Tamil Nadu

StateCommission

A/206/2019

M/s.National Insurance Co Ltd, Represented by its Manager, City Branch III, 1670, Trichy Raod, Ramanathapuram, Coimbatore 641 001. - Complainant(s)

Versus

1.Thiru.Shravan Bohra at Sarvan kumar Bohra, S/o. Gordhan Lal Bohra, Vakrangee Hard wards, No.56, Mi - Opp.Party(s)

M/s.Nageswaran and Narichania

14 Feb 2023

ORDER

IN THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI

 

BEFORE :       Hon’ble Thiru Justice R. SUBBIAH               PRESIDENT

Thiru R  VENKATESAPERUMAL                   MEMBER

                        

F.A.NO.206/2019

(Against order in CC.NO.190/2016 on the file of the DCDRC, Coimbatore)

 

      DATED THIS THE 14^th DAY OF FEBRUARY 2023

 

M/s. National Insurance Co. Ltd.,

Rep. by its Manager

City Branch – III, 1670, Trichy Road                   M/s.Nageswaran & Narichania

Ramanathapuram                                                        Counsel for

Coimbatore – 641 001                                       Appellant /1^st  Opposite party

 

                                                         Vs.

 

1.       Shravan Bohra @ Sarvan Kumar Bohra

          S/o. Gordhan Lal Bohra

          Vakrangee Hardwards                                    M/s. Paneer Selvam

          No.56, Mill Road,                                              Counsel for

 Coimbatore-641 001                                   Respondent / Complainant

 

2.       M/s. Good Health Plan Limited

          Rep. by its Manager

          21, V.H.Road,                                                    Given up

Coimbatore – 641 001                      2^nd Respondent/ 2^nd Opposite party

 

          The 1^st Respondent as complainant filed a complaint before the District Commission against the opposite parties praying for certain direction. The District Commission had allowed the complaint. Against the said order, this appeal is preferred by the 1^st opposite party praying to set aside the order of the District Commission dt.16.7.2018 in CC.No.190/2016.

 

          This appeal coming before us for hearing finally today, upon hearing the arguments of the counsel appearing for the appellant and the 1^st Respondent and on perusing the documents, lower court records, and the order passed by the District Commission, this commission made the following order in the open court:

 

ORDER

 

JUSTICE R. SUBBIAH,  PRESIDENT  (Open court)

 

 

1.       This appeal has been filed by the appellant/ 1^st opposite party as against the order dt.16.7.2018 in CC.No.190/2016 passed by the District Consumer Disputes Redressal Commission, Coimbatore,  in allowing the complaint in part.   

 

2.       For the sake of convenience, the parties shall be referred as per the rankings before the District Commission.

 

3.       The brief facts which are necessary to decide the appeal is as follows:

           The complainant alongwith his wife Mrs.Usha S.Bohra took a Mediclaim Insurance Policy under No.650201/48/09/8500003465 with the 1^st opposite party on 12.11.2009.  The 2^nd opposite party is the Third Party Agent of the said policy.  The policy period starts from 14.11.2009 to 13.11.2010.  As per the terms and conditions of the policy, the complainant and his family members are entitled to get the reimbursement of the hospital expenses, which they have incurred during the policy period. 

          While so, the complainant’s wife Mrs. Usha S.Bohra was admitted in the GKNM Hospital, Coimbatore on 9.4.2010, for her ill-health, and she was discharged on 20.4.2010.  Even after the discharge from the hospital, she was under continuous treatment for her illness, and she was subsequently admitted in the same hospital two times on 14.5.2010 and 9.6.2010 and was discharged on 19.5.2010 and 14.6.2010 respectively.  Further she was under the constant medical treatment in the same hospital from 28.6.2010 to 5.7.2010.  But unfortunately she passed away on 5.7.2010 at 4.00 a.m in the said hospital.  The complainant had spent more than Rs.350000/- for the treatment of his wife   at the hospital.  The complainant’s native place is Rajasthan.  After the funeral of his wife, he left for Rajasthan to perform the religious rites, and had to necessarily     stay there for several months.  During his wife’s continuous treatment and after her sudden demise, he was put to untold stress.  Thus, he was unable to submit the claim form in time to the opposite party.   The complainant could submit his claim intimation cum requisition  letter to the 2^nd opposite party only on 7.1.2011 and he submitted the claim to the 1^st opposite party on 31.1.2011 for Rs.2,80,460/- by enclosing all the documents.  After nearly two months, the 1^st opposite party gave a reply on 28.4.2011, by rejecting the claim, as it was not made in time as per clause 5.3.  Infact as per clause 5.4 it had a waiver of this condition, which authorises the authorities to consider the claim in extreme cases of hardship, where it is proved to the satisfaction of the company.  Hence he issued a legal notice on 20.7.2011.  Though the 1^st opposite party had admitted the mediclaim policy,  it had given an untenable reply dt.3.8.2011, by repudiating the claim.  The complainant therefore filed a complaint before the District Commission, Coimbatore, vide CC.No.318/2011, which was dismissed on 27.2.2012.  Against the said order, the complainant had preferred an appeal before this commission vide FA.No.295/2012, which was allowed on 8.1.2015, by giving direction to the opposite parties 1 and 2 to reconsider the claim of the complainant in the interest of justice as per policy condition under 5.4 as a special case.  But the 1^st opposite party had abruptly by way of letter dt.19.3.2015 had repudiated the claim again, which is against the observation made by this commission.  Thus alleging negligence on the part of the opposite parties, the complainant filed the present complaint before the District Commission, praying for a direction to the opposite parties to reimburse a sum of Rs.280460/- being the medical expenses incurred by the complainant, alongwith compensation of Rs.1 lakh and cost.

 

4.       By denying the entire averments made in the complaint, the 1^st opposite party had filed their version stating as follows:

          It is the specific defence of the 1^st opposite party that as per policy condition 5.1, 5.3 and 5.4 the complainant had not intimated the opposite party within the stipulated time as per the policy, and had thus violated the policy condition.  Hence he is not entitled to maintain the present complaint.   There was a delay of 9 more months in submitting the claim.  Therefore, there was a clear violation of the policy condition.  The State Commission had directed the opposite party only to reconsider the claim.  Therefore, there was no deficiency of service on their part.   Thus they sought for dismissal of the complaint. 

 

5.       The 2^nd opposite party, remained absent and was set exparte before the District Commission.

 

6.       In order to prove their case, on the side of the complainant 16 documents have been filed, which were marked as Ex.A1 to 16.  There was no document filed on the side of the 1^st opposite party.

7.       The District Commission, after considering the submissions of bothsides, had come to a conclusion that there is deficiency of service on the part of the opposite parties, and thus directed the 1^st and 2^nd opposite parties jointly and severally to pay a sum of Rs.2,80,460/- towards the claim amount, alongwith interest @9% p.a., from the date of 1^st repudiation till realisation, and to pay a nominal compensation of R.5000/- alongwith cost of Rs.5000/-. 

 

8.       When the matter was taken up for consideration, the learned counsel for the Appellant/ 1^st opposite party had submitted that as per policy condition clause 5.4 the claim has to be filed within 30 days from the date of discharge from the hospital.  Whereas, in the instant case there was a delay of 9 months in lodging the claim.  Thus, there is a clear violation of policy condition.  Therefore, the repudiation cannot be find fault with, and hence there is no deficiency in service on their part.  Thus he prayed for setting aside the order passed by the District Commission.

 

9.       We have heard the submissions of bothsides, perused the materials placed on record and the order impugned. 

 

10.     Having considered the submissions made, we are of the opinion that in the version the 1^st opposite party had not denied the claim of the complainant specifically with regard to the bill amount, or the disease or treatment undergone by the complainant’s wife, and her demise, and the only  reason attributed by the 1^st opposite party for repudiating the claim that there was a late submission of the claim form by the complainant. 

 

11.     In this connection the learned counsel for the complainant would submit that due to the sudden demise of the complainant’s wife he was under depression, and he had been to Rajasthan to perform the last rites of his wife  and thereafter stayed there for few months.  Therefore after coming back from Rajasthan he preferred the claim.  Thus, the delay had been caused unintentionally due to unavoidable and under compelling circumstances. 

 

12.     In this connection it is pertinent to see the policy condition clause 5.4, wherein it has been stated as follows:

          5.4:    Claim must be filed within 30 days from the date of discharge from the Hospital.

          “Note:  Waiver of this condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the company that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit”

 

 13.    Inspite of the above provision of waiver, the 1^st opposite party failed to consider the claim of the complainant, though he would contend the reason for the delay was due to the sudden demise of his wife he was forced to stay in Rajasthan. 

          Moreover, as per the order of this commission in FA.No.295/2012 dt.8.1.2015, it was held as follows:

          “Hence we are of the view by considering the facts and circumstances of the case and considering the relevant provision of the policy condition in favour of the insured in the interest of justice to invoke such provision to the benefit of the policy holders/ claimants, we are of the view that this case is deserved to be allowed in order to give direction to the opposite party to consider the claim of the complainant by invoking the condition No.5.4 as per the policy terms and condition as a special case. 

 

14.     In view of the above, we feel that the 1^st opposite party,  had failed to consider the claim of the complainant by virtue of clause 5.4 of the Policy condition, inspite of the direction of this commission to treat it as a special case, especially when there is no denial of the claim for anyother reason except for the delayed submission.  Therefore, we do not find any justification in repudiating the claim, and thus we hold that there is no infirmity in the order of the District Commission in allowing the complaint. 

 

15.     However considering the facts and circumstances of the case, we feel that the interest awarded @9% p.a., on Rs.2,80,460/- shall be  reduced to 6%, which shall be paid from the date of complaint till realisation instead of from the date of 1^st repudiation till realisation.  Since admittedly there was a delay in preferring the claim, we find no justification in awarding compensation, which has to be set aside.  Accordingly a sum of Rs.5000/- with 9% interest awarded as compensation is hereby set aside.  Thus the appeal is partly allowed in favour of the appellant.

 

16.     In the result, the appeal is partly allowed, by modifying the order of the District Commission, Coimbatore in CC.No.190/2016 dt.16.7.2018 as follows:

 

          The 1^st and 2^nd opposite parties are jointly and severally directed to pay a sum of Rs.2,80,460/- alongwith interest @6% p.a., from the date of complaint till date of realisation, alongwith cost of Rs.5000/-. Time for compliance two months from the date of receipt of copy of the order.

          There is no order as to cost in the appeal. 

 

         

 

 

  R VENKATESAPERUMAL                                                             R. SUBBIAH

               MEMBER                                                                               PRESIDENT

 

 

 

 

INDEX : YES / NO

Rsh/d/rsj/ Open court