The District Consumer Disputes Redressal Commission-II, U.T. Chandigarh, comprising Amrinder Singh Sidhu, President, and Brij Mohan Sharma, Member, has held Oriental Insurance Company Limited and Raksha Health Insurance TPA Private Limited guilty of deficiency in service and unfair trade practice for closing a genuine mediclaim as “No Claim” despite treatment records being available on record. The Commission, however, dismissed the complaint against Punjab National Bank, finding no deficiency in service on its part.

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The complaint was filed by Subhash Chander Jindal, who maintained a savings bank account with Punjab National Bank. According to the complainant, on the persuasion of bank officials, he purchased a Mediclaim Health Insurance Policy issued by Oriental Insurance Company Ltd. and administered through Raksha Health Insurance TPA Pvt. Ltd. The policy, first taken in 2016, covered the complainant, his wife and children for a sum insured of ₹5,00,000 and was continuously renewed, including for the policy period from 25 January 2019 to 24 January 2020.

During the currency of the policy, the complainant fell ill with dengue on 4 September 2019 and was admitted to Max Hospital, SAS Nagar, Mohali, from 8 September 2019 to 13 September 2019. Despite informing the hospital about his mediclaim coverage, he was denied cashless treatment and was required to deposit ₹10,000 at the time of admission. The complainant ultimately incurred total medical expenses amounting to ₹32,137.25 for his treatment.

The complainant lodged a reimbursement claim on 8 September 2019 and sent a reminder on 12 November 2019. However, the insurer and the TPA issued multiple communications seeking documents and, by letter dated 17 September 2020, closed the claim as “No Claim,” stating that the admissibility of the claim could not be decided due to non-submission of requisite documents. Aggrieved by the closure of his claim despite having undergone treatment during the policy period, the complainant approached the Consumer Commission alleging deficiency in service and unfair trade practice.

Punjab National Bank, arrayed as Opposite Party No.1, contended that it had no role in the issuance, administration, settlement or repudiation of the insurance policy. It submitted that the policy was issued by the insurer and that mere payment of premium through the bank did not create any liability on its part, as there was no privity of contract between the bank and the complainant in respect of the insurance claim.

Opposite Parties Nos.2 to 4, namely Oriental Insurance Company Ltd. and Raksha Health Insurance TPA Pvt. Ltd., admitted issuance of the policy and receipt of the reimbursement claim. They asserted that the claim was closed as “No Claim” only because the complainant allegedly failed to submit the required documents despite repeated reminders, and therefore denied any deficiency in service or unfair trade practice on their part.

After considering the pleadings and evidence, the Commission noted that it was an admitted position that the complainant was duly covered under the mediclaim policy during the relevant period and that his claim had been closed as “No Claim” by the insurer and the TPA. However, the Commission observed that from the insurer’s own letter dated 23 July 2020, it was evident that the complainant had already submitted the claim papers to Raksha Health Insurance TPA Pvt. Ltd. The Commission noted that although the insurer referred to earlier letters allegedly sent by the TPA seeking additional documents, none of those letters were placed on record, warranting an adverse inference against the insurer and the TPA.

The Commission further observed that if the insurer and the TPA were genuinely interested in settling the claim, they could have independently obtained the relevant treatment records from the hospital. It noted that even otherwise, most of the documents, including discharge summary, bills and medical reports, were already part of the record and were in possession of the insurer. In such circumstances, the Commission found no justification for denying a genuine claim of ₹32,137.25.

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Holding that the act of closing the complainant’s claim as “No Claim” amounted to deficiency in service and unfair trade practice, the Commission partly allowed the complaint. Oriental Insurance Company Ltd. and Raksha Health Insurance TPA Pvt. Ltd. were directed to reimburse ₹32,137.25 to the complainant along with interest at 9% per annum from 21 September 2022, the date of institution of the complaint, till realization. They were further directed to pay ₹10,000 as lump-sum compensation towards mental harassment and litigation expenses. The complaint against Punjab National Bank was dismissed, as no deficiency in service was established against it.

Cause Title: Subhash Chander Jindal v. Punjab National Bank and others

Case No: CC/685/2022

Coram: Amrinder Singh Sidhu, President, and Brij Mohan Sharma, Member