DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
MUCHIPARA, BURDWAN.
Consumer Complaint No 98 of 2014
Date of filing: 19.5.2014 Date of disposal: 08.7.2015
Complainant: Tapas Kumar Bera, S/o. Tushar Kanti Bera, resident of Circus Maidan, PO. & PS: Katwa, District: Burdwan, PIN – 713 130.
-V E R S U S-
Opposite Party: 1. The Branch Manager, ICICI Lombard General Insurance Co. Ltd., Burdwan Branch, having its office at 23 City Tower, 2nd Floor, G. T. Road, PO. & PS: Burdwan, PIN – 713 101.
2. ICICI Lombard General Insurance Co. Ltd., ICICI Lombard House, 414 Veer Sabharkar Marg, near Siddhi Binayak Temple, Prabhadevi, Mumbai – 400 025.
Present: Hon’ble President: Sri Asoke Kumar Mandal
Hon’ble Member: Smt. Silpi Majumder
Appeared for the Complainant: Ld. Advocate, Suvro Chakraborty.
Appeared for the Opposite Party (s): Ld. Advocate, Saurav Kumar Mitra.
J U D G E M E N T
This complaint is filed by the complainant u/S. 12 of the C. P. Act, 1986 alleging deficiency in service and unfair trade practice against the Ops as the Ops did not settle his legitimate insurance claim.
The brief fact of the case of the complainant is that he as covered under the risk of an insurance policy relating to medical treatment, which was obtained from the Ops on 26.01.2012 by making payment of Rs. 15,000=00 as premium after filing the proposal form. The name of the said policy was Tax Gain-Health Advantage Plus. The same was issued for treatment expenses of the complainant and his wife. The policy was valid for the period from 26.01.2012 to 25.01.2013. Due to ill luck the complainant on 29.10.2012 at about 10 pm while he was returning by riding his cycle, suddenly he lost his balance and fell down from the cycle and he was dashed by a motor cycle. Due to said incident his right leg got severe injuries. With the help of the local people the complainant was shifted at the chamber of Dr. M.S. Roychowdhury. On 30.10.2012 he again attended the chamber of the said doctor and as per advice of the doctor he got an expert opinion from Dr. Satyabrata Bute at Katwa on 02.11.2012. Thereafter he got the opinion from Dr. Siddhartha Sen, who also treated him and as per his advice he consulted with Dr. Soumya Ghosh relating to his injuries. As per instruction of Dr. Soumya Ghosh he was admitted at Chittaranjan Advanced Medical Referral Institute where his right leg was operated upon by Dr. Ghosh on 04.11.2012 and the complainant got discharge on 06.11.2012. Due to post -operative evaluation he again visited Dr. Ghosh on 18.11.2012 and 18.12.2012. On 30.12.2012 he intimated the Insurance Company regarding his injury and accordingly one claim form was issued by the OP. The complainant filled up the proposal form and submitted the same before the OP at Burdwan. On 04.01.2013 at about 12.49.53 pm he got a message in his mobile that his claim has been registered vide number CL-001475810. In the said message one e-mail number also provided by the OP. Through the mail dated 07.01.2013 the Ops have disclosed the claim number of the complainant being no. 220100215242 and also intimated that the status of the said claim would be updated within 14 working day. Thereafter, several correspondences were made by the complainant with the Ops. Inspite of sending all the documents relating to the treatment of the complainant, the Ops have made allegation of non-furnishing or tendering of the related documents. The complainant gave appropriate reply to such baseless allegations. Lastly, on 29.3.2013 the OP through a mobile message informed that the response of the query has been received by them. But as the claim of the complainant has not been settled by the OP, the complainant visited the office of the OP at Burdwan on several occasions. It is mentioned that after that an amount of Rs. 2, 45,000=00 has been spent for medical expenses. Being a bonafide customer of the Ops neither the complainant nor his wife has ever violated any terms and conditions of the policy. But the Ops did not settle his claim inspite of several reminders and fulfillment of all requirements; on the contrary, they have adopted dilatory tactics for settlement of the genuine claim. Being aggrieved with such action of the Ops the complainant has approached before this ld. Forum by filing this complaint has prayed for direction upon the Ops to pay a sum of Rs. 2, 12,482=00 as mentioned in the schedule for unnecessary delay in settlement of the claim illegally and arbitrarily, interest @18% per annum on the said amount from the date of the accident till realization of the amount.
The complaint has been contested by the Ops by filing conjoint written version wherein it is stated that one insurance policy was issued by the Ops in favour of Ellora Bera by securing the risk of hospitalization and OPD of herself and her husband Tapas Kumar Bera. Along with the policy copy terms and condition were also provided to the complainant. Upon receipt of the intimation from the complainant the claim form was issued in his favour wherein he was asked to submit the same along with required document as mentioned in term no. 6. After receipt of certain documents the claim form was sent to the appropriate department of the Op for verification and settlement. During such verification it was detected that further document was required for settlement of the claim and for that purpose two letters dated 05.11.2012 & 06.11.2012 were sent to CAMRI Hospital but no response has yet been come from that end. Thereafter the Ops issued some letters dated 22.01.2013, 12.02.2013, 19.4.2013 & 06.5.2013 upon the complainant asking for production of the documents. But neither the proposer nor the complainant has made any reply or sent the documents as required. For this reason the claim was repudiated on 23.5.2013 and the same was intimated to the proposer. Therefore there was no deficiency in service, as well as, unfair trade practice on behalf of the Ops rather the complainant with ulterior motive did not produce the said document and filed this complaint before this ld. Forum with a view to gain some money through an illegal manner. As the Op being Insurance Company is under obligation to depend upon the document for settlement of the claim, so until and unless the said document is produced, the claim cannot be decided. There was no carelessness or laches on the part of the OP as it has taken appropriate step for settling the claim but as the complainant and the proposer did not pay any heed to the request of the OP, being compelled the OP had repudiated the insurance claim as the claim cannot stand alive for an unending period as per IRDA guideline. Therefore, as this complaint is false, frivolous and baseless prayer has been made by the Ops for dismissal of the same with exemplary cost.
Parties have filed several documents in support of their respective contention.
We have carefully perused the record and the papers and heard argument advanced by the ld. Counsel for the parties at length. It is seen by us that there are some admitted facts involved in this case i.e. the complainant obtained one mediclaim policy for himself and his spouse, premium amount was paid, the nomenclature of the said policy is Tax Gain-Health Advantage Plus, the policy was valid for the pried form 26.01.2012 to 25.01.2013, during validity of the policy the complainant got injury by a motor cycle while he was returning by his cycle and suddenly lost his balance, fell down on 29.10.2012, he was shifted at the chamber of Dr. M.S. Roychowdhury, thereafter several doctors attended him namely, Dr. S. Bute, Dr. Siddhartha Sen and Dr. Soumya Ghosh, as per instruction of Dr. Ghosh he was admitted at Chittaranjan Advanced Medical Referral Institute, his right leg was operated upon on 04.11.2012, got discharge on 06.11.2012, for post- operative evaluation he visited Dr. Ghosh on 18.11.2012, 18.12.2012, the Insurance Company was intimated by him about his injury on 30.12.2012, claim form lodged along with relevant papers and documents, claim has been registered, several written correspondences was made by the complainant with the OP for settlement of his claim, inspite of submission of entire relevant documents the Insurance Company sought for further documents in original, complainant replied the same, according to the complainant the letter of the Op is vague and baseless, ultimately the claim of the complainant has not been decided till filing of this complaint. The allegation of the complainant is that it is the bounden duty of the Insurance Company to decide a claim within 30 days from the date of his received. As per in the case in hand the Insurance Company has miserably failed to comply with their guidelines. The rebuttal case of the Ops is that after lodgment of the claim on several occasions several documents was sought for from the complainant as per requirement, but the complainant has failed to comply with the said direction and for this reason till filing of this complaint the claim of the complainant lying undecided. Further submission of the Insurance Company is that if the complainant is inclined to file the required document in original as per the letters, the Insurance Company is ready to decide his claim forthwith. We have noticed that during lodgment of the claim form the complainant had submitted the insurance policy, discharge summary, hospital bills, hospital payment receipt, investigation reports, medicine/pharmacy bills, indoor test papers and other relevant documents. As the implant was not done, name of the implant and invoice did not arise for filing. The ld. Counsel for the Ops during hearing has filed some documents from where it is evident that admittedly the Ops issued some letters upon the complainant for providing some documents for taking decision of the claim in question. It is seen by us that the Ops have stated that discharge summary, payment receipts, final bill, investigation reports were not received by them in original from the complainant. In this connection the Ops have issued three letter dated 22.01.2013, 12.02.2013 & 19.4.2013 upon the complainant. But from the claim form it is evident that at the time of lodgment of the form the above-mentioned documents were submitted by the complainant before the Ops. Moreover, it is to be mentioned that in case of lodgment of a mediclaim, at the very outset document and relevant papers should be filed in original. Therefore, where the complainant ones had already filed the original document as sought for, how can it be possible for him to submit the same in original? So in our opinion the three letters as issued by the Ops wherein some documents were sought for are baseless and vague. As the complainant has already remitted entire medical documents of his treatment to the Ops for settlement of the claim, now submission for the second time of the same document in original has no legs to stand upon. In our view the Ops did not decide the claim of the complainant not only till filing of this complaint, but not within 30 days from the date of receipt of the entire documents as per IRDA guidelines. The Insurance Company cannot disobey their own guideline. Therefore, such inaction of the Ops in our view can be termed as deficiency in service and for this reason the complainant had to run from pillar to post for getting reimbursement of his claim, but ultimately failed. For redressal of his grievance the complainant being compelled had to come before this Ld. Forum and incurred some expenditure for proceeding of this complaint. Therefore, the complainant is entitled to get compensation and litigation cost from the Ops.
Going by the foregoing discussion, hence, it is
o r d e r e d
that the complaint is allowed on contest with cost. The Ops shall settle the claim of the complainant within 45 days from the date of passing of this judgment, in default; the entire settled amount shall carry interest @9% per annum for the default period. The Ops shall pay Rs. 3,000=00 towards compensation due to deficiency in service and for this reason the complainant had to face harassment, mental agony and pain and Rs. 1,000=00 as litigation cost to the complainant within 45 from the date of passing of judgment, in default, the complainant will be at liberty to put the entire decree as per provisions of law.
Let a plain copy of this final order be supplied to the parties free of charge.
(Asoke Kumar Mandal)
Dictated and corrected by me. President
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
