For the complaint - Mr.Pradip Kumar Kar, Advocate
For the OPs - Miss. Ananya Chatterjee, Advocate
FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER
This is an application u/s.12 of the C.P. Act, 1986. The Complainant being the husband of Smt Purna Ghosal is the holder of a Health Insurance Policy bearing No. 150100/11051/1000345335 – 02 of Apollo Munich Health Insurance Company. The Sum Assured was Rs.3,00,000/- and gross premium is Rs.16,828.63. Smt. Purna Ghosal being one of the beneficiaries of the said policy got admitted to Columbia Asia Hospital on 17.05.2015 with acute low back pain. After investigation it was diagnosed that she had been suffering from acute low back pain with intravertebral Disc Annual tear prolapsed intervertebral disc L4-L5. The admission was made known in writing to the OP Insurance Company by the Complainant vide letter dated 17.05.2015 and OP accordingly issued letter dated 18.05.2015 to the said Hospital. The Complainant submitted expense bill of Rs.57,689/- to the OP on 10.06.2015 and another on 15.9.2015. The claim papers were acknowledged by the OP on 11.6.2015 and subsequently on 24.06.2015 they rejected the claim. The Complainant again sent a G – mail on 15.9.2015 requesting the OP for settlement of the claim. But the Op vide their mail dated 01.10.2015 confirmed the said rejection. Then the Complainant asked them to return the original document submitted to the OP through mail dated 02.10.2015 but those documents have not been returned to the Complainant till date. Then Legal Notice was sent to the OP but reply to the said Notice has also not been received by the Complainant. Being aggrieved by the action of the OP the Complainant has filed the instant case to this Forum for Justice.
The OP Insurance Company has contested the case by filing W/V contending inter alia that the Complaint is harassive, baseless, vague, frivolous and devoid of any merit and ought to be dismissed on such grounds. The OP has stated that the complainant had a health insurance policy since 2012 in the name of Easy Health Group Insurance Policy bearing No. 150100 / 11051/ 1000345335-02 wherein his wife was one of the insured and the sum assured of the said policy was Rs.3,00,000/-.The said policy has been renewing from time to time. On or about 18.05.2015 the OP received the request for cashless facility. The request was however rejected by the OP vide letter dated 19.5.2015 with an observation “ Cashless facility cannot be granted as patient is admitted primarily for Investigation & evaluation only. However, insured can file the claim for reimbursement post completion of the treatment with all medical & financial records. The admissibility of the claim would be decided post review of the documents and policy conditions. Thereafter the OP received a claim for reimbursement of Rs.40,642/- from the complainant for the treatment of his wife in the Columbia Asia Hospital. The said claim was rejected by the OP Insurance Company vide letter dated 30.06.2015 on the ground that “ the Admission is for Investigation and Evaluation of the ailment only as per submitted documents. Hence we regret to inform that your claim is repudiated.” The OP has stated that the reimbursement of claim was denied in accordance with the terms and conditions of the policy. There was neither any deficiency in service nor any act committed by the OP which can be termed as unfair trade practice. The OP has also stated that the claim was denied way in 2015 and the complaint has been filed beyond the limitation period and there is no petition for condonation of delay with the complaint petition. Therefore the complaint is hopelessly barred by limitation.
Point for Determination
On the pleading of both the parties the following points have necessarily come up for determination.
- Whether the Complainant had a valid Insurance Policy.
- Whether the Complaint is barred by limitation.
- Whether the OP have any deficiency in service or there is any indulgences of unfair trade practices on the part of OP.
- Whether the Complainant is entitled for any relief as prayed for.
Decision with Reasons
Point Nos. 1 to 4:-
All the points are taken up together for the sake of convenience and brevity in discussion.
Both parties have tendered their Evidence on Affidavit. They have filed replies to the Questionnaire set forth by their adversaries. They have also submitted their BNAs.
We have travelled over all the documents placed on record.
Facts remain that the Complainant is the holder of a Health Insurance Policy bearing No.150100/11051/1000345335-02 with the OP Insurance Company covering himself, his wife and his daughter since 2012. The sum assured was Rs.3,00,000/-. There is no dispute in the matter of existence and validity of the said Health Insurance Policy in between the parties. The dispute is related to repudiation of the claim lodged by the Complainant on 10.06.2015 for the treatment of his wife Smt. Purna Ghosal in the Columbia Asia Hospital, Salt lake, Kolkata – 700091 by the OP Insurance Company.
Now let us examine the Limitation Period of filing the instant case to this Forum. From the record it stands that the case has been filed with the Forum on 03.05.2018 whereas the cause of action arose on 30.6.2015 i.e. the date of repudiation of the claim by the OP Insurance Company. As such the case has been filed after a period of two years 10 months i.e. after a lapse of 10 months beyond the Limitation Period. While reviewing the Complaint Petition and its Annexure we don’t find any record or any whisper in the matter of Condonation of Delay for filing the instant Complaint Petition. The said point has been agitated by the OP in their Written Version in the following way. “In the present case, the Pre authorization request and claim was denied way in 2015, thus the complaint has been filed beyond the limitation period and their is no petition for condonation of delay with the complaint petition. Therefore, the complaint is hopelessly barred by limitation. Thus the complaint is not maintainable in its present form. It is denied that any prayers as sought for by the complainant can be awarded to the complainant, let alone costs or compensation.” The learned Advocate for the OP has cited the relevant case law of the Hon’ble Supreme Court vide Civil Appeal No.2067 of 2002 decided on 20.3.2009, State Bank of India vs M/S B.S. Agricultural Industries . In the said Judgement the Hon’ble Apex Court has mentioned that Provision as to limitation under Section 24A of the C.P.Act,1986 is mandatory in nature and Consumer Forum is duty bound to determine whether complaint is within limitation period. The expression “shall not admit a complaint “ occurring in Sec.24A is a legislative command to consumer forum to examine on its own whether a complaint is filed within prescribed limitation period. It is also decided that if complaint is barred by time and yet, the complaint is decided on merits, the forum would be committing an illegality and aggrieved party would be entitled to have such order set side.”
Here in this case, there is no application for condonation of delay nor any sufficient cause shown and, therefore the question of condonation of delay in filing the complaint does not arise. Since the complaint is barred by time and liable to be dismissed on that count, it would be unnecessary to examine the other grounds of challenge.
In view of the above, we are of the considered view that the instant case is barred by limitation and we have no scope to consider the other issues.
In the result the Complaint fails.
Hence,
Ordered
That the complaint case be and the same is dismissed on contest against the OPs without any cost.
