Order-12.

Date-02/06/2016.

This is an application u/s.12 of the C.P. Act, 1986.

           Complainant by filing this complaint has submitted that complainant is a policy holder of OP being No.005677150 dated 20-07-2012 and the premium of the said policy is Rs.35,000/- and policy covers an amount of Rs.75,000/- as sum insured.  Subsequently, as per advice of the agent, complainant purchased another policy being no.005724238 dated 24-08-2012 and premium amount is Rs.35,502-61 covering for 18 years and sum assured is Rs.1,50,000/- and same are being continued.

          In the mean time complainant’s son was seriously ill and complainant submitted bill of Rs.25,485-60 for medical expenses and requested the OP for settlement of the claim.  But OP did not settle the claim then complainant sent letter to the OP but OP did not take any action although OP wrote a letter to the complainant on 30-09-2013 and informed that the claim would be registered on the basis of the documents provided by the complainant to their MD and within 8 weeks complainant shall have to reply.  Again OP sent a letter on 13-05-2014 stating that they examined the policy and due to cancellation of policy refused to pay the legitimate claim of the complainant.

          In the above circumstances, complainant prayed for proper redressal and to dispose the legitimate claim to the complainant to the extent of Rs.25,485-65 and other relief.

          On the other hand OP by filing written statement submitted that fact remains complainant vide his letter dated 04-09-2012 prayed for cancellation of the policy but by letter dated 10-10-2012 the complainant’s such prayer for request of cancellation was waived beyond the freelook period, for which it was not cancelled.

          Admitted position is that complainant filed a claim for the amount as claimed in the compliant and vide letter dated 03-09-2012 complainant was asked to file medical requirement and to submit appropriate documents but no such document is received till date so, claim was not cleared.  So, there was no negligence and deficiency on the part of the OP and most interesting factor is that complainant has not filed all those documents to make payment if that would be filed before the OP authority complainant can get proper settlement.  So, in the above circumstances, OP prayed for dismissal of the case.

Decision with Reasons

On proper consideration of the complaint and the written version and also hearing the argument it is found that complainant submitted a medical claim to the OP but without any medical certificate or document.  So, for want of document practically the claim of the complainant could not be settled.  But fact remains OP sent several reminders to the complainant directing him to submit all the original medical bills, certificates and other reports but complainant did not submit it but even then again OP directed the complainant to submit the same for immediate disposal of the claim but complainant was found silent.  But fact remains again and again complainant sent a letter for payment but in the eye of law as per terms and condition of the policy it is the duty of the complainant insured to submit all original policies, medical certificate etc. but that has not been submitted.

          In the above circumstances, the matter cannot be properly disposed by the OP and considering their conduct it is clear that OP has no fault or negligence on in this regard but only for non-submission of the original medical bills medical certificate prescription etc. complainant’s claim cannot be properly settled and it is now at stalemate condition so, fault is not on the part of the OP for which we are passing such final order.

Hence,

Ordered

That the case be and the same is dismissed on contest against the OP but without any cost. 

          Complainant is directed to submit all the original medical bills, prescription and other relevant documents as required by the OP immediately for disposal of the claim of the complainant and if it is not filed within 45 days within the date of this order in that case invariably complainant shall not get any further claim.

          Complainant is requested to be more cooperative to get his relief and redressal from the OP because OP is ready to dispose of the same but for want of document it is in stalemate condition but that is not the fault of the OP.