First Additional Bench

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB

DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.

First Appeal No.470 of 2014

Date of institution: 21.04.2014.

Date of Decision : 22.12.2016.

Dalip Kumar aged 64 years son of Hazari Lal resident of Village Bodiwala

Pitha, Tehsil & Distt. Fazilka.

Appellant/Complainant.

Versus

United India Insurance Co. Ltd., Branch Thana Road, Abohar, Tehsil

Abohar, Distt. Fazilka through its Branch Manager.

......Respondent/OP.

First Appeal against order dated 24.02.2014

passed

by

District

Consumer

Disputes

Redressal Forum, Ferozepur.

Quorum:-

Shri J.S.Klar, Presiding Judicial Member

Shri Harcharan Singh Guram, Member

Present:-

For the appellant

:

Sh.Sanjeev Goyal, Advocate

For the respondent

:

Sh.Munish Goel, Advocate

Harcharan Singh Guram, Member

This appeal has been preferred by the appellant (the

complainant in the original complaint before District Forum) against

order dated 24.02.2014 passed by the District Consumer Disputes

Redressal Forum, Ferozepur (hereinafter referred as 'the District

Forum') in consumer complaint No.457 dated 23.09.2013, dismissing

the complaint of the complainant. Respondent of this appeal is

opposite party in the original complaint before District Forum,

Ferozepur and they be referred as such hereinafter.

First Appeal No.470 of 2014 2

2.

Brief facts of the case are that the complainant took a

mediclaim insurance policy for himself and his wife Nirmla Devi for a

total insured sum of Rs.5.00 Lacs (Rs.2.75 Lacs for himself and

Rs.2.25 Lacs for his wife). He paid a premium of Rs.14,456/- and the

validity period of insurance was from 29.11.2010 to 28.11.2011. It

was averred in the complaint that during the currency of insurance,

the complainant developed some problem in his vocal card and he

contacted Dr.Rishi of Omni Hospital, Chandigarh. He was examined

and admitted in the hospital on 30.05.2011 at Chandigarh. He

incurred expenses on his treatment to the extent of Rs.36,052/-. He

was discharged from Omni Hospital on 31.05.2011. It was further

pleaded that the insurance policy was renewed by him for last 15

years without any fail. It was further averred that immediately after

getting his discharge card from the hospital, he submitted his claim

with OP. However, claim papers were kept by OP at their end and

after some time, the claim papers were sent to third party

administrator for sanction of claim. Instead of settling the claim,

some queries were raised by TPA, which were replied by insurance

company. TPA raised certain queries on 05.09.2011 and 28.09.2011

addressed to insurance company, whereby the reply was sought from

OP regarding some delay in submission of papers and the OP was

advised to submit a letter of condonation of delay. These letters were

addressed to insurance company and same were not addressed to

him and he was not aware about any query raised by TPA regarding

delay. It was pleaded that it was the insurance company, which was

required to get the delay condoned by way of writing a letter to the

First Appeal No.470 of 2014 3

concerned authorities, as the claimant was regular subscriber of

insurance policy for the last 15 years without any fail. It was averred

that if there was any delay in submission of papers by OP to the third

party administrator, it was between the OP and its authorised agent

to settle the claim and he could be blamed for late submission of the

papers. It was averred that the claim filed by him was not settled in

due time, inspite of the fact that the relevant papers were submitted

by him. As such, he was put to unnecessary harassment for non-

sanctioning of his medical reimbursement bill in time. It was averred

that non-settl