D.O.F:30/11/2018

                                                                                                  D.O.O:19/07/2021

IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD

CC.No.194/2018

Dated this, the 19^th day of July 2021

PRESENT:

SRI.KRISHNAN.K                         :PRESIDENT

SRI.RADHAKRISHNAN NAIR.M : MEMBER

SMT.BEENA.K.G                            : MEMBER

C. Radhakrishnan Nair, Retired Employee of Vijaya Bank,

Employee Code No. 9264, Now R/at “Devi”

House No. 4/200, Melangot, Kanhangad,                                               : Complainant

Hosdurg Taluk, Kasaragod District, 671315

(Adv: Shrikanta Shetty)

                                                            And

1. Divisional Manager, United India Insurance Co.Ltd,

      IBA. Cell, Valcan Insurance Building, Ground Floor, No.77

      V.N Road, Church Gate, Mumbai.400020

2.  M/s Vidal Health TPA Private Ltd, SJR Park, 1^st Floor,

      Tower No.2, EPIP Zone, White Field, KR Puram,

      Bangalore- 560066.

3. M/s Medi Assist Insurance TPA Pvt. Ltd, Tower “D”,4^th Floor, IBC Knowledge Park, 4/1 Bannerghetta Road,      

Bangalore – 960029.

(Adv: C. Damodaran OP: 1&3)
 

4. Deputy General Manager, Vijaya Bank,

Salary and Pension Division, Head Office, Trinity Circle,

ORDER

 SRI.KRISHNAN.K  :PRESIDENT

            The Complaint filed under section 12 of Consumer Protection Act.

            Case of the complainant is as follows:-

The complainant is a retired Bank employee.  He obtained an insurance policy issued by Opposite Party No.1.  Policy No is 500100/28/16/P1/11639367 and MA-ID of the complainant is 5030905120 and EMI No. Rs 9264.  Due to illness he was admitted in Amrita Institute of Medical Science on 26/03/2017.  He was discharged on 29/03/2017. He paid Rs. 2,37,000/- as hospital bills besides medical expenses.  Insurance claim is made to Opposite Party No.1.  Opposite Party No 1suggested to approach Opposite Party No.2.  claim with medical records were sent to Opposite Party No.2 .  Opposite Party No.2 informed that it is under process of expert panel of doctors.  Complainant sent all the documents to Opposite Party No.2 on 24/04/2017 through courier service.  So far insurance claim not paid.  It is a deficiency in service and unfair trade practice.  Complainant prayed for award of Rs. 2 lakh 37 thousand as hospital bill and compensation and Rs. 2 Lakh towards mental pain and sufferings, inconvenience.

2.     The   Opposite Party No.1 filed written version, admitting that the complainant is a beneficiary under the policy and contents that claim should have been intimated in writing within 14 days and there is delay of 7 months in preferring the claim.  Claim is submitted on 25/10/2017.  Essential documents were not submitted by complainant to Opposite Party No.3.  It was sent to Opposite Party No.2 instead.  Repeated reminders were sent to the complainant to submit the documents.  There is no deficiency in service on the part of Opposite Party No.1 to 3 and complainant is not entitled for any relief and complainant to be dismissed with costs.

3.     The Complainant filed chief affidavit and was cross examined as PW1, Ext A1 to A8 documents marked from his side.  Ext A1 is lawyer notice, Ext A2 is postal acknowledgment(series) Ext A3 discharge summary, Ext A4 discharge bill, Ext A5 claim form, copy of claim form send to Opposite Party No.2.  Ext A6 copy of receipt of courier service, Ext A7 e-mail, Ext A8 E-mail communications.  The Opposite Party  produced documents marked as Ext B1 to B5,  Ext B1 is copy of policy, Ext B2 E-mail communication, Ext B3 reminder, Ext B4 E-mail communication ,Ext B5 E-mail communication.  Both parties filed argument notes.

4.     Based on claims, its denial, following points raised for consideration.

            (a) Whether repudiation of claim by Opposite Party No.1 to 3 to complainant is

                Justifiable?

            (b) Whether there is any deficiency in service Opposite Party?  Whether

              Complainant is entitled for compensation?  If so for what reliefs?

ISSUE No:1

            Here it is an admitted facts that complainant is a retired Vijaya bank official and also the fact that he is a policy holder aforesaid and further he is admitted in hospital and incurred the claim for insurance benefits but disallowed by insurance company.  Opposite Party No 1 and 3 raised the plea that there is non-compliance of policy conditions.     

5.     Insurance companies can no longer reject claim solely on the basis of delayed filing as settled by decision of Honourable Supreme Court of India.  The court ruled that “if the reason for delay in making a claim is satisfactory explained, such a claim cannot be rejected on the ground of delay.  It is also necessary to state here that it would not be fair to reject genuine claims which had already been verified and found to be correct by the investigator”.  The Bench also observed that rejection of claims on purely technical grounds will erode customer confidence in the insurance company.  We have referred the citations in GURSHINDER SINGH Vs SHIRAM GENERAL INSURANCE Co.Ltd, 24 January 2020 reported 2020 O AIR (SC) 1395 – 2020 11 C HC 576.

6.     Considering the E-mail communications Ext A7 series insurance company did not repudiate the claim in to on the ground of delay initially.  But reply shows that they have received the document and further message show that the hospital people have not yet shared it with MESI ASSIST because of which our insurance claim is not getting processed.

7.    So for reasons stated above, we hold that the repudiation of insurance claim by Opposite Party No. 1 to 3 to the complainant is not justified by valid reason and claim is sustainable and complainant is entitled to the insurance claim with interest at 6% per annum from date of complaint till payment.

8.     Insurance claim cannot be denied on technical ground and even on delay only, and in the present case insurance is denied only on the ground of delay and hence amounts to unfair trade practice and there is deficiency in service on the part of Opposite Parties and complainant is entitled for compensation thereof.

9.     Complainant claimed Rs. 2 lakh as compensation for which there is legal or acceptable evidence.  But still having undergone mental tension and sufferings and loss of money and considering the nature and circumstances of the case.  We are of the opinion that a sum of Rs. 25000/- is found reasonable compensation and also eligible for cost of litigation and it is fixed as Rs. 10,000/- considering the present day difficulties and inconvenience for travel and conduct litigation.

            In the result complaint allowed in part directing Opposite Party No.1 to 4 jointly and severally to pay Rs. 2,37,000/- to the complainant with interest at 6% per annum from date of complaint till disbursement to the complaint jointly and severally, and also pay Rs. 25,000/- (Rupees Twenty Five thousand only) as compensation to the complainant jointly and  severally , besides that Opposite Parties are directed to pay   Rs. 10,000/- (Rupees Ten thousand only) as cost of litigation within 30 days of the receipt of the order.

   Sd/-                                                       Sd/-                                         Sd/-

MEMBER                                          MEMBER                              PRESIDENT

A1- Lawyer notice

A2- Postal Acknowledgment card

A3-  Discharge Summary

A4- Detail bill

A5- Claim form

A6- copy of receipt of courier service

A7- E-mail

A8- E- mail communications

B1- Copy of Policy

B2- E- mail communication

B3- Reminder

B4 & B5-  E- mail Communication

Witness Examined

Pw1. C. Radhakrishnan

        Sd/-                                                   Sd/-                                          Sd/-

MEMBER                                          MEMBER                              PRESIDENT

Forwarded by Order

                                                                                    Senior Superintendent

Ps/