STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

                        UNION TERRITORY, CHANDIGARH

Sarabjit Rai Kakkar resident of H.No.7420, Baba Nihal Singh Street, Kot Kapura Road, Muktsar.

….…Appellant/Complainant

V E R S U S

Apollo DKV Health Insurance Co. Ltd., 4^th Floor, Sector 34, Near Mukat Hospital, Chandigarh.

.…..Respondent/Opposite Party  

BEFORE: JUSTICE SHAM SUNDER (RETD.), PRESIDENT

                MRS. NEENA SANDHU, MEMBER

Argued by:   Sh.Sandeep Jasuja, Advocate for the appellant.

                                                _------

MRS. NEENA SANDHU, MEMBER

1.                This appeal is directed against the order dated 16.03.2012, rendered by the District Consumer Disputes Redressal Forum-I, UT, Chandigarh (hereinafter to be called as the District Forum only) vide which it disposed of the complaint filed by the filed by the complainant (now the appellant) as under:-

“11.          As a result of the above discussion, the complainant is directed to supply the copy of hospital registration certificate or number of beds in hospital, discharge summary on proper hospital format, original hospital final bill and all investigation reports done during hospitalization etc. to the OP within a period of one month from the date of order and, thereafter, the OP is directed to settle the claim within a period of two months from the receipt of copy of the order. However, it is made clear that, in case, the complainant is not satisfied with the settlement of the claim, he has a right to approach the Forum again, as per law. No order as to costs. The complaint stands disposed of accordingly”. 

2.                In brief, the facts of the case are that the complainant purchased “Easy Health Insurance (Family Floater Standard) Policy” from Opposite Party on 12.12.2009, which was valid upto midnight of 11.12.2010. As per the terms & conditions of the policy, the complainant and his family members were covered for the sum assured of Rs.3 lacs.  It was stated that the wife of the complainant namely Mrs.Santosh got ill during the subsistence of the said policy and admitted in ICU ward of Aashirwad Hospital, Muktsar. She was discharged on 30.8.2010. The complainant submitted the claim of Rs.22,645/- along with medical record and medical bills with the Opposite Party on 27.9.2010.  It was further stated that the Opposite Party vide letter dated 25.10.2010 repudiated the claim, on the ground, that the complainant submitted the claim after delay. It was further stated that after the receipt of repudiation letter, the complainant made repeated visits and requests to the Opposite Party, to pay the claim of Rs.22,645/- but all in vain.  It was further stated that the Opposite Party was deficient, in rendering service, as also, indulged into unfair trade practice.  When the grievance of the complainant was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the “Act” only), was filed.

3.                In its written reply, the fact with regard to the issuance of the Insurance Policy, in question, was admitted. It was stated that the complainant was required to submit the claim within 10 days of discharge, under Section 7 (h) of the Policy. The wife of the complainant was discharged from the hospital on 30.8.2010, whereas, the claim was lodged on 27.9.2010. Thus, there was a delay of 27 days in lodging the claim with the Opposite Party and, thus, the complainant violated the terms and conditions of the policy. It was further stated that the complainant was provided complete Policy kit, which contained Policy schedule, claim procedure, network hospital list, insured guidebook, insured ID card etc.   It was further stated that despite repudiation of claim, the complainant requested the TPA to reopen his case and, accordingly, the TPA reviewed the case treating it as an exceptional one. The TPA observed certain discrepancies, in the documents submitted by the complainant, and, as such, the request was made to the complainant vide its letter dated 3.12.2010, Exhibit RW-1/I to submit the following documents.

i)              Copy of Hospital Registration Certificate or number of beds in hospital.

ii)             Discharge summary on proper hospital format.

iii)            Original Hospital final bill.

iv)            All investigation reports done during hospitalization.

It was further stated that despite receipt of the above said letter, the complainant neither replied to the same nor submitted the aforesaid documents. The TPA again sent reminders vide its letter dated 17.12.2010 (Exhibit RW-1/J) and 5.1.2011 (Exhibit RW-1/K) to the complainant but he neither replied the same nor submitted the required documents. Ultimately, the claim was closed vide its letter dated 20.1.2011 – Exhibit RW-1/L. It was further stated that, the Opposite Party was neither deficient, in rendering service nor indulged into unfair trade practice.

4.                The Parties led evidence, in support of their case.

5.                After hearing the Counsel for the parties and, on going through the evidence and record of the case, the District Forum, disposed of the complaint, in the manner, referred to, in the opening para of the instant order. 

6.                Feeling aggrieved, the instant appeal, has been filed by the appellant/complainant.

7.                            We have heard the Counsel for the appellant and, have gone through the evidence and record of the case, carefully. 

8.                The Counsel for the appellant/complainant  submitted that the complainant never received the letters/reminders (Ex.R-1/H to RW-1/K) as alleged by the Opposite Party, whereby, he (complainant) was required to submit the documents, as aforesaid. He further submitted that the respondent failed to produce, on record, any postal receipts/despatch record to show that the same were ever sent to the complainant. He further submitted that the Opposite Party, thus, illegally closed the claim vide letter (Ex.RW/1/L).  He further submitted that the complainant in his rejoinder in the shape of short affidavit, filed before the District Forum, vehemently denied that no such letters/reminders were ever received by him. He further submitted that the District Forum failed to appreciate the evidence, on record, and disposed of the complaint with directions, as aforesaid, without awarding any compensation on account of harassment and mental agony etc. suffered by  the complainant, at the hands of the Opposite Party.  However, we find no force in the contentions of the Counsel for the appellant, because the documents, as required by the Opposite Party were necessary for processing the claim in order to establish the genuineness of the same, and as to whether the amount claimed by the complainant was payable, as per the terms and conditions of the Policy, Otherwise also, according to Clause (h)  of the terms and conditions of the Policy under the heading of Supporting Documentation and Examination (Annexure C-2), the complainant was required to produce all the documents as required by the Opposite Party for processing the claim which he failed to do.   Further, the submission of the Counsel for the appellant that the respondent fabricated the documents (Annexures RW-1/H to  RW-1/K) is not correct. These documents, were produced by the Opposite Party, from its official record. These documents were prepared by the officials of the Opposite Party, in the due discharge of their official duties. These documents, therefore, carry a presumption of correctness, until and unless otherwise proved. This presumption could not be rebutted by the complainant. The District Forum was, thus, right in directing the complainant to supply the documents aforesaid to the Opposite Party, within a period of one month from the date of order. The District Forum was also correct in directing the Opposite Party to settle the claim within a period of two months from the date of receipt of a copy of the order. The District Forum was further right, in holding that, in case, the complainant was not satisfied with the settlement of his claim, he had a right to approach the Forum again, as per law. Taking all these facts into consideration, we are of the considered view, that the order of the District Forum, being legal and valid, is liable to be upheld.

9.                The order, passed by the District Forum, does not suffer from any illegality or perversity, warranting the interference of this Commission.

10.              For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the District Forum is upheld.

11.              Certified Copies of this order be sent to the parties, free of charge.

12.              The file be consigned to Record Room, after completion

Pronounced.                                                                          Sd/-

 13.07.2012                              [JUSTICE SHAM SUNDER[RETD.]

                                                                                 PRESIDENT         

                                                                                                            Sd/-                                  [NEENA SANDHU]

                                                                                                MEMBER

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APPEAL No. 200     of 2012

Dated July 13, 2012.

Argued by:      

Sh.Sandeep Jasuja, Advocate for the applicant-appellant.

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                        Alongwith the appeal, an application for condonation of delay of 48 days, in filing the appeal, has been filed.

                Arguments, on the application for condonation of delay and in the main appeal, heard.

                For the reasons stated, in the application, which is supported by a duly sworn affidavit, the delay aforesaid is condoned.

                Vide our detailed order of the even date recorded separately, the appeal is dismissed, at the preliminary stage, with no order as to costs and the order of the District Forum is upheld as per the directions passed therein.

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