease, illness/injury and name and interest of the attending medical practitioner/hospital Nursing Home etc. should be given to the company/TPA while taking treatment in the hospital/nursing home by fax, e-mail. Such written notice should be given within 48 hrs (Forty Eight Hours) of admission or before discharge from the hospital/nursing home, whichever is earlier unless waived in writing. In the present case, despite the aforesaid letters written by Opposite Party No. 3, the complainant has not given any reason for submission of claim documents after 15 days of discharge from the hospital and as such, the claim file of the complainant was made no claim. Thus, the complainant is estopped by his own act and conduct from filing the present complaint. On merits, the factum with regard to taking health companion policy by the complainant for his family is admitted and it is also admitted that the father of the complainant make the payment of the premium of insurance policy for the period 06.02.2016 to 05.02.2017, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement. 

4.                In order to prove their respective versions, both the parties have produced on the file their respective evidence.

5.                We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.

6.                The case of the complainant is that the complainant purchased one Happy Family Floater Policy bearing No.233704/48/2016/2215 which was valid from 06.02.2016 to 05.02.2017 from the OPs, which is evident from Ex.C-1/Ex.OP1-2/1 and the said policy include the coverage of all kinds of risks of medical expenses of medical treatment of the complainant and her family members upto Rs.5,00,000/-. During the validity of the said policy, the complainant became ill and due to his medical problem/ill-health, he was admitted in Vedanta Multispecialty Hospital on 12.09.2016 and discharged on 14.09.2016 and paid a sum of Rs.20,415/- to the said hospital for medical treatment etc. Copy of bills of expenses incurred by the complainant for getting the medical treatment is Ex.C-3 & Ex.C-9. The complainant lodged the claim of the said amount vide claim form Ex.C-10 and also completed all the necessary formalities, but the OP has not paid the claim amount to the complainant.

7.                The complainant having Happy Family Floater policy is not denied by the OPs. It has also not been denied that the complainant lodged the claim with the OP No.2. The case of the OPs as per submission of the Ld. Counsel for the OPs is that he has referred letters Ex.OP1-2/2 to Ex.OP1-2/4 and as per these letters the OPs have sought only the reason for delay in submission of the claim documents after 15 days of discharge from the hospital. No other document has been sought by the OPs from the complainant. It is the duty of the OPs to settle the claim, even if no reason is given by the complainant for delay in filing the complaint as the delay in filing has nothing to do with the settlement of the claim. The claim is to be settled as per the documents i.e. medical record which includes bills, reports etc. and as per the insurance policy. However, in such circumstances, the complainant is directed to supply the necessary required information/documents, if any, to the OPs, within 15 days from the date of receipt of the copy of the order and then the OPs will settle the claim of the complainant within 15 days from the date of receipt of the necessary documents/information, failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then he is at liberty to file a fresh complaint. Original documents submitted alongwith the complaint be returned to the complainant for onward submission of the same to OPs for the settlement of the claim. Thus, this complaint is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.

8.                Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

16.11.2022         Member                          Member           President