| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No.42 of 05-02-2018 Decided on : 09-09-2022 Shinderpal Kaur aged about 40 years Wd/o Lal Singh S/o Banta Singh R/o 752-A Near Ravidass Dharamshala, Village Balianwala, Tehsil Phul, District Bathinda-151103. ..…..Complainant Versus United India Insurance Co. Ltd., Divisional Office, The Mall, Bathinda through its Divisional Manager. United India Insurance Co. Ltd., Divisional Office, SCO-72, Floor No.2 Phase 9, Mohali-160063, through its Divisional Manager. Punjab Health Systems Corporation, State Institute of Health and Family Welfare Complex Near Civil Hospital, Phase VI, SAS Nagar, Mohali-160056. Through its Incharge/Auth. Person/Secretary. Chief Secretary, Punjab, Govt. of Punjab, Secretariat Punjab, Chandigarh. Reliance General Insurance Co.Ltd., SCO 147/148, 2nd Floor, Madhya Marg, Sector 9C, Chandigarh-160009. Through its Manager/Incharge. The Balianwala Multipurpose Co-operative Society Ltd., Balianwala District Bathinda, through its Secretary.
.......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh. Kanwar Sandeep Singh, President Sh. Paramjeet Kaur, Member. Present For the complainant : Sh.Naresh Garg, Advocate For opposite parties : Sh.Sunder Gupta for OPs No.1 & 2. Sh.Lachhman Kumar for OPs No.3 & 4. Sh.Vinod Garg for OP No.5. Opposite party No.6 ex-parte. ORDER Kanwar Sandeep Singh, President The complainant Shinderpal Kaur (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against United India Insurance Co. Ltd., & others (here-in-after referred to as opposite parties). Briefly stated the case of the complainant is that Lal Singh S/o Banta Singh is duly insured to the tune of Rs. 5 Laks under PA insurance with opposite party Nos.1 to 5 under Bhagat Puran Singh Sehat Bima Yojana (BPSSBY) through opposite party No.6 at village Balianwali. The complainant is nominee-cum-widow and class-I Legal heir of Lal Singh insured. Opposite party Nos.1 and 2 issued the Master Insurance Coverage alongwith opposite party No.5 as opposite party Nos.1 and 2 cover the mediclaim insurance and accidental death is covered by opposite party No.5. Opposite parties issued one card bearing No.9304 6000 2130 3570 3 under 'Bhagat Puran Singh Sehat Bima Yojana (BPSSBY)' to the insured and his family, but no policy or its terms and conditions were ever supplied to the insured or complainant and stated that it is Master Policy and will be kept in their office. Opposite parties allotted toll free No.104 in case of any mis-happening and assured that the total system is online and each and every call will be treated as urgent and total claim will be passed within one month. It is further alleged that Lal Singh @ Lali insured met with road side accident on 27.3.2016 and died on 29.3.2016. DDR No.18 dated 30.3.2016 was duly registered at P.S Sadar Rampura and postmortem of Lal Singh was also conducted at Civil Hospital, Rampura Phul on 30.3.2016. The complainant also spent about Rs.1 lakh on the treatment of Lal Singh at Adesh Hospital. The complainant found the insurance and lodged the claim on toll free No.104. Opposite party Nos.1 to 4 and 6 appointed Mr.Ravi Mani from Chandigarh as an investigator, he visited the village of complainant and took her signatures being nominee on claim form and also obtained the attested copy of PMR, DDR, Original Death Certificate and Medical Bills of Adesh Hospital to the tune of Rs.1 Lakh, photocopy of Aadhar Card and one letter from Nagar Panchayat and other papers etc. with photocopy of card of Bhagat Puran Singh Sehat Bima Yojana (BPSSBY) and assured that the total claim will be paid within 15-20 days. It is further alleged that the complainant recieved one call from Mr.Vinod Kumar, Divisional Manager of opposite party Nos.1 and 2, he disclosed that the insurance under Bhagat Puran Singh Sehat Bima Yojana (BPSSBY) also covered with opposite party No.5 and now she sent the complete file with original papers and investigation report to opposite party No.5 as the medical bill covered with UIIC and death covered with opposite party No.5. It is also alleged that the complainant raised the objection that on card under Bhagat Puran Singh Sehat Bima Yojana (BPSSBY), the name of UIIC mentioned, but opposite parties did not listen and told that it is now insured with RGIC and stated that they are master of the policy. Thereafter more than 20 months elapsed, but opposite parties niether replied nor paid the single penny to the complainant till date. Opposite parties did not disclose the said fact of insurance coverage with UIIC and RGIC on the card of Bhagat Puran Singh Sehat Bima Yojana (BPSSBY) where the name of opposite party Nos.1 and 2 only mentioned on the card and now, illegally sitting on the claim of the complainant whereas complainant lodged the claim with opposite parties through toll free No.104. It is alleged that the complainant many times approached opposite parties and investigator, but they did not listen to her. The complainant also demanded the investigation report and insurance policy and complete papers/details of BPSSBY and the present status of the claim, but to no avail.. It is further alleged that complainant got issued the legal notice through his counsel on 18.1.2018 to the opposite parties, but till date neither any reply has been given by them nor any single penny has been paid. Due to non-payment of claim amount of Rs.5 lakhs on accidental death claim and Rs.1,00,000/- on account of medical bills as per loss to the complainant on account of death of Lal Singh insured, she is suffering heavy damages on account of interest loss @ 18 p.a. with monthly rests from the date of accident 27.3.2016 till payment. On this backdrop of facts, the complainant has prayed for directions to opposite parties to pay the amount of Rs.6,00,000/- alongwith interest @18 p.a. compounding with monthly rests alongwith Rs.1,00,000/- on account of mental agony pains and Rs.50,000/- as litigation expenses or any other additional or alternative relief. Upon notice, opposite party Nos.1 and 2 appeared through their counsel and contested the complaint by filing joint written version. Opposite party Nos.1 and 2 in their written version have raised legal objections that the complaint is not maintainable in its present form. There is no privity of contract between complainant and opposite party Nos.3 and 4 with opposite party Nos.1 and 2 as they entered into an agreement with Govt. of Punjab (Nodel Officer, Punjab Health System Corporation), Mohali to insure Blue Cards holders under BPSSBY Scheme w.e.f. 1.11.2016 to 31.10.2017 only and Lal Singh S/o Banta Sing allegedly met with an accident on 27.3.2016 and died and opposite party Nos.1 and 2 are not liable to pay any compensation to the complainant for the accident and for accidental death that has occurred prior to 1.11.2016. After receipt of intimation regarding the death of Lal Singh, claimant lodged PA claim of her husband on toll free No.104 of Govt. of Punjab. Opposite party Nos.1 and 2 sent the case to Punjab Health System Corporation as per letter dated 20.11.2017. Opposite party Nos.1 and 2 have not received complete file from head office till date, so they reserve their right to file amended reply after receipt of complete record from head office. The complaint is bad for non-joinder of necessary parties as all the legal heirs of deceased Lal Singh have not been impleaded as parties. The complainant has not come to this Forum with clean hands, rather she has intentionally concealed the material facts from this Forum. The complaint is false, frivolous and vexatious to the knowledge of the complainant. As such, it is liable to be dismissed with special costs. On merits, opposite party Nos.1 and 2 have reiterated their stand as taken in the legal objections as detailed above and denied all other averments of complainant and prayed for dismissal of complaint with special costs. Opposite party Nos.3 and 4 filed written version and raised legal objections that they have no relationship with the claim. This complaint is not maintainable in its present form. The complainant does not fall under the definition of 'consumer' as she has not paid any premium for availing any facility under the scheme. The claimant has no pre-existing right to file the claim against opposite party Nos.3 and 4 under 'Act'. She has no cause-of-action or locus-standi to file the claim. This Forum has no jurisdiction to entertain and decide the claim as the complainant does not fall under the definition of 'consumer'. On merits, opposite party Nos.3 and 4 pleaded that if the complainant had any issues or complaint, it should have been brought to their notice, but she never approached them. As per guidelines of Bhagat Puran Singh Sehat Bima Yojana duly farmed by Govt. of Punjab and implemented by State Nodal Agency i.e. Punjab Health Systems Corporation Mohali, if any dispute arises under this scheme, then as per Punjab Govt. Notification No.469-560 dated 2.5.2016 issued by Principal Secretary Health and Family Welfare Punjab, matter was required to be brought before District Grievance Redressal Committee (DGRC). No individual insurance policy was issuable to the complainant as Bhagat Puran Singh Sehat Bima Yojna (BPSSBY) is a mass insurance policy under which a smart card is issued to the beneficiary. It is further pleaded that as per scheme guidelines, patient had to be registered online through Aadhar (UID) server for cashless treatment. If patient (now deceased) Lal Singh alias Lali was admitted at Adesh Hospital, Bathinda on 27.3.2016, he or his kin accompanying him should have produced the smart card of BPSSBY issued to him to the treating hospital within 24 hours of indoor admission that was empanelled hospital under BPSSBY for cashless treatment on the date in question, but no smart card was every presented for cashless treatment purpose before the treating hospital. As such, the complainant has himself/herself violated the guidelines of the scheme. As per the guidelines of the BPSSBY scheme, any reimbursement of expenses incurred on treatment is not payable under this scheme. All other averments of the complainant are denied. In the end, opposite party Nos.3 and 4 have prayed for dismissal of complaint. Opposite party No.5 filed its separate written version and raised the legal objections that the intricate questions of law and facts are involved in the complaint. They require voluminous documents and evidence for determination. It is not possible in the summary procedure under 'Act'. The appropriate remedy, if any, lies only in the civil court. The complainant has concealed the material facts and documents from this Forum and opposite parties. As such, she is not entitled to any relief. She has concealed the fact that the insured died on 29.3.2016 due to road accident occurred on 27.3.2016, but till date no claim has been lodged with the opposite party No.5. The policy expired on 31.10.2016. The benefit of insurance under the BPSSBY scheme was given by State of Punjab and as per letter dated 12.1.2017, benefit of accident death and permanent disability claims raised under BPSSBY policy period 2015-2016 could be entertained for claims intimated upto 31.1.2017 only. As such, no claims is payable in this case. The complainant has not impleaded all the legal heirs of Lal Singh and State of Punjab who are necessary parties. The complainant is not 'consumer' of opposite party No.5. She has no locus-standi or cause-of-action to file the complaint. The complaint is not maintainable in its present form and is liable to be dismissed. On merits, opposite party No.5 has denied all the averments of the complainant and prayed for dismissal of complaint. Opposite party No.6 filed its separate written version and raised legal objections that the complaint has no locus-standi or cause-of-action to file complaint against it. This complaint is bad for mis-joinder of necessary party. The complaint is not maintainable and opposite party No.6 is not concerned with the facts and circumstances mentioned in the complaint. As such, the complaint is liable to be dismissed. On merits, it is pleaded that no card under BPSSBY was ever issued by opposite party No.6 and there is no policy of insurance of the complainant and his family in the office of opposite party No.6 nor there is any record regarding insurance under BPSSBY with the office of opposite party No.6. The policy did not bear the signature of opposite party No.6. As such, the question of supply of insurance company by opposite party No.6 does not rise as it is not aware of any such insurance policy. Opposite party No.6 did not appoint any Mr.Ravi Mani as an investigator nor facts and circumstances are in anyway related to opposite party No.6. All other averments of the complainant are denied by opposite party No.6. In the end, opposite party No.6 has prayed for dismissal of complaint. After filing written version, none appeared on behalf of opposite party No.6. As such, ex-parte proceedings were taken against it on 9.8.2018. In support of his complainant, the complainant has tendered into evidence affidavit of Shinderpal Kaur dated 6.8.2019 (Ex.C1) and photocopies of documents (Ex.C2 to Ex.C12). In order to rebut the evidence of complainant, opposite party No.1 and 2 tendered into evidence affidavit of Baldev Singh dated 27.11.2019 (Ex.OP1/1) and other documents (Ex.OP1/2 to Ex.OP1/7). Opposite party No.3 and 4 tendered into evidence photocopy of notification, (Ex.OP3/1). Opposite party No.5 tendered into evidence affidavit of Suryadeep Singh Thakur dated 27.11.2019, (Ex.OP5/1) and other documents, (Ex.OP5/2 to Ex.OP5/4). We have heard learned counsel for the parties and gone through the record. Learned counsel for the parties have reiterated their stand as taken in their respective pleadings as detailed above. We have given careful consideration to these submissions and gone through the record. Admittedly, deceased Lal Singh, husband of the complainant was duly insured under Bhagat Puran Singh Sehat Bima Yojana (BPSSBY) vide card, (Ex.C2). The complainant is nominee-cum-widow and class-I Legal heir of Lal Singh insured. Insured Lal Singh @ Lali, husband of the complainant met with an accident on 27.3.2016 and died on 28.3.2016. DDR No.18 dated 30.3.2016, (Ex.C3) was duly registered at P.S Sadar Rampura and postmortem of Lal Singh, (Ex.C4) was conducted at Civil Hospital, Rampura Phul on 30.3.2016. The complainant has spent about Rs.1 lakh on the treatment of Lal Singh at Adesh Hospital. Being nominee-cum-widow of Lal Singh, the complainant lodged the claim through “104” toll free number of the government under the scheme and also with opposite party Nos.1 and 2 vide claim form, (Ex.C10). Opposite party Nos.1 and 2 appointed investigator Mr.Ravi Mani, he visited the village of complainant and made report. In his report dated 20.11.2017, (Ex.C9), he has given opinion that 'in view of facts and circumstances, it is clear that Lal Singh has died on 30.3.2016 due to road accident, but he died before the issuance of the policy i.e. (Period of policy 1.11.2016 to 31.10.2017, therefore, the claim is not genuine'. Thus, as per report of investigator, period of policy with opposite party Nos.1 and 2 was from 1.11.2016 to 31.10.2017 and as per death certificate, (Ex.C5), husband of the complainant Lal Singh had died on 28.3.2016. Therefore, opposite party Nos.1 and 2 are not liable to pay any claim to the complainant as death of her husband did not occur during policy period. As per notification, (Ex.OP3/1), opposite party Nos.1 and 2 cover the health insurance and accidental death covered by opposite party No.5 to the tune of Rs.5 lakhs. Thus as per this document, opposite party No.5 was liable to process the claim of the complainant. As per Group Personal Accident Schedule of opposite party No.5, (Ex.OP5/2), the period of insurance was from 1.1.2016 to midnight on 31.10.2016. As husband of the complainant Lal Singh @ Lali insured met with an accident on 27.3.2016 and died on 28.3.2016 i.e during the insurance period, therefore, the claim of the complainant covers under this policy against opposite party No.5. Suryadeep Singh Thakur, Authorized Signatory of opposite party No.5 in his affidavit, (Ex.OP5/1) has pleaded that no claim has been lodged with opposite party No.5. Perusal of the scheme card, (Ex.C8) reveals that the claim was to be lodged on toll free No.104 and further perusal of document, (Ex.C12) reply to RTI application by opposite party No.2 reveals that the applicant has lodged PA claim of her husband under BPSSBY Scheme of the Government of Punjab through “104” toll free number of the government under the scheme. Thus, this document proves that the complainant has lodged the claim with opposite party Nos.3 and 4 on toll free No.104 and it was duty of opposite party Nos.3 and 4 to forward the claim of the complainant to concerned insurer i.e. opposite party No.5. Opposite party No.5 has placed on file copy of agreement, (Ex.OP5/3). As per Condition No.7.3(i) and 7.3(iii) of this agreement between opposite party Nos.3 and 5:- “i) The intimation of happening of any accident and/or injury or accidental death is to be given on toll free helpline No.104 within 30 days after the accident and/or inquiry or accidental death. The report regarding intimation received on 104 shall be further forwarded to the insurer on the designated number. iii) Delay in intimation/non-intimation of the even, would not construe a reason for rejection of the claim by the insurance company.” Thus, the document placed on file reply to RTI application, (Ex.C12) proves that the complainant has lodged the claim with opposite party Nos.3 and 4 on toll free No.104 as per terms and conditions of agreement, (Ex.OP5/3) without any delay. Therefore, the complainant is not at fault to lodge the claim with opposite party Nos.3 and 4. The complainant has placed on file one letter, (Ex.C11). It proves that opposite party Nos.1 and 2 have forwarded the claim of the complainant to opposite party No.3 on the plea that P.A claim file does not pertain to them as it pertains to M/s Reliance General Insurance. There is no document placed on file to show that opposite party Nos.3 and 4 did any efforts to get the claim of the complainant lodged with opposite party No.5. Even opposite party No.5 after appearing before this Commission, has neither processed the claim of the complainant nor it get the matter investigated from surveyor if needed (as the claim was already investigated by opposite party Nos.1 and 2) or it has not given any offer to the complainant regarding her claim. Thus, opposite party Nos.3 to 5 are equally liable to pay the claim of the complainant. As discussed above, this Commission is of the considered view that as husband of the complainant had died on 28.3.2016 due to an accident and claim was was lodged by the complainant on toll free helpline No.104. So, it was duty of opposite party Nos.3 and 4 to further forward the claim to opposite party No.5. As such, opposite party Nos.3 to 5 are liable to pay the accidental claim to the complainant as he was covered under Bhagat Puran Singh Sehat Bima Yojana (BPSSBY) with opposite party No.5, but opposite party Nos.3 to 5 have neither given any single penny to the complainant nor processed her claim till date. Thus, there is deficiency in services and unfair trade practice on the part of opposite party Nos.3 to 5. In view of above discussion, this complaint is partly allowed with Rs.10,000/- as cost and compensation against opposite party Nos.3 to 5 and dismissed qua opposite party Nos.1, 2 and 6. Opposite party Nos.3 to 5 are directed to process the claim of the complainant and pay her claim as per policy under Bhagat Puran Singh Sehat Bima Yojana (BPSSBY) after getting complete all formalities, if required by law alongwith interest @ 8% per annum from the date of filing of this complaint i.e. 5.2.2018 till realization. However if the claim is paid by opposite party Nos.3 and 4 then they will have liberty to recover it from opposite party No.5 as per law. The compliance of this order be made by the opposite party Nos.3 to 5 jointly and severally within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.
Announced : 09-09-2022 (Kanwar Sandeep Singh) President (Paramjeet Kaur) Member
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