Haryana

StateCommission

A/1227/2016

MAX LIFE INSURANCE CO.LTD. - Complainant(s)

Versus

BRIJ LAL - Opp.Party(s)

NITESH SINGHI

10 Aug 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      1227 of 2016

Date of Institution:        15.12.2016

Date of Decision :         10.08.2017

1.     Max Life Insurance Company Limited Branch Office, S.C.O. No.7, and 8, Sector-17, Kurukshetra.

2.     Managing Director, Max Life Insurance Company Limited, Registered Office, Max House No.3^rd Floor 1, Dr. Jha Marg, Okhla, New Delhi-110020.

                                      Appellants-Opposite Parties

Versus

 

Brij Lal s/o Sh. Manohar Lal, Resident of Village Raogarh, P.O. Jyotisar, Tehsil Thanesar, District Kurukshetra.

                                      Respondent-Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. Balbir Singh, Judicial Member.

                                                                                                         

Argued by:          Shri Nitesh Singhi, Advocate for appellant.

                             Shri Raghav Sharma, Advocate for respondent.

 

                                                   O R D E R

 

BALBIR SINGH, JUDICIAL MEMBER

 

        This appeal has been preferred against the order dated March 15^th, 2016 passed by District Consumer Disputes Redressal Forum, Kurukshetra (for short ‘the District Forum’) in Complaint No.27 of 2013.

2.                Brij Lal-complainant (respondent herein) was provided medi-claim insurance policy known as Max New York Life Fortune Builder bearing No.770930873 (Exhibit R-1) from Max New York Life Insurance Company Limited (for short ‘the Insurance Company’) regarding the period from February 28^th, 2010 to February 28^th, 2020.  The sum assured was Rs.4.00 lacs regarding Peronal Accident Benefit and Rs.1.00 lac regarding Dread Disease.  Annuual Target Premium (ATP) payable was Rs.25,000/-.

3.                    On September 24^th, 2012 due a road accident, the complainant sustained multiple serious and grievous injuries on his body including fracture in leg.  The complainant remained admitted in Anand Orthopaedic Centre, Kurukshetra from September 24^th, 2012 to October 12^th, 2012.  The complainant spent more than Rs.1.00 lac for his treatment in the hospital.  Regarding this accident, a criminal case was registered on September 29^th, 2012 under Sections 279,337 of the Indian Penal Code at Police Station, Kurukshetra University, Kurukshetra.  Intimation was also given to the Insurance Company-opposite parties immediately. A letter was also written to the Insurance Company on November 26^th, 2012 regarding insurance claim.  Thereafter, also despite time and again requests and service of legal notice, the insurance claim of the complainant was not accepted.  The complaint filed the instant complaint under Section 12 of the Consumer Protection Act, 1987 before the District Forum with prayer that the opposite parties be directed to pay an amount of Rs.1.00 lac regarding the expenses incurred by the complainant for his treatment; an amount of Rs.50,000/- on account of un-necessary harassment and mental agony with interest at the rate of 12% per annum.

4.                The opposite parties in their written version have taken plea that the complaint is not maintainable in the present form; that the complainant has not approached the District Forum with clean hands and that the complainant has concealed true and material facts.  It is pleaded that the complaint filed by the complainant is pre-mature as prior to that the complainant never approached the opposite parties for insurance claim.  The opposite parties can consider the prayer of the complainant regarding insurance claim.  In case, the complainant produces the relevant documents i.e. copy of the F.I.R. and Medical Record etc., as mentioned in the written version, the opposite parties also can repudiate the claim if the documents filed by the complainant are not as per the terms and conditions of the insurance policy.  In these circumstances, it is not a case of deficiency in service on the part of the opposite parties. The opposite parties have prayed that the complaint be dismissed with cost.

5.                The parties led evidence in support of their respective claims before the District Forum.

6.                After hearing arguments, vide impugned order dated March 15^th, 2016 passed by the District Forum, complaint filed by the complainant was allowed partly and the opposite parties were directed to pay an amount of Rs.50,000/- to the complainant within a period of two months, failing which the complainant shall also be entitled for simple interest at the rate of 6% per annum on the awarded amount of Rs.50,000/- from the date of the impugned order dated March 15^th, 2016. 

7.                Aggrieved with the impugned order dated March 15^th, 2016 passed by the District Forum, the opposite parties-Insurance Company have filed the present appeal with a prayer to set aside the impugned order and to dismiss the complaint.

8.                We have heard learned counsel for the parties and perused the case file.

9.                It is admitted fact that the medi-claim insurance policy (Exhibit R-1) was provided to the complainant by the opposite parties mentioning total sum assured as 4.00 lacs regarding the period from February 28^th, 2010 up to February 28^th, 2020.  It is also admitted fact that due to a road accident, as mentioned in the copy of F.I.R. (Exhibit P-20), the complainant sustained multiple serious and grievous injuries on his body including fracture in leg on September 24^th, 2012 during the insured period. It is evident from the documents i.e. hospital bills and bills regarding purchase of medicines etc, that the complainant spent an amount of Rs.70,659.74 for his treatment during the period he remained admitted in the hospital.  The opposite parties have taken only one plea in their written version stating that compensation claimed could not be allowed as the complainant did not submit insurance claim before the Insurance Company.

10.              During the course of arguments, learned counsel for the opposite parties has argued that the complainant is not entitled to receive any amount as claimed in the complaint as the complaint is premature as the complainant never submitted his insurance claim with relevant documents before the Insurance Company.  We are not much impressed with this contention of the learned counsel for the opposite parties because the complainant has been able to prove that he had informed the insurance company regarding the injuries sustained in the accident and the amount spent by him for his treatment vide letter Exhibit P-17 which was received by the opposite parties on November 26^th, 2012.  By writing this letter, the complainant claimed an amount of Rs.1.00 lac from the Insurance Company.  We feel, as and when the above mentioned letter (Exhibit P-17) was received by the opposite parties, the process should have been initiated and if there was any problem, directions should have been given to the complainant to provide the documents needed for sanction of the insurance claim.  In these circumstances, it is held that the complaint filed by the complainant is not pre-mature and that the complainant is entitled to receive the insurance claim amount. It is evident from the hospital bills and other bills regarding purchase of medicines (Exhibit P-1 to P-16) that the complainant spent an amount of Rs.70,659/- for his treatment when he remained admitted in hospital for a period of 19 days.  The learned District Forum has awarded only an amount of Rs.50,000/- to the complainant.  Anyhow, the complainant himself is also satisfied with the compensation amount awarded to him as he did not file any appeal against the impugned order dated March 15^th, 2016. 

11.              In these circumstances, we find no illegality and invalidity in the impugned order dated March 15^th, 2016 passed by the learned District Forum.  Accordingly, findings of the learned District Forum stand affirmed and appeal stands dismissed.

12.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced: 10.08.2017

(Balbir Singh) Judicial Member

(Nawab Singh) President

 

CL