State Consumer Disputes Redressal Commission
United India Insurance Co. vs Arun Sharma on 13 September, 2017
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA First Appeal No : 302 of 2017 Date of Institution: 15.03.2017 Date of Decision : 13.09.2017 1. United India Insurance Company Limited through its Deputy Manager (Legal), Regional Office, SCO 123-124, Sector 17-B, Chandigarh. 2. United India Insurance Company Limited having its office at New Colony More, above State Bank of India, Gurgaon. Appellants-Opposite Parties Versus Arun Sharma s/o Sh. Ram Avtar, Resident of House No.K1/166-B, Part-I, New Palam Vihar, Phase-I, Gurgaon. Respondent-Complainant CORAM: Hon'ble Mr. Justice Nawab Singh, President. Mr. Balbir Singh, Judicial Member.
Argued by: Shri B.S. Taunque, Advocate for appellants. Shri Arun Sharma-respondent in person. O R D E R BALBIR SINGH, JUDICIAL MEMBER
This appeal has been preferred against the order dated December 09th, 2016 passed by District Consumer Disputes Redressal Forum, Gurgaon (for short 'the District Forum') in Consumer Complaint No.270 of 2016.
2. Arun Sharma-complainant (respondent herein) was provided Insurance Policy known as 'Family Medicare Policy' bearing No.0412022814P105476113 (Exhibit C-9) by United India Insurance Company Limited (for short 'the Insurance Company')-Opposite Parties regarding the period from October 17th, 2014 up to October 16th, 2015 mentioning the total sum insured as Rs.3.00 lacs. The complainant, on account of acute pancreatitis, was got admitted in East West Medical Centre, 711, Sector-14, Gurgaon for his treatment. The complainant remained admitted in the above mentioned hospital from February 23rd, 2015 to March 08th, 2015 where he was provided treatment by Dr. Hema Kapoor. The complainant spent an amount of Rs.1,75,421/- for his treatment. The complainant was assured by the opposite parties-Insurance Company of cashless benefit to the policy holder stating that he shall not have to make any payment in hospital and the insurance company would bear the treatment expenses. The complainant requested the opposite parties time and again to make payment of an amount of Rs.1,75,421/- spent for his treatment but the opposite parties did not make payment of the amount. In this way, it is a clear case of deficiency in service.
3. The complainant thereafter filed an application before the Insurance Ombudsman but the Insurance Ombudsman also declined the prayer of the complainant vide order dated July 06th, 2015 (Exhibit C-1). However, the complainant was provided an approval of Rs.50,000/- under cashless facility by the third party administrator. It is pleaded that the complainant is also entitled to receive an amount of Rs.50,000/- on account of un-necessary harassment and mental agony. Earlier also, an application was filed by the complainant under Section 22C of The Legal Services Authority Act, 1987 before the Permanent Lok Adalat Public Utility Services and that application was dismissed as withdrawn with liberty to file afresh complaint before the competent authority.
4. The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 with a prayer that the opposite parties be directed to pay an amount of Rs.1,75,421/- spent for his treatment to the complainant with interest at the rate of 12% per annum and to pay an amount of Rs.50,000/- as compensation on account of un-necessary harassment and mental agony.
5. On May 31st, 2016 date fixed before the learned District Forum, the Opposite Parties/Insurance Company did not appear despite service through process serving agency and the opposite parties were proceeded against ex-parte.
6. In his ex-parte evidence, the complainant tendered documents Exhibits C-1 to C-11 and mark C-1 to C-12.
7. After hearing arguments, vide impugned order dated December 09th, 2016 passed by the learned District Forum, complaint filed by the complainant was allowed directing the Opposite Parties-Insurance Company to pay an amount of Rs.1,60,061/- as compensation on account of the amount spent by the complainant for his treatment with interest at the rate of 9% per annum from the date of filing of the complaint till realisation and to pay an amount of Rs.10,000/- as compensation on account of un-necessary harassment and mental agony.
8. Aggrieved with the impugned order dated December 09th, 2016 passed by the learned District Forum, the Insurance Company after receiving copy of the impugned order on December 21st, 2016 filed the present appeal bearing No.302 of 2017 with a prayer to set aside the ex-parte order dated May 31st, 2016 as well as the impugned order dated December 09th, 2016 with a prayer to allow the opposite parties to file written version and lead evidence in this complaint case.
9. As per version of the appellants-opposite parties, the Insurance Company received notice of the complaint issued on May 04th, 2016 on May 05th, 2016 through Smt. Padam Lata, an official working in the office of the Insurance Company. Smt. Padam Lata after receiving the notice forgot to put up the summons received from the District Forum, before the Deputy Manager (Legal) or the Divisional Manager. Due to oversight and casual attitude of the official Smt. Padam Lata, the opposite parties could not appear in the proceedings of the pending consumer complaint on date fixed on May 31st, 2016 and was proceeded against ex-part and after recording evidence, the District Forum passed the impugned order dated December 09th, 2016 and allowed the complaint.
10. It is pleaded that gap in between the date of receipt of the summons and the date fixed for appearance was only 26 days. So, ex-parte order should not have been passed before expiry of the period of 30 days from the date of service. It is prayed that the ex-parte order dated May 31st, 2016 be set aside and the appellant-opposite parties be given opportunity to file written version and lead evidence before the District Forum.
11. We have heard learned counsel for the appellants, the respondent-complainant in person and perused the case file.
12. The claim of the complainant was repudiated vide letter dated June 03rd, 2015 (Annexure A-4) on the basis of investigation as per report of TPA wherein Dr. Sakeel Ahmad has given findings that the complainant was not got admitted at all for his treatment and the insurance policy was purchased to commit fraud by claiming false insurance claim. Report of Dr. Sakeel Ahmad and other documents could not be adduced in evidence as the opposite parties were proceeded against ex-parte. Dr. Sakeel Ahmad has made observations that the complainant claimed compensation second time within a period of six months under this insurance policy and East West Medical Centre, 711, Sector-14, Gurgaon has already been black listed by some other insurance companies. During investigation, the patient was not found present in the hospital and there were only four patients admitted as per IPD register. He talked to treating Dr. Hema Kapoor also. All medicines are shown to have been supplied to the patient from the hospital. Considering TPA report on the basis of investigation by Dr. Sakeel Ahmad, the claim was repudiated by the Insurance Company vide letter dated June 03rd, 2015.
13. Prior to filing of the present complaint, earlier also complainant filed a complaint before the Insurance Ombudsman claiming the same amount spent for his treatment but his that complaint was dismissed by the Insurance Ombudsman vide order dated July 06th, 2015 (Exhibit C-1). Thereafter, the complainant filed an application before the Permanent Lok Adalat/Public Utility Services, Gurgaon also under Section 22C of the Legal Services Authority Act but no relief was granted to the complainant. The application filed before the Permanent Lok Adalat for Public Utility Services, Gurgaon was dismissed as withdrawn with liberty to the applicant to take fresh proceedings before the Civil Court or any other appropriate Forum, vide order dated January 27th, 2016 (Annexure A-7). Remaining pleas taken in the memorandum of appeal need not be mentioned in detail in this order. It is prayed that ex-parte order dated May 31st, 2016 as well as the impugned order dated December 09th, 2016 passed by the learned District Forum be set aside and the opposite parties be given opportunity to file written version and to adduce evidence.
14. It is admitted fact that the summons were issued to the opposite parties during pendency of the complaint before the learned District Forum on May 04th, 2016; summons were received on behalf of the Insurance Company on May 05th, 2016 and that none appeared on behalf of the opposite parties on the date fixed i.e. May 31st, 2016 the day ex-parte order was passed against the opposite parties. The cause of non-appearance of the opposite parties is mentioned that Smt. Padam Lata, an official of the Insurance Company, took summons casually and did not put up the summons before the Deputy Manager (Legal) and Divisional Manager and forgot to do the needful. In support their this version, the opposite parties have placed on the file a duly attested affidavit of Shri Parveen Gupta, Deputy Manager (Legal), dated March 14th, 2017. As per version of the appellants-opposite parties, all it happened due to fault of Smt. Padam Lata but it is strange that neither the duly attested affidavit of Padam Lata nor any such document has been placed on the file to prove that the insurance company has taken any disciplinary action against Padam Lata regarding her this act of carelessness and negligence. Neither Smt. Padam Lata has been examined nor her duly attested affidavit has been tendered in evidence by the opposite parties to prove their version. Record does not show that explanation of Smt. Padam Lata was called by the competent authority on account of her this serious lapse. In this way, it clearly appears that the Insurance Company remained absent from the proceedings of the complaint before the District Forum for such a long period of approximately six months without any sufficient cause and did not appear on the date fixed May 31st, 2016. It appears that Padam Lata is being blamed only to create a ground to get the impugned order dated May 31st, 2016 set aside. It is strange that the insurance company did not appear on the date fixed May 31st, 2016 despite service and appeal was also filed against the impugned order dated May 31st, 2016 and dated December 09th, 2016 on April 07th, 2017 after more than a period of ten months from the date of passing ex-parte order on May 31st, 2016. It appears that the Insurance Company un-necessarily created problems for the complainant. The complainant had to face un-necessary harassment and mental agony as the opposite parties, we can say, intentionally caused delay in making payment of the amount spent by the complainant at the time of her treatment when he remained admitted in hospital.
15. Keeping in mind all the facts and circumstances of this case, we feel such type of clever tactics used by the litigants should not be encouraged more particularly in such type of matters. Keeping in mind all these circumstances, the prayer of the opposite parties-Insurance Company to set aside the impugned order dated May 31st, 2016 is declined and the appeal filed by the opposite parties regarding this plea stands dismissed.
16. During the course of arguments, there was no controversy of any type that the complainant was provided Family Medicare Policy Exhibit C-9 regarding the period from October 17th, 2014 up to October 16th, 2015. It is evident from the order dated July 06th, 2015 (Exhibit C-1) passed by Insurance Ombudsman that prayer of the complainant to make payment of the total amount claimed Rs.1,75,421/- was declined. It is evident from the copy of order dated January 27th, 2016 passed by Permanent Lok Adalat/Public Utility Services, Gurgaon that an application filed by the complainant under Section 22C of The Legal Services Authority Act, 1987 was dismissed as withdrawn with liberty to the applicant to initiate fresh proceedings before the Civil Court or any other appropriate forum.
17. Version of the complainant is that he was got admitted in East West Medical Centre, 711, Sector-14, Gurgaon on February 23rd, 2015 where he was diagnosed as a patient of acute pancreatitis and remained admitted in the above said hospital up to March 08th, 2015. The complainant spent an amount of Rs.1,75,421/- on his treatment. It is evident from the hospital bill mark C-1 that an amount of Rs.1,60,061/- was paid by the complainant during his treatment. The complainant adduced in evidence photo copy of other documents, receipts and hospital bills etc Mark C-1 to C-12. In fact, most of the amount mentioned in these receipts appears to be the same which was mentioned in the hospital bill Mark C-1. Findings given by the learned District Forum that only an amount of Rs.1,60,061/- was spent by the complainant for his treatment when he remained admitted in the hospital, appears to be justified. In document Exhibit C-4, detail is mentioned regarding doctors available in the hospital as well as other infrastructure and other facilities which are available in the hospital. Opposite Parties could not adduce any evidence and even could not file written version to rebut the pleas taken by the complainant in his complaint. The evidence adduced by the complainant referred above is also un-rebutted.
18. The findings and observations made by Dr. Sakeel Ahmad on Heritage Health TPA Private Limited have been placed on the appeal file but the same has not been exhibited in evidence. Dr. Sakeel Ahmad in his report has mentioned that it was the second insurance claim submitted by the complainant during a period of six months under this insurance policy. East West Medical Centre, 711, Sector-14, Gurgaon, has been black listed by some other Insurance Companies and address of the patient given in that insurance policy was different. He could not mention the name of any particular insurance company by whom the East West Medical Centre, Gurgaon, has been declared black listed. For want of any specific plea and evidence, findings cannot be given in favour of the opposite parties-Insurance Company in this regard. Moreover, the observations made by Sakeel Ahmad mentioned in his report, are not supported by documentary evidence. Dr. Sakeel Ahmad also mentioned that he could not receive certain important information from the hospital like Bed number and other documents in connection with treatment of the complainant and Dr. Hema Kapoor could not give proper reply to his questions. In our view on this ground alone also, the claim of the complainant should not be declined. We cannot say that the complainant was not at fault if the hospital authorities failed to provide any particular information to Dr. Sakeel Ahmad. Dr. Sakeel Ahmad should have obtained any such information or document from the complainant. In these circumstances, no weight can be given to the report of Dr. Sakeel Ahmad also.
19. As a result, as per discussions above in detail, awarding of an amount of Rs.1,60,061/- spent on the treatment of the complainant, with interest at the rate of 9% per annum from the date of filing of the complaint as well as awarding of an amount of Rs.10,000/- as compensation on account of un-necessary harassment and mental agony appears to be valid and justified. In view of this, we find no illegality and invalidity in the impugned order dated December 09th, 2016 passed by the learned District Forum. Hence, the appeal fails and is hereby dismissed.
20. The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after expiry of period of appeal/revision, if any.
Announced:
13.09.2017 (Balbir Singh) Judicial Member (Nawab Singh) President CL