Punjab

Ludhiana

CC/20/259

Naveen Bali - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

M.S.Sethi

16 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:259 dated 21.10.2020.                                                        Date of decision: 16.03.2023.

Naveen Bahl S/o. Om Parkash, R/o.159, Basant City, Pakhowal Road, Near Silver Oak Resort, Village-Dad, Ludhiana, Punjab-142022.                                                                                                           ..…Complainant

                                                Versus

1. United India Insurance Company Limited, UIIC, Corporate Cell, Vulcan Insurance Building, Ground Floor, 77, V.N. Road, Churchgate, Mumbai-400020 through authorized signatory.
2. United India Insurance Company Limited, Regional Office-136, Feroze Gandhi Market, Ludhiana-141001 through authorized signatory.
3.  Raksha Health Insurance TPA Pvt. Ltd., C/o. Escorts Corporate Center, 15/5 Mathura Road, Faridabad, Haryana-121003 through authorized signatory.                                                                                                                                                                              …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. M.S. Sethi, Advocate.

For OPs                         :         Sh. Mandeep Sharma, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant and his family were insured under Group Mediclaim Policy with opposite party No.1 and 2 through Indian Bank’s Association a/c Oriental Bank of Commerce vide policy No.5001002816P110866030 for the period 01.10.2016 to 30.09.2017. The complainant submitted during the policy period, his son Ritesh Bahl was admitted in Dayanand Medical Hospital on 31.08.2017 for the problem of vomiting and acute abdomen pain and was discharged on 11.09.2017. The cashless facility was rejected firstly by opposite party No.3. Thereafter, the complainant lodged the reimbursement claim with opposite party NO.1 and 2 for amount of Rs.1,07,798/- but they approved only sum of Rs.34,528/- on 13.11.2017 which was transferred to the salary account of the complainant on 02.11.2017 and the remaining claim amount of Rs.73,270/- was rejected on the reason that ‘No Active Treatment Given by the doctors during hospitalization’. The complainant submitted that after repudiation of claim amount of Rs.73,270/-, he approached opposite parties on various times through registered letters and emails but they failed to redress his genuine grievance then he filed a complaint with Insurance Ombudsman, Chandigarh vide complaint No.CHD-H-051-1920-0043 dated 20.04.2019 and Ombudsman vide its award dated 24.12.2019 directed the opposite parties to pay the balance admissible claim within 30 days after receipt of copy of award. The opposite parties complied with the order and transferred the balance claim amount of Rs.73,270/- in bank account of complainant on 27.01.2020. The complainant further submitted that as the opposite parties have not paid the entire claim at the first instance due to which he has to pay hospitalization charged from his own pocked and they further caused delay in settlement of claim and failed to pay the full claim for which the complainant has to approach Ombudsman which has caused mental tension, harassment, mental agony and financial loss to the complainant. The complainant claimed that the opposite parties firstly rejected his cashless facility on 31.08.2017 and partially paid Rs.34,528/- out of Rs.1,07,798/- and remaining balance of Rs.73,270/- was paid on 27.01.2020 for which they are liable to pay interest @9% per annum from 13.11.2017 to 27.01.2020 on the amount of Rs.73,270/- and the opposite parties have rendered deficient and negligent services and they are liable to be penalized for adopting unfair trade practice as well. In the end, the opposite parties be directed to pay interest @9% per annum on Rs.73,270/- from 11.09.2017 to 27.01.2020  along with compensation of Rs.50,000/- and litigation cost of Rs.15,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement and assailed the complaint on the ground of mis-joinder of parties, maintainability of complaint and there is no deficiency on the part of the opposite parties. The opposite parties alleged that after receipt of the intimation regarding the claim lodged by the complainant and expenditure incurred by him on treatment of his son Ritesh Behal to the tune of Rs.1,07,798/-, the opposite parties got investigated the claim through opposite party No.3 and after going through the documents, they settled and paid the claim of Rs.34,258/- on 13.11.2017 as per terms and conditions of the policy. The complainant approached Insurance Ombudsman, Chandigarh by alleging that the claim is settled and paid less and also demanded remaining claim amount of Rs.73,270/- who directed the opposite parties to pay the remaining amount of Rs.73,270/- vide order dated 24.12.2019 within 30 days from the receipt of copy of award. The opposite parties further claimed that they complied the order of Insurance Ombudsman, Chandigarh by paying the amount of Rs.73,270/- on 27.01.2020 which was received by the complainant as full and final and now they are not liable to pay any interest as demanded by the complainant.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties submitted that the cashless facility was rejected due to certain reasons as they had to take certain measure in terms of the insurance policy. The complainant is not entitled to any more amount as alleged.  The opposite parties denied any deficiency in service on its part and in the end, prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of claim settlement voucher, Ex. C2 and Ex. C3 are the copies of letters dated 15.01.2018, dated 10.07.2018 written by Oriental Bank of Commerce to the insurance company, Ex. C3A is the copy of complaint moved by the complainant to the Insurance Ombudsman, Ex. C4 is the copy of letter dated 14.03.2019 written by the complainant to Grievance Redressal Officer, Ex. C5 is the copy of email, Ex. C6 is the copy of award of Insurance Ombudsman dated 24.12.2019, Ex. C7 is the copy of in-patient final bill dated 11.09.2017 of DMC hospital and closed the evidence.

4.                On the other hand, the counsel for the opposite parties tendered affidavit Ex. RA of Sh. Ashok Paul, Senior Divisional Manager, United India Insurance Company Limited, Divisional Office No.1, Pakhowal Road, Ludhiana and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statement, affidavit and documents produced on record by both the parties.     

6.                Perusal of the record shows that the son of the complainant Ritesh Bahl was admitted in Ludhiana Mediways Pvt. Ltd. from 14.07.2017 to 16.07.2017 and had taken treatment for acute gastroenteritis and the claim amounting to Rs.12,960/- was paid. Again on his hospitalization from 14.08.2017 to 16.08.2017 in DMC Hospital a cashless claim of Rs.22,019/- was paid to the complainant. However, these facts were not mentioned by the complainant in the complaint and these facts have been extracted from the award passed by the Insurance Ombudsman Ex. C6. Further, a total claim of Rs.1,07,798/- was submitted for the hospitalization but only an amount of Rs.34,528/- was paid on 13.11.2017. The claim of Rs.71,520/- was deducted as opposite parties observed that no active management as patient was kept under observation and evaluated for chronic pain abdomen. Thereafter, it is the complainant who obtained a certificate from the treating doctor and submitted the same on 27.05.2019. He also lodged his grievance with the Insurance Ombudsman and Grievance Redressal Officer of the opposite parties vide Ex. C3 and Ex. C4 respectively. The award was passed on 24.12.2019 whereby the opposite parties were directed to make payment within 30 days after receipt of award copy. It can be gathered from the aforesaid facts and circumstances that it is due to non-submission of certain documents, the claim of Rs.73,270/- was not approved. Then the matter remained pending with the Insurance Ombudsman from 20.04.2019 till 24.12.2019. The compliance of the order of award Ex. C9 was promptly done by the opposite parties. Considering the chronology of events there is no willful or intentional delay on the part of the opposite parties. Grant of interest on the delayed payment is an equitable relief and from the facts and circumstances, no equity arises in favour of the complainant. Hence the complaint of the complainant is dismissed.

7.                As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

8.                Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:16.03.2023.

Gobind Ram.

 

 

Naveen Bahl Vs United India Insurance Co. Ltd.                             CC/20/259

Present:       Sh. M.S. Sethi, Advocate for complainant.

                   Sh. Mandeep Sharma, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:16.03.2023.

Gobind Ram.