BEFORE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD
F.A.No. 233 OF 2011 AGAINST C.C.NO. 166 OF 2007 DISTRICT FORUM NELLORE
Between:
1. Bajaj Allianz General Insurance Co.Ltd.,
rep. by its General Manager
regd.off: GE Plaza, Air Port Road,
Yerwada, Pune-006
2. Bajaj Allianz General Insurance Co.Ltd.,
Rep. by it’s Branch Manager, 20/12/07
1st Floor, Indira Bhavan Road
Opposite to Hotel Chinni International
Nellore-001
3. Bajaj Allianz General Insurance Co.Ltd.,
rep. by its Regional Manager,
Regional Office NO.25/26, Prince Towers
4th Floor, College Road, Nungambakkam
Chennai
Appellant/opposite parties
A N D
1. Dr.M.Harischandra Reddy
S/o late M.Krishna Reddy
aged 61 years, Dental Surgeon
R/o 16/1835, Sreenivasa Agraharam
Nellore
2. M.Neeraja Reddy W/o Dr.Harischandra Reddy
aged 54 years, Home Maker
R/o 16/1835, Sreenivasa Agraharam
Nellore
Respondents/complainants
Counsel for the Appellants Sri N.Mohan Krishna
Counsel for the Respondent Sri Sanathana Bhaarath
QUORUM: SRI R.LAKSHMINARASIMHA RAO, HON’BLE MEMBER
AND
SRI S.BHUJANGA RAO, HON’BLE MEMBER
THURSDAY THE TWENTY SIXTH DAY OF APRIL
TWO THOUSAND TWELVE
Oral Order (As per Sri R.Lakshminarasimha Rao, Hon’ble Member)
***
1. The opposite party insurance company is the appellant. The respondents obtained two Health Insurance Policies from the appellant insurance company for the period from 15.05.2007 to 28.07.2007 and they had been to the USA and there at Richmand City, the first respondent developed radiating pain in spincal chord and Lumbargo bachache and he stated to have consulted Dr. Sujatha who is of Indian origin and paid 100 dollars as consultation fee. As prescribed by the doctor the first respondent said to have purchased the tablets and was relieved of the pain. After returning to India, the respondents said to have handed over the prescription and package to the appellant insurance company. The claim preferred by the respondents had drawn no response from the appellant insurance company.
2. The appellant resisted the claim on the premise that the respondents had not submitted any claim form nor any documents and that the claim was not repudiated as the respondents did not submit the relevant documents.
3. The first respondent in support of their claim filed his affidavit and the documents Exs.A1 to A12 and on behalf of the appellant insurance company, Anwar Basha, Deputy Manager(Legal) has filed his affidavit and the documents Exs.B1 to B3.
4. Points for consideration are
1. Whether the respondents have submitted relevant documents for processing the claim?
2. Whether the appellant rendered deficient service to the respondents?
3. To what relief?
5. POINT No.1 The facts not in dispute are that the respondents obtained two health insurance policies from the appellant insurance company from the period from 15.05.2007 to 28.07.2007 and from 15.05.2007 to 28.7.2007. The first respondent informed the appellant insurance company by way email on 8.09.2007 that he and the second respondent had been to the USA and he suffered from back pain for treatment of which he incurred 100 dollars towards consultation, without bill. The appellant insurance company had sent reply email requesting the respondents to submit the documents.
I respectfully submit that the complainant no.1 informed the opposite party no.3, by way of e-mail on 8.9.2007 stating that he went along with his wife to USA for visit and he had taken the above said policy and he suffered severe back pain and incurred 100 dollors towards consultation without bill. Soon after receipt of the mail the claims department of the OP3 requested the complainant through reply e-mail, to submit the required documents like (1) Emergency room summary (2) Original admission and Discharge card (3) Doctor’s medical report and prescriptions in original (4) Original bills and payment receipts for payments made (5) X-ray report, pathological report, investigation report, (6) Copy of passport, Visa with entry and exist stamp (7) Copy of signed release of medical information from authorizing treatment doctor and medical doctor in India to release medical information of the complainant. But the complainant did not choose to submit all the documents, but filed the present complaint with false allegations. There is no proof that the complainants underwent alleged pain or disease or that the complainants underwent any treatment at USA. The opposite parties are custodians of public money and the claims cannot be settled without required documents. Hence the claim of the complainant was not processed and absolutely there is no deficiency of service or negligence on the part of the opposite parties.
6. The contention of the appellant insurance company is that the claim could not process as the respondents had not submitted the documents sought for. In his affidavit, the deputy manager of the appellant insurance company has stated that the letter addressed to the appellant insurance company by the first respondent and marked ExA11 would support their contention that the first respondent had not filed all the required documents for processing the claim. In his affidavit he has stated that :
I respectfully submit that the complainant filed the copy of the e-mail addressed to OP3 as document No.5 and reply of Miss V.Lavanya of OP3 to the complainant by way of mail dated 8.9.2007 as document no.6. Even the document no.7 filed by the complainants shows that they have submitted the claim form, policy copy, boarding pass, flight tickets, itinery information copy and tablets box. But the required documents as per the mail of Miss Lavanya of Chennai Office were not furnished; hence the claim of the complainant was not processed. There is no proof that the complainant no.1 had suffered severe pain on spinal card or backache as alleged in the complaint.
7. A perusal of the letter of the first respondent would establish the contention of the appellant insurance company that he had not furnished all the required documents for the purpose of processing the claim.
8. The appellant insurance company has denied the backache said to have been suffered by the first respondent at Richmand and the treatment stated to have been administered to him by doctor Sujatha , and the amount claimed by the first respondent. In the circumstances, it is incumbent upon the first respondent to furnish the documents sought for, by the appellant insurance company. Plea taken by the appellant that it did not settle the claim of the Respondent as it did not receive the required documents from them, can be accepted.
9. For the foregoing reasons, we are of the opinion that the deficiency in service on the part of the appellant insurance company can be established only if the appellant fails to repudiate or settle the claim on receiving the relevant documents from the insured. The respondents cannot claim for settlement of the claim only based on the documents furnished by them and not on the basis of the documents required by the insurance company. It is not the case of the respondents that the documents sought for, are irrelevant and the claim can be processed even in absence of the documents required by the Insurance Company. As such we are inclined to send back the complaint and the respondents would be in a position to produce the documents sought for by the appellant insurance company.
10. In the result, the appeal is allowed by setting aside the order of the District Forum. The parties are at liberty to adduce evidence in support of their claim. There shall be no order as to costs
MEMBER
MEMBER
Dt.26.04.2012
KMK*
