Date of Filing: 10.08.2015 Date of Final Order: 11-07-2017
Smt. Runa Ganguly, Member.
The factual matrix of the present case is that the Complainant obtained a Mediclaim Policy from the OP Insurance Company on 12.09.2011. During the subsistence of the said Policy the Complainant admitted in a hospital for a major operation that was covered by the said Policy. The Complainant informed the O.P. and accordingly he was asked to submit a claim with relevant documents. The Complainant submitted his claim to the Office of the O.P. for an amount of Rs.1,15.000/- along with all necessary documents. The OP Insurance Company did not settle the claim even after elapsing so many months on the ground that the policy was not in force. The Complainant used to pay the next two premiums but the O.P. send back the two cheques to the Complainant. The Complainant made several contact with the O.P. to know the reason but to no good. Thus, finding no other alternative, the Complainant filed the present case seeking redress and relief as incorporated in the prayer portion of the Complainant.
Besides, the O.P. Insurance Company by appearing before this Forum contested the case through Ld. Agent.
The OP Insurance Company by filing w/v contending inter-alia that the present case is not maintainable in its present form as well as in law.
The OP admitted that this answering OP issued a Birla Saral Health Plan Policy No.005094283 for the whole life in the name of the present Complainant. This answering O.P. contended that this Forum has no jurisdiction to try the present case as some complex question and allegation of fraud involved in the complaint petition. Thus, the Complainant has better option to go civil court for seeking relief. In this context the O.P. referred some judgement in its W/V.
The further contention of the O.P. is that the cheques in connection with third and fourth premiums were returned to the Complainant as the policy has been lapsed. This O.P. also averred that the O.P regularly apprised the Complainant for renewal of his lapsed policy on payment of certain amount but the Complainant did not pay any amount for revival of the lapsed policy. Thus, this O.P. has no deficiency in service and prayed for dismissal of the present case with cost.
In the light of foregoing discussion, the following moot points came up for discussion to reach final decision:
POINTS FOR CONSIDERATION
- Is the Complainant Consumer as per provision under Section 2(1)(d)(ii) of the C.P. Act, 1986?
- Has this Forum jurisdiction to entertain the instant complaint?
- Has the O.P any deficiency in service by non-settling the claim of the Complainant?
- Whether the Complainant is entitled to get relief/reliefs as prayed for?
DECISION WITH REASONS
We have gone through the record very carefully and perused the documents made available in the record. Perused also the Evidence on Affidavit, BNA filed by the parties and heard the argument at a length advanced by the parties. Peruse also the Insurance Book Let.
Point No.1
The Complainant obtained a Policy from the Opposite Party on payment of certain amount as consideration and hired service of the O.P. Insurance Company. Thus, we have no hesitation to hold that the Complainant is a Consumer as per C.P. Act 1986.
Point No.2
The place of business of the O.P. is situated within this district and the complaint value of the present case is far less than the prescribed limit for which this forum has territorial as well as pecuniary jurisdiction to try the present case.
Further the O.P. has taken plea that this Forum has no jurisdiction to try the present case. In our considered view, there is no such complexity involved in the present case and it can be easily adjudicated in the summary procedure. Thus, this Forum has every jurisdiction to try the present case.
Point No.3 & 4
Both the points are taken up together for sake of convenience and brevity also the points are related with each other.
Undisputedly, the Complainant obtained Saral Health Plan Policy No.005094283 on 12.09.2011 from Birla Sun life Insurance office, Cooch Behar Branch. The annual premium of the said policy was Rs.13,828/-. The benefit term of the policy is 10 years with sum assured of Rs. 10.00.000/-. The point of the dispute is that within the validity of the said Insurance, the Complainant underwent a surgery and he preferred claim for reimbursement of his treatment cost but the OP did not settle the claim even after proper intimation with relevant documents.
It is the case of the Complainant that the Complainant felt ill during the subsistence of the said policy and accordingly went Secendrabad and admitted in Yashoda Hospital for treatment on 31.07.2012.
The Complainant underwent a major operation there and after returning there the Complainant preferred a claim the O.P. in connection with his policy bearing No 005094238 and submitted all the relevant documents but the O.P did not settle the claim of the Complainant.
Evidently, the Complainant admitted in Yashoda Hospital on 31.07.2012 and stayed there up to 02.08.2012. Laparoscopic Deroofing of Right Renal cyst was done under general anaesthesia on 31.07.2012 i. e during the subsistence of the policy.
It is the case of the O.P that the Complainant paid premium on 23.10.2013 and 17.06.2014 but the O.P. returned the said two cheques for Post lapsation of the policy. The O.P. on two occasions asked for reinstate the policy but the Complainant did not pay any heed towards it. Admittedly, the O.P. received the claim of the Complainant against policy No. 005094238.
On a meticulous scrutiny the documents made available in the record we do find that after obtaining the policy on 12.09.2011 by paying Rs.13,828/- the complainant paid three premiums of Rs.13,830/- on 28.09.2012, Rs.13,826/- on 23.10.2013 and Rs.13,826/- on 17.06.2014.
Evidently, the O.P. by their letter dated 13.11.2013 and 03.06.2015 asked the Complainant to reinstate his policy with required amount of Rs.27,654/-. The complainant did not pay the said amount also did not take any step for revival of his policy . It is the further case of the O.P. is that the Complainant also failed to submit relevant documents as required by the O.P. for settlement of the claim.
Evidently, the complainant obtained a Mediclaim Policy from Birla Sun Life on 12.09.2011 and paid Rs.13.828/- the date of deposit the amount is 09.09.2011. It is also evident from the record that the complainant paid 2nd premium on 28.09.2012 of Rs.13,830/-.
The documents filed by the Complainant go to show that the complainant admitted in Yashodha Hospital ( Secendrabad) on 31.07.2012 and discharged from there on 02.08.2012. Operation done on 31.07.2012. Thus, it is very much clear that the Complainant admitted in the Yashodha Hospital when the policy was in force. Thus, he was well eligible to get the treatment cost from the O.P. Company against his Mediclaim Policy bearing No 005094238.
The O.P. in its w/v & BNA and also during the course of argument has taken plea that the policy in question was lapsed for which the O.P. send several reminder to the Complainant for revival of the policy. It is surprising enough to hold “policy not in force” even after payment of premium which was duly received by the O.P. company.
The individual with a desire to get relief in their exigency took the Mediclaim policy but the said desire of the Complainant totally satire due to whimsical decision of the O.P. company. By receiving the premium in due time in no way the O.P. Insurance Company hold that the policy has been lapsed. Further it is very much unfortunate that even after receiving the claim from the Complainant they did not settle the same on the flimsy ground also returned the cheques which the complainant deposited as 3rd & 4th premium on the ground of post lapsation. But the O.P. failed to submit any single scrap of paper to show that the Policy already has been lapsed during the treatment period of the Complainant.
For the sake of argument if we hold that the policy was lapsed in the year 2013 then we have to consider whether the treatment taken by the Complainant within the policy period or not ? It is very much clear from the Discharge Summary of Yashoda Hospital as well the Policy certificate that when the complainant took admission in the Hospital and underwent a major operation i.e. on 31.07.2012, the policy in question was in force.
It is not clear from the documents supplied by the O.P. that on which ground the O.P. hold that the policy of the Complainant has been lapsed.
Be that as it may, on the foregoing discussion and materials to its entirety together with the attitude of the parties and the documents made available in the record it is crystal clear that the Complainant took treatment when the policy was in force. Thus, he is entitled to get claim as per policy condition. The O.P. did not settle the claim on a false and flimsy ground which amounts to deficiency in service. It is settled principal that any insurance claim must be settled within a period of two months. Thus, the deficiency in service of the O.P. cannot be ruled out in any way.
All the points are decided in favour of the Complainant.
Thus, the complaint succeeds.
As per the Policy terms and condition the Complainant is entitled to get Health Insurance Benefit to the tune of Rs. 12,000/- (Rs. 4,000/- for each days per policy year) along with Health and Medical related expenses including medical tests drugs, medicines consultation fees for surgeon etc. a tune of Rs.84039/- as per Bill of Yashoda Hospital.
Hence,
Ordered,
The present case be and the same is allowed on contest but in part with cost of Rs. 5000/- against the O.P.
The O.P. Insurance Company is hereby directed to make payment of Rs.12,000/- as cost of Hospitalization plus Rs. 84039/- along with 10,000/- as compensation for deficiency in service of O.P. for non-settling the claim of the Complainant.
The entire order shall be complied with by the O.P. within 45 days i/d the entire amount shall carry interest @ 8% p.a. till its full realisation.
A plain copy of this order be made available and be sent to each of the parties free of cost by registered post with A/D forthwith as per rules.
Dictated and corrected by me.
