DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
EAST KHASI HILLS DISTRICT
MEGHALAYA, SHILLONG
(Lower Lachumiere, Admn Building 2nd Floor, Shillong – 793 001.)
CONSUMER CASE NO 29/2010
Meghali Roy , Shillong - Complainant
Versus
Oriental Insurance Company Ltd, Shillong - Opposite Party
ORDER
Dated: 11/11/2013
The facts of this case in brief are that Complainant and her sister were insured under mediclaim scheme with the OP on 02.05.2009. Her sister was hospitalized in Woodland Hospital, Shillong from 09.01.2010 to 11.01.2010. All relevant documents including hospital bills and payment receipt etc amounting to Rs 14,034/- were submitted to the OP for reimbursement on 25.02.2010. After a lapse of 2 months when there was no correspondence from the OP, the Complainant sent a reminder on 23.04.2010 for settlement of the claim. Another reminder was sent on 31.05.2010 giving the OP 15 days time to response. The OP did not respond even after one and half month. The Complainant case is that being from a poor family; she had to borrow money from individual at exorbitant interest to pay hospital bills and is still in the process of re-paying the loan with interest in monthly installments. Hence she filed this complaint and prays for the claim amount along with interest and compensation for the delay and deficiency in service.
Notice was issued to OP who also filed the show cause. In their reply the OP admitted the facts as stated by the Complainant in her complaint petition as the same are matter of records. The OP denied correspondences made by Complainant during February, April and May 2010. The OP further mentioned that the case needs to be proved with documentary evidence and by calling the witness. The OP denied the prayer clause made by Complainant as the same are false, frivolous and misconceived. Hence Complainant is not entitled to any relief and the petition be dismissed with cost.
The Complainant filed the rejoinder and mentioned that OP in reply to letter dated 25.02.1010 sent a letter dated 08.07.2010 wherein it was stated that the claim is in advanced stage of processing and require the original discharge summary and the original prescription of the doctor so as to enable them to settle the claim of the Complainant. Complainant mentioned that the letter was dated as 08.07.2010 whereas the envelope was stamped dated 16.07.2010. The Complainant in reply to OP’s letter dated 08.07.2010 sent a letter dated 09.08.2010 stating that the said documents required by the Insurance Company were already submitted and received by the OP on 26.02.2010.
The OP examined Shri Vishwanath Shah, the Divisional Manager. He confirmed that the mediclaim insurance policy can be issued to the sister or any unmarried sister (dependent). He stated as per policy Smti Meghali Roy is aged about 33 years and she is a proposer of the mediclaim, and that at the time of obtaining mediclaim policy Smti Jonali Roy was mentioned as dependent child which is false information given by her. The age difference between the Complainant and the dependent child is only 7 years. He was not aware if the Complainant had come personally at the time of issuance of the policy since was not posted at Shillong. During his cross examination he stated that he was posted in Shillong on 01.09.2010. He further stated that the Branch Manager or any officer is the authorized person to sign for issuing the policy. He further stated that it is possible that there was error but those are very rare cases and the insured persons are to be present personally at the time of opening the policy. He is not sure about the relation between the insured person and the Complainant.
Both parties were heard and also filed their arguments in writing.
The Complainant argued that a claim for reimbursement for Rs 14,034/- was submitted on 25.02.2010 along with all the relevant documents clearly mentioned which documents were submitted in original and which documents were the photocopies. A reminder was sent since 23.04.2010 and another on 31.05.2010 and both reminders were ignored by the OP. After filing of the complaint before the Forum, the OP chose to respond to the letter of the Complainant and it was posted on 16.07.2010 while the letter was backdated as 08.07.2010. In the said letter the OP asked the Complainant to submit certain documents in original. The Complainant argued that why the OP took more than 4 ½ months to ask any document if so required. The Complainant also stated that the policy was not a fresh policy but a renewal of the previous policy. The Complainant also argued that the claim could have been settled in 3-4 months time but has dragged on for several years thereby causing harassment to the Complainant.
The OP in their argument mentioned that the Complainant had taken the mediclaim policy with effect from 02.05.2009 to 01.05.2019 and as per policy the Complainant has taken the mediclaim policy for herself as well as her dependent child whereas claims for hospitalization bills was for her sister Jonali Roy. The OP argued that the Complainant has obtained policy by providing false information so the OP Insurance Company is not in a position to provide the claim asked for. The OP further argued that the policy was taken on 02.05.2009 to 01.05.2010 whereas the Complainant’s sister was admitted in hospital on 09.01.2010 and if there was any mistake at the time of issuing the policy, it is the duty of the Complainant to provide application for correction in the policy but she did not do so.
On the basis of documents on record and the arguments put forth by both the parties, this Forum makes the following observations:
- The undisputed facts are that the Complainant and one Smti Jonali Roy aged 25 years has taken mediclaim insurance policy under Policy No 322406/48/2010/90 which is a renewal of the previous policy No. 322406/48/2009/126 which valid from 02.05.2009 to midnight 01.05.2010.
- The contention of the OP is that Smti Jonali Roy was admitted in hospital on 09.01.2010 whereas the policy was taken on 02.05.2009. However we observe that the policy taken was a continuation of the previous policy, hence there was no fresh policy.
- Another contention of the OP is that the Complainant has given false information at the time of taking the policy by stating ‘dependent child’ whereas in the hospital bills it was mentioned as sister. This Forum is of the opinion that the OP Insurance Company should have examined properly the relationship of the Complainant and the insured person before entering ‘dependent child’ in the column relationship of the policy. Since the age given was 25 years that of the insured person and 33 years that of the Complainant therefore it’s naturally not possible to say that the insured person was a dependent child because the age difference is just 7 years.
- The OP has not repudiated the claim of the Complainant. Instead in their letter dated 08.07.2010 OP has asked the complainant to submit certain documents in original, i.e discharge summary and a copy of doctor’s prescription. The Complainant in her letter dated 25.02.2010 has specifically mentioned ‘Woodland Hospital Discharge Summary submitted 2 sheets photocopy, bills & cash receipts of hospital stay, medicines subscription and receipts in original, doctor’s certificate of diagnosed in original. The contention of the Complainant is that the OP did not take any steps even after two reminders sent to them to settle the claim of the Complainant, and that after filing the case before the Forum that the OP took initiative to sent a letter asking for certain documents.
On the basis above observations and opinions, we are inclined to decide this case in favour of the Complainant and decide that it is clear case of deficiency in service by the OP in delaying the settlement of the claim of the Complainant. Therefore this Forum directs the OP to settle the claim of the complainant of Rs 14,034/- along with interest of 6 % per annum from the date when Complainant presented her claim. Also we direct the OP to pay a compensation of an amount of Rs 3,000/- (Rupees Three Thousand) only for deficiency in service and delay in settling the claim of the Complainant. The OP is directed to comply with this order within 30 days from the date of receipt of this order.
Case disposed off.
