DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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        Sarabjit Rai Kakkar, r/o House No.7420, Bawa Nihal Singh Street, Kotkapura Road, Muktsar-152107.

                                                        …..Complainant

                                V E R S U S

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

                ……Opposite Party

CORAM:   SH.P.D.GOEL                                       PRESIDENT

                SH.RAJINDER SINGH GILL                   MEMBER

DR.(MRS.) MADANJIT KAUR SAHOTA  MEMBER

Argued by:  Sh.Sandeep Jasuja, Counsel for the complainant.

                         Sh.Nitin Thatai, Counsel for OP.           

PER P.D. GOEL, PRESIDENT

1.           Briefly stated, the facts of the case are that the complainant purchased “Easy Health Insurance (Family Floater Standard) Policy” from OP 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 sum assured of Rs.3 lacs.

              It is the case of the complainant that his wife Mrs.Santosh got ill during the subsistence of the said policy. She was admitted in ICU ward of Aashirwad Hospital, Muktsar and was discharged on 30.8.2010. The complainant submitted the claim of Rs.22,645/- along with medical record and medical bills in the office of the OP on 27.9.2010.

              It is the allegation of the complainant that he was surprised to receive a letter dated 25.10.2010 from the OP vide which the claim was repudiated on the ground that the complainant has submitted the claim with delay. After the receipt of the repudiation letter, the complainant made repeated visits and requests to the OP to pay the claim of Rs.22,645/- but all in vain. Hence, this complaint.

2.           OP filed the reply. The preliminary objection with regard to jurisdiction was raised. On merits, it is replied 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 got discharged from the hospital on 30.8.2010, whereas, the claim was lodged on 27.9.2010. Thus, there is a delay of 27 days in lodging of the claim with the OP and in this way, the complainant had violated the terms and conditions of the policy. It is further replied that the complainant was provided complete policy kit, which contains policy schedule, claim procedure, network hospital list, insured guidebook, insured ID card etc. It is further replied that in case the complainant had not received the complete policy, he should have lodged a written protest/objection with the OP regarding non receipt of the policy.

              It is further replied that despite repudiation of alleged 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.

However, despite receipt of the above said letter, the complainant neither replied to the letter nor submitted the aforesaid documents. The TPA again sent a reminder vide its letter dated 17.12.2010 – Exhibit RW-1/J (Page No.56) of the evidence of OP. However, the complainant again neither replied to the said letter nor submitted the above documents. The TPA again sent a reminder dated 5.1.2011 – Exhibit RW-1/K but the complainant again did not reply to the said letter nor submitted the above documents. It is further replied that due to non cooperative attitude of the complainant, the claim was closed vide its letter dated 20.1.2011 – Exhibit RW-1/L (Page No.58). Denying all the material allegations of the complainant and pleading that there has been no deficiency in service on its part and prayer for dismissal of the complaint with costs has been made.  

3.           Parties led evidence in support of their contentions.

4.           We have heard the learned Counsel for the parties and have also perused the record. 

5.           It is an admitted fact that the complainant purchased Easy Health Floater Standard Policy from the OP on 12.12.2009 – Annexure C-1, which was valid upto midnight of 11.12.2010. It is also an admitted fact that the complainant and his family members were covered for sum assured of Rs.3 lacs.

6.           The learned Counsel for the complainant contended that the wife of the complainant Mrs. Santosh got ill during the validity of the said policy. She was admitted in Aashirward Hospital, Muktsar and was discharged on 30.8.2010. The complainant submitted the claim of Rs.22,645/- along with relevant documents but the OP had repudiated the claim on the ground of delay vide repudiation letter dated 25.10.2010 - Annexure C-4.

7.           The learned Counsel for the OP raised the arguments that the complainant is required to submit  the claim within 10 days of discharge of the patient under Section 7 (h) of the policy. As per averments contained in the complaint, the wife of the complainant got discharged from the hospital on 30.8.2010, so there is a delay of 27 days in lodging of the claim with the OP. It was further argued that as the claim was lodged after a delay of 27 days, so the complainant has breached the terms and conditions of the policy and the claim has been rightly repudiated by the OP - Insurance Company. The learned Counsel for the OP lastly argued that the complainant was asked to submit 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 but he failed to submit the same despite of different reminders and ultimately, the case was closed vide its letter dated 20.1.2011 – Exhibit  RW-1/L.

8.           Now, it is proved on record that the OP asked the complainant to submit the documents,  through letters and reminders – Exhibits RW-1/I, RW-1/J & RW-1/K but he failed to submit it and ultimately, the case was closed vide its letter dated 20.1.2011 - Exhibit RW-1/L due to non-submission of requisite documents. It is not the case of the complainant that he had not received the letters and reminders - Exhibits RW-1/I, RW-1/J & RW-1/K of the OP, therefore, the only possible conclusion which can be drawn is that the complainant did not cooperate with the OP as he failed to submit the documents which were required for settlement of the claim. Thus, it is held that the OP has only closed the case and has not finally repudiated it.

9.           The letter dated 20.1.2011- Exhibit RW-1/L is on the record, wherein, it has been specifically recorded that due to non-submission of 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, case has been closed.

10.          Now, it is established on record that the OP could not settle the claim as the complainant did not 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. Therefore, we are of the opinion that the ends of justice would be well served, if direction is given to the complainant to supply the relevant record, which is required for assessment of the loss.

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. 

12.          Certified copies of this order be sent to the parties free of charge. The file be consigned.