PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

1)        By this complaint the Complainant has prayed that the Opposite Party be directed to pay Rs.1,00,000/- towards medical insured amount with interest @18% p.a. from the date of submission of claim till the realization of the amount.  It is also prayed that it be held that there is deficiency in service on the part of the Opposite Party and the Opposite Parties be directed to pay Rs.50,000/- in respect of deficiency in service and for mental and physical agony caused to the Complainant for not settling his claim. The Complainant has also prayed to direct the Opposite Parties to pay cost of Rs.25,000/- of this proceedings. 

2)        According to the Complainant, he is bachelor and senior citizen who is consumer of the Opposite Parties.  It is alleged that the Complainant had obtained mediclaim insurance of Opposite Party Nos.1 & 2 and the Opposite Party No.3 is the TPA appointed by Opposite Party Nos.1 & 2 to settle the claims of the consumers.  It is submitted that the Complainant is insured since 2002 previously the insurance coverage of the Complainant was of Rs.2,50,000/- but later on he had reduced the same upto Rs.1,00,000/-.  The chart is enclosed alongwith insurance policies, yearly certificates which is marked as Annexure - ‘C-1’.  According to the Complainant, during the relevant policy period 05/11/2009 to 04/11/2010 the insured amount was Rs.1,00,000/-.  The Opposite Parties paid claim for stomach problem to the tune of Rs.16,686/-.  The copy of the settlement letter and consent documents are marked as Annexure - ‘C-2’. 

3)        It is the case of the Complainant that during the validity of the same policy period the Complainant failed seek and he was hospitalized in Shushrusha Citizens Co-operative Hospital Ltd. and S.L. Raheja Hospital between 10/09/2010 to 16/09/2010.  In S.L. Raheja Hospital surgery for Hamstring Apses on his left eye was performed.  The Complainant was under observations of Dr. Rajeshri P. Kelkar and after the discharge and proper follow the Complainant submitted his mediclaim for Rs.1,17,914/- through insurance agent Ms. Nikita Jigar with all the medical bills and medical papers with the Opposite Parties.  The Opposite Party No.3 acknowledged the said documents on 30/09/2010.  The copies of which are marked as Annexure - ‘C-3’.  It is submitted that after several correspondence made to the Opposite Parties as mentioned in para 8 to 11 and the copies of the said correspondence marked as Annexure - ‘C-4’ to C-7 the Complainant tried follow-up his claim, but the Opposite Parties did not respond to it and therefore, the Complainant has filed this complaint for the reliefs mentioned in para 1 of this order.

4)        The Opposite Party Nos.1 & 2 have filed its written statement and contested the claim.  It is contended that the Complainant is not entitled to file the present complaint and to seek reliefs claim in this complaint.  According to the Opposite Party Nos. 1 & 2 the Complainant was provided with all conditions exceptions and limitations forming part of mediclaim policy.  He was aware of the said terms and conditions of the insurance policy.  The Complainant was bound and liable by the said conditions.  It is contended that the complaint is barred by waiver clause in the policy and therefore, the claim is not maintainable.  As the Complainant has filed this complaint after the waiver provided in the policy. According to the Opposite Party Nos. 1 & 2 the Complainant failed to submit the relevant and important documents in respect of his alleged hospitalization and therefore, the Opposite Party No.3 rightly closed the claim as ‘No Claim’.  It is submitted that the Complainant was informed that he did not submit the course in the hospital and what management has been done during hospitalization.  It is the case of the Opposite Party Nos.1 & 2 as the Complainant failed to submit complete attested inpatient record and therefore, the claim of the Complainant was rejected.  It is denied that there is deficiency in service on the part of the Opposite Parties and the Complainant is entitled for the claim made in the complaint.  The Opposite Party Nos.1 &  2 prayed for dismissal of the complaint with cost.

5)        The Complainant has filed his affidavit of evidence.  The Opposite Party Nos.1 & 2 have filed affidavit of evidence of Laiju Marar, Asst. Manager.  Both the parties have filed their written arguments.  We have heard oral arguments of Shri. Kiran Patil, Ld.Advocate for the Complainant and Shri. A.S.Vidyarthi, Ld.Advocate for the Opposite Party Nos.1 & 2.  We have perused the documents filed in the complaint.

6)        While considering the claim made in the complaint, it is necessary to be sent that the Opposite Party No.3 by letter dtd.20/11/2010 called upon the Complainant to submit the following documents. 

            1.   Continuation of policy is awaited from Insurance Company.

            2.   Course in the hospital what management have been done during hospitalization. 

            3.   Complete attested Inpatient Record.

            4.   City films with reports.

By the said letter the Opposite Party No.3 had requested  to  submit the original documents/details as mentioned above, during 15 days from the receipt of the said letter. It was also requested that the conclusion regarding eligibility of coverage admissible amount can only be arrived at, once the Opposite Party No.3 have full set of original documents.  The Complainant had replied to the said letter to the Opposite Party No.3 on 23/11/2010, 23/05/2011.  In the said letters there is no mention that the Complainant had complied the required documents called by the Opposite Party No.3.  Furthermore, as per letter dtd.23/05/2011 issued by Opposite Party No.3, it appears that the Opposite Party No.3 had sent letter dtd.25/03/2011 to the Complainant intimating that the Complainant has ‘No Claim’ since the Opposite Party No.3 had not received any reply from the Complainant within stipulated period and the Opposite Party No.3 has repudiated the Complainant’s claim and closed his claim.  The copy of the letter dtd.23/05/2011 is also filed by the Complainant at page 45 with the complaint. The documents which the Complainant has relied for the grant of claim have gone through by us from the said documents it appears that the Complainant has not filed the copy of bill of Raheja Hospital showing that the Complainant had paid an amount of Rs.1,05,970/- towards interim bills to Raheja Hospital.  In the claim lodged by him to Opposite Party No.3 though there is mention of payment of bills to Raheja Hospital the Complainant has not produced the authenticated receipts of such payments made to Raheja Hospital.  It is also pertinent to note that in this complaint also the Complainant did not ask the Opposite Parties to produce the original claim submitted by him alongwith the documents submitted to the Opposite Party No.3.  The Complainant has also not produced the copy of the terms and conditions of the policy issued by the Opposite Party Nos.1 & 2 showing that his claim submitted to the Opposite Party No.3 was within the ambit of the terms and conditions of the said policy and the defence raised by the Opposite Party Nos.1 & 2 that the Complainant’s claim was barred by waiver clause in the policy is not at all applicable to the claim made in the complaint.  Considering these facts and the Opposite Party No.3 have closed the claim as the Complainant failed to submit relevant documents in respect of his hospitalization as mentioned in the aforesaid letter of Opposite Party No.3, we are of the view that the Complainant has failed to prove there is any deficiency of service on the part of the Opposite Parties.  We therefore, hold that the Complainant has failed to prove that he is entitle for the claim made in the complaint. In the result the following order is passed –

O R D E R

                      i.      Complaint No.141/2012 is dismissed with no order as to cost.

ii.      Certified copies of this order be furnished to the parties.