BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.186 of 2019

      Date of Instt. 27.05.2019

      Date of Decision: 16.11.2022

Rajni age 46 years wife of Sh. Raj Kumar, resident of House No.112, Basti Nau, Opp. PNB, Jalandhar.

..........Complainant

Versus

1.       The Oriental Insurance Co. Ltd., Divisional Office, Opp. Bus Stand, G. T. Road, Jalandhar, through its Sr. Divisional Manager.

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

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 her husband Raj Kumar from the OPs for the last so many years by obtaining the Health Companion policy for their family, which includes she herself, her husband Raj Kumar (Principal Policy Holder),her sons namely Manav and Ashu. The complainant and her husband 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 became critical ill and due to her medical problem/ill-health, she also got admitted in Vedanta Multispecialty on 10.10.2016 and discharged on 12.10.2016 after her treatment. During that period, complainant was diagnosed by the doctors of the said hospital. The complainant and her family members had paid an amount of Rs.17,970/- on her 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 her 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 through her husband Raj Kumar also issued legal notice to the OP and the same is attached but no action was taken by them. Earlier husband 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 herself in her 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.17,970/- 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.17,970/- for the treatment taken by her from Vedanta Multispeciality Hospital, Jalandhar from 10.10.2016 to 12.10.2016 with OP No.2 on 12.01.2017 vide claim form 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 03.02.2017 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 non compliance of condition of policy of insurance regarding notice of claim, all the policy copies confirming coverage of patient under mediclaim policy prior to 2013, if any and certificate from the attending consultant providing the duration of hypertension, calling upon him to submit the same within a period of 15 days from the date of said letter. Thereafter reminder dated 18.02.2017 was sent to said Raj Kumar by OP No.3 and thereafter final reminder cum closure letter dated 07.03.2017 was written to Sh. Raj Kumar S/o Sh. Som Nath asking for supply of desired information within a period of 15 days 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 the 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 non-submission of claim documents within time as per condition no.5.5 of the policy of insurance and has not supplied the desired information as called for vide the aforesaid letters from the complainant 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 her family is admitted and it is also admitted that the complainant and her husband paid 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 critical/ill and due to her medical problem/ill-health, she was admitted in Vedanta Multispecialty Hospital on 10.10.2016 and discharged on 12.10.2016 and paid a sum of Rs.17,970/- 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-4 & Ex.C-18. The complainant lodged the claim of the said amount vide claim form Ex.C-19 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. The case of the OPs as per submission of the Ld. Counsel for the OPs is that the complainant has been intimated number of times vide separate letters to supply the desired information alongwith documents, but it is the complainant who has not furnished the documents. The complainant was informed that if the information is not supplied, the claim of the complainant shall be considered as ‘no claim’. The Ld. Counsel for the OPs has referred the letters Ex.OP1-2/3 and Ex.OP1-2/5. Perusal of these letters shows that in all the letters, the OPs have demanded documents to process and finalize the claim, but as per these letters, they had suggested to recommend the closure of the file as no claim, but still the claim has not been settled.

8.                The contention of the complainant is that all the documents were supplied to the OP number of times whichever were in their possession. This clearly shows that the claim of the complainant has not been settled. In such circumstances, the complainant is directed to produce the documents, which are required for settling/deciding the claim, 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 on the basis of these documents within 15 days from the date of receipt of the documents, 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.

9.                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