BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No. 218 of 2014

Date of Instt. 03.7.2014

Date of Decision :8.12.2014

Sweety Sharma wife of Manoj Sharma son of Kundan Lal Sharma, R/o 160-A, First Floor, Rajiv Gandhi Vihar, Surya Enclave, Backside J.S.Resorts, Chogitti Bye Pass, Jalandhar-144009.

..........Complainant

Versus

1. Apollo Munich Health Insurance Company Limited, Branch Office Ist Floor, Satnam Complex, BMC Chowk, Jalandhar-144001(Punjab) through its Branch Manager.

2. Apollo Munich Health Insurance Company Limited, (Claim Department) Plot No.277, Udyog Vihar, Phase-VII, Gurgaon-122016.

.........Opposite parties

Complaint under section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Present: Sh.KC Malhotra Adv., counsel for complainant.

Sh.Vikas Gupta Adv., counsel for opposite parties.

Order

J.S.Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act 1986, against the opposite parties on the averments that law abiding citizen, insurance minded conscious to the need for health insurance complainant allured by tempting benefits obtained Apollo Munich Health Insurance Optima Restore Floater Mediclaim Insurance Policy for herself and also her husband Manoj Sharma co-insured from opposite party No.1. The medicalim insurance policy schedule Optima Restore Floater was issued in the name of the complainant being policy holder Manoj Sharma, husband of the complainant, as co-insured. The total premium amounting to Rs.8451-72 paise was paid as a consideration. The policy period commenced from 10.4.2012 to 9.4.2013. Policy number allotted is 180200/00021/60000026907 and renewed till 9..4.2014. Above said policy was again renewed on payment of total renewal premium Rs.8451.72 paise effective from 23.4.2014 to 22.4.2015 without any strings and rancor by opposite party No.1 in basic sum assured of Rs.3,00,000/- for each insured. However, both insured have become entitled to sum assured Rs.6,00,000/- each by way of increase of basic sum insured. Manoj Sharma co-insured and husband of the complainant unfortunately on 13.1.2014 was accidentally burnt by fire in the night while performing Lohri festival ceremony to lit fire. The mishap was accidental. He was immediately taken to Kapoor Bone and Children Hospital, Pathankot bye pass chowk, Jalandhar. He remain admitted in hospital from 13.1.2014 to 19.1.2014. On discharge from the hospital the complainant made a claim to opposite parties through opposite party No.1 for amount of Rs.40,570/- for reimbursement of medical expenses incurred for treatment, hospitalization, domiciliary hospitalization and medicine. The complainant also completed and submitted prescribed claim form, bills, receipts and discharge certificate with proper prescription, clinical tests and all the documents submitted are with opposite parties. All formalities and requirements whichever possible were completed and complied with for settlement and payment of mediclaim. Opposite parties instead of setting and paying the mediclaim started piecemeal query, unwarranted, superfluous and frivolous and unrelated to incident of burning by fire. The complainant through several email and mobile calls responded to all the queries and orally explained her woe, difficulty and harassment in not settling the claim. Opposite party No.1 also sent email to higher officials of opposite parties but all efforts and persuasions went in vain. The complainant submitted a certificate dated 11.4.2014 from Dr.Jashneev Kapoor who treated Manoj Sharma as demanded by opposite parties. In this certificate it is categorically confirmed that patient Manoj Sharma had not been earlier treated by Dr.Jashneev Kapoor and he had no past history of diabetes mellitus and hypertension before admission on 13.1.2014 and the same has no nexus with the accidental burn injuries. It is further alleged that opposite parties have not settled the claim of the complainant. On such like averments, the complainant has prayed for directing the opposite parties to pay her Rs.40,570/- on account of medical expenses alongwith interest. She has also claimed compensation and litigation expenses. She has further prayed for directing the opposite parties to enhance basic sum assured to Rs.6 Lacs for each insured.

2. Upon notice, the opposite parties appeared and filed a written reply pleading that on 20.2.2014, the alleged claim form of the complainant's husband Manoj Sharma was received alongwith discharge card, medical documents and medical bills for reimbursement of Rs.22650/- during his hospitalization from 13.1.2014 and DOD 19.1.2014 at Kapoor Bone & Children Hospital, Jalandhar. Upon scrutiny of the documents submitted, certain documents were required to evaluate the admissibility of the claim, hence vide an additional information letter dated 25.2.2014 complainant was asked to provide the following documents:-

3. Although the documents were called from the complainant, to have fair evaluation of the claim, the said claim was also put on investigation through independent third party i.e Sanjiv Aurora who had submitted its report on 28.2.2014. As per the investigator report, it was established that complainant's husband was having history of Diabetes Mellitus and hypertension. It is further pleaded that complainant has submitted some of the documents but has failed to provide the necessary documents and as such they have closed the claim for non submission of documents vide letter dated 14.5.2014 and also been asked to provide the pending documents. They denied other material averments of the complaint.

4. In support of her complaint, learned counsel for the complainant has tendered into evidence affidavits Ex.CA and Ex.CB along with copies of documents Ex.C1 and Ex.C13 and closed her evidence.

5. On the other hand, learned counsel for opposite parties has tendered affidavit Ex.OPA alongwith copies of documents Ex.OP1 to OP12 and closed evidence.

6. We have carefully gone through the record and also heard learned counsel for the parties.

7. The opposite party insurance company has not decided the claim of the complainant on merits so far. It has closed the claim file for want of submission of certain documents by the complainant. Counsel for the complainant during the course of arguments stated at bar that complainant has already submitted the necessary documents to the opposite party insurance company and has also produced the documents during trial of the present complaint and is not to submit any further document but opposite party insurance company has unnecessarily asked for certain documents which has no nexus with claim filed by the complainant. Since the opposite party insurance company has not decided the claim of the complainant one way or another as such we feel that it should be given an opportunity to decide the claim of the complainant on merits within time bound frame.

8. Consequently the present complaint is disposed off with the directions to the opposite parties to decide the claim of the complainant one way or another i.e either to accept it or rejected it, wholly or partly, on the basis of documents already submitted by her and further on the basis of documents produced by her during the trial of the present complaint within 30 days from the date of receipt of copy of this order positively failing which it shall be presumed that the claim of the complainant for Rs.40,570/- has been accepted by the opposite parties in toto. In the circumstances of the case, there shall be no order as to cost. Copies of the order be sent to the parties free of costs under the rules. File be consigned to the record room.

Dated Jyotsna Thatai Jaspal Singh Bhatia

8.12.2014 Member President