Adv.for the complainant – None.
Adv.for the O.P No.1 - None.
Adv.for the O.P.No.2 - Sri A.Sarangi & K.K.Sahu.
Adv.for the O.P.No.3 - Sri P.S.Nanda.
Date of filing of the case- 28.11.2013
Date of order of the case –10.04.2015
JUDGMENT.
Sri P.Samantara,President.
In the matter of an application u/s.12 of the C.P.Act filed by the complainant against the O.Ps alleging deficiency in service.
2. The facts leading to the case is that complainant has obtained one AB AROGYADAAN from Good Health Plan Limited (TPA License No.23) a Group of mediclaim Insurance Policy No. 050400/48/12/41/00000314 for the period 12.10.2012 to 08.06.2013. The family plan ;policy covered the Insured named- Sudhir Kumar Jain, Bimaladevi Jain, Hemaraj Jain and Jyoti Jain.
3. The complainant further averred on dt.29.12.2012 met an road accident and sustained injury. The matter reported with police, the FIR No.216/2012. In consequence admitted to Govt. hospital Kantabanji and in further treatment on advise at Apex Hospital Vishakhapatna, from 30.12.2012 to 17.02.2013.The O.P registered and three claim bearing No.105557, 105524 and 15437.
4. It also stated claims respectively 105557,105524 and 105437 was intimated to be settled respective against Rs 6,592/- ,Rs 40,212/- and Rs 6,278/- totaling to Rs 53,082/- whereas the amount settled by the O.P respectively amounts to Rs 634/-, Rs 25,165/- and Rs 1,422/- after protracted approach, reminder and harassment which is pitiably lower side in settlement and the O.P repeatedly approach for one after one documents which is not necessarily required in aid of the settlement. Thus the case and relied upon E-mail content in print format obtained copy, FIR photo copy, Injury report, Apex Hospital discharge summary, M.L.C document copy, Smart card photocopy, D.L & PAN card copy and affidavit.
5. On notice, the O.P appeared and filed the version in deferred date, in admitting the issuance of policy, the road accident and there of hospitalization at Govt. hospital and subsequently at Apex Hospital,Vizag. It is also contended, no documents as to the fact of accident or police papers have been submitted by the complainant to substantiate his claim as advanced.
6. It is also stated, the petitioner has intimated the hospitalization by email, by Regd. post and also by telephone and the opposite party has registered three nos of claim and allotted the claim. number respectively 10557,105524 and 105437,same contending partly true and partly false. And also averring the insured intimated the admission at Apex Hospital on dated 20.12.2013 over telephone to M/S. GHPL however the necessary documents pertaining to the admission/treatment was reached by the Insurer only on 27.02.2013. But the matter was not intimated within 24 hours to the Insurer and delayed submission of documents made the processing of petitioners claim delayed.
7. Further stated as per contractual obligation, condition of policy, the insurer settles the claims. On the contrary, the complaint is falsely alleging the answering O.P without any basis rather this answering O.P has promptly and timely helped the complainant to settle his claim. All the claims have been settled and the petitioner has also received the same as full and final settlement on the basis of details provided by him. There is absolutely no cause of action for filing of the present complaint petition and it is liable to be rejected with cost. Relied on letter intimation dated 21.07.2014,letters dated 14.03.2014, and 02.06.2014, dt.04.05.2014 and Email copy, AB-Arogyaddan proposal form for account holder, Arogyadaan policy condition, policy certified, true copy and policy agreement copy.
8. Heard the submissions of the complainant and reliable facts leading to evidential proof also the submission of learned advocate on the contending issue and reliance made thereof .Perused the documents at hand and substantive papers in records and written argument as submitted by O.P.
9. We find no contention prevails over the status of consumer, jurisdiction and limitation so the case is maintainable. The grouse of the complainant was on the lower side in settlement and contention in submission document and deferred-ment in settlement.
10. Prima-facie, the claim on settlement amount as lodged is to reimbursed in admission of hospitalization under AB-AROGYADAAN policy.
11. The insured claimed respectively Rs 40.212/- under claim No.105524, Rs 6,592/- under claim No.105524-1, Rs 6,278/- under claim No.105437. But the bill submitted Rs 35,230/- ,Rs 2,392/- and Rs 2,578/- and the approved amount comes to respectively Rs 31,456/-, Rs 792/- and Rs 1,778/- with deductible/disallowed amount @ 20% admissible under appendix section,Sl.No.6 of page No.2 of annexure-1,that clearly express 20% deductible will be applied in all admissible claims.
12. We come across, the dates of admission and discharge with subsequent check up neither is contended nor rejected. Again perusal of the policy condition under head-expenses in respect of the following specified illness will be restricted as detailed below. In respect of all claims -20% deductible will be applied on all admissible claims. Hence the deduction on claimed amount 20% under head co- pay is as per the obligatory terms of the contract and non deviation on the part of the O.P, the computation is as per the standard rules framed under the mediclaim policy and correct to the terms.
13. On the intimation to TPA, it is admitted, the insured has admitted to have received the photo call and later on email and by post, so no delay happened in the part of the petitioner, even the clause-8 claim procedure-head express is that;-
Claim documents shall be submitted by claimants to TPA within 30 days from the date of Hospitalization. TPA shall settle the claim within 7 days from the date of submission of all documents. In the unlikely event of delay beyond one month, no penalty can be charged. In any case, if all the relevant, documents are not submitted within one year of the accident/hospitalization the claim will be treated as “No claim” and closed after sending two reminders.
14. In this case, plausibly, the petitioner had abided the claim procedure as mentioned within the spirit of the agreement but we denounce the delayed plea as argued by the O.P as to have not committed any fault negligence and imperfection with manner of performance is false and misleading, rather they charged with negligence, leading to deficiency in not rendering proper service within time frame.
15. Again clause (ii)- VALID DISCHARGE AGAINST CLAIMS:-
(a) xx xx xx xx
(b)All correspondence, including those related to submission and settlement of claim is to be made between the insurer and the insured.
(c ) xx xx xx
(d) No liability should devolve on the bank on account of non settlement or delayed settlement of claims by insurance company.
16. In the back drop such expression we inclined to say, the insurer can not disown the substantive delay in settlement of the claim being short of valid and cogent reason, for which he is liable to pay under consumer protection Act.
Hence ordered;
We hereby direct O.P No.1 and 3 are jointly and severally to pay a sum of Rs 500/- each consecutively in each case towards harassment and mental agony sustained along with Rs 500/- as litigation expenses incurred within 35 days of this order, failing which the entire amount shall carry interest @ 9% per annum from the date of hospitalization till realization .
(ii) We do not find any negligence on the part of the O.P.2 in the case to affix any liability.
ORDER PRONOUNCED IN OPEN FORUM THIS THE 10TH DAY OF APRIL 2015.
I agree.
( S.Rath) (P.Samantara)
MEMBER. PRESIDENT.
