Haryana

Karnal

CC/106/2016

Balwan Singh S/o Narsi Ram - Complainant(s)

Versus

Cholamandalam MS General Insurance Company Limited - Opp.Party(s)

Om Parkash Kashyap

20 Apr 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                      Complaint No.106 of 2016

                                                      Date of instt. 06.04.2016

                                                      Date of decision 20.04.2018

 

Balwan Singh aged about 46 years son of Shri Narsi Ram resident of village Haibetpur Khasla Tehsil Nighdu District Karnal.

…….Complainant.

                                                Versus              

 

1. Cholamandlam MS General Insurance Co. Ltd. (Claim processing centre) Hari Niwas Tower, 2^nd floor, 163, Thambu Chetty Street, Parrys Corner, Chennai-600001 through its Managing Director.

2. Cholamandlam MS General Insurance Co. Ltd. Having its Branch office at Sector 12, Karnal through its Branch Manager.

 

                                                                        …..Opposite Parties.

       

           Complaint u/s 12 of the Consumer Protection Act.          

 

Before    Sh. Jagmal Singh……President.

      Sh. Anil Sharma………Member

               

 

 Present   Shri O.P.Kashyap Advocate for complainant.

                  Shri Rohit Gupta Advocate for OPs.            

                  

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant purchased a health insurance policy bearing no.2842/00107052/001/02 from OPs and unfortunately during the tenure of said policy he met with an accident due to which he was admitted in New Apna Hospital, Kurukshetra on 28.0.6.2015 and was discharged on 15.07.2015. He sustained fracture on Tibia. He gave due intimation to the OP no.2 about the said accident. Hospital charged Rs.47490/- as hospital charges, medicines and doctors fee and beside this complainant spent an amount of Rs.2500/- on transportation and special diet. Then he lodged a claim of Rs.50,000/- with OPs, vide claim application no.2842061790. After completed all the formalities the OPs assured that the claim amount will be disbursed to him by the company within a period of two months but OPs have not paid the said amount to complainant despite repeated requests made to OPs and written applications moved to OP no.1. Complainant approached and requested the OPs are postponing the matter on one pretext or the other. Then complainant sent a legal notice dated 11.02.2016 in this regard but in vain. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written statement raising preliminary objections with regard to premature; maintainability; jurisdiction; locus standi and complicated questions of law and facts are involved, which cannot be decided in summary jurisdiction. On merits, it is admitted fact that the complainant purchased a health insurance policy no.2842/00107052/001/02 from the OP no.1. Complainant met with an accident and was admitted in New Apna Hospital, Kurukshetra on 28.06.2015 and was discharged on 15.07.2015 and gave intimation to the OPs about the said accident. It is submitted that the complaint of the complainant is premature one since the complainant has failed to respond the letters dated 27.08.2015, 11.09.2015 and 26.09.2015 sent by the OP, by which complainant had requested to submit/provide the original detailed discharge summary, original paid receipt for total hospital expenses incurred, treating doctor certificate confirming the nature and circumstances injury, treating doctor certificate stating the justified reasons for prolonged hospitalization and as such the claim of the complainant has already been closed as ‘No Claim’ in the absence of any response from the side of the complainant. The OP has neither repudiated nor denied the claim of the complainant and will decide the admissibility of the claim of the complainant on receiving the response as required. Hence there was no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C15 and closed the evidence on 3.11.2017.

4.             On the other hand, OPs led no evidence.

5.             We have heard the learned counsel for both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

6.             According to the pleadings of the parties, there is no dispute between the parties that the complainant has purchased a health policy no.2842/00107052/001/02 from the OPs. The complainant met with an accident and sustained fracture on tibia regarding which the complainant remained admitted in New Apna Hospital, Kurukshetra from 28.6.2015 to 15.07.2015. The hospital charged Rs.47490/- from the complainant and besides this the complainant spent Rs.2500/- on transportation and special diet. The complainant made the claim with the OPs.

7.             According to the OPs, the complainant has failed to respond the letters dated 27.08.2015, 11.09.2015 and 26.09.2015 sent by the OPs, vide which the complainant was requested to provide original detailed discharge summary, original paid receipts of expenses, treating doctor certificate confirming the nature and circumstances, injury and justified reason of prolonged hospitalization. The claim of the complainant has been closed as ‘No Claim’ in the absence of above documents. This Forum has no jurisdiction as the policy was issued from Chennai.

8.             The learned counsel for complainant argued that the demanded documents have already been furnished to the OPs and the photostat copies are placed on the file. So, it is not possible to submit the original again.

9.             To prove his case complainant produced in his evidence his affidavit Ex.CW1/A and documents Ex.C-1 to Ex.C-15. Out of these documents, Ex.C-1 and Ex.C-2 are original and the remaining are photostat copies. On the other hand, the OPs have not produced any evidence as the evidence of the OPs was closed by this Forum vide order dated 22.3.2018 after granting two last opportunities. It is pertinent to mention here that the OPs moved an application on 16.04.2018 for additional evidence for producing the affidavit and documents but the said appliction was dismissed as this Forum has no power to review its order. So the evidence of the complainant goes unrebutted. From the reply of the OPs, it is clear that the claim of the complainant has not been repudiated but the same was closed as ‘No Claim’ for want of documents.

10.            The completion of documentation is necessary for allowing a claim. The argument of complainant that it is not possible to submit the original documents again as the original has already been submitted has force. In this situation, the complainant can submit the document after getting the same certified by the doctor/hospital concerned.

11.            In view of the above discussion, we allow the complaint and direct the OPs to make the payment of the claim of the complainant  as per terms and conditions of the policy subject to the condition of submitting the documents as required vide letter dated 26.09.2015. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:20.04.2018

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

                     (Anil Sharma)

                          Member