IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the22ndday of March, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member,
Sri. K.M. Anto, Member
C C No. 152/2019 (filed on 01-08-2019)
Petitioner : Rajesh Kumar K.
Palazhi House,
Pattithanam P.O.
Ettumanoor
Kottayam – 686631
(Adv. Jossy Bastian)
Vs.
Opposite parties : (1) Family Health Plan (TPA)
Ltd. Neelkanth Corporate Park,.
Office No.710 & 711,
7th Floor, Kirol Road,
Opposite party. Vidyavihar –
RailwayStation (West)
Mumbai – 400086
(2) United India Insurance Co. Ltd
Registered & Head Office 24
Whites Road, Chennai-600014
(Adv. P.G. Girija)
(3) HDFC Bank Ltd.
Golden Towers, M.C. Road,
Vezhakattuchira,
Changanacherry,
Kottayam – 686 101.
(Adv. V.K. Sathyavan Nair and
Adv. Saji S. Nair)
O R D E R
Smt. Bindhu R. Member
The complaint is filed under sec. 12 of Consumer Protection Act, 1986.
The complainant had enrolled the name of his wife with the second opposite party for afamily health plan mediclaim policy. Thereafter the complainant’s wife washospitalised for delivery (LSCS) and the complainant submitted a claim alongwith all the required documents. All the documents were sent to the TPAfamily health plan (TPA LTD) as per the direction of the 2 opposite party. Thereafterwhen the complainant enquired the status of the claim he was informed thatsonographic report was pending and he sent the original of the same. Thereaftereven after repeated phone calls and emails he had been getting the reply that theclaim was under processing. At last when the complainant sent an email toenquire about the claim the 2nd opposite party replied that they did not receive thedocuments. The complainant sent the delivery receipt received from the DTDCcourier with the signature and seal of the staff of FHEL (TPA).Thereafter no information or contact from the FHPL.(TPA). The claim IDis 1775020 and policy no. is 0204002817 P 100652001. Hence the complaint isfiled for getting the insurance amount and compensation for the deficiency ofservice from the opposite party along with cost.
The opposite parties were noticed and opposite party1 to 3 appeared. The 1 opposite party did not care to fileversion and was set exparte. The 2nd and 3rd opposite parties filed their version separately.
The 2nd opposite party denying all the averments in the compliant contents that thepolicy was issued as a group health policy in the name of M/s HDFC Bank ltd.
The 1 opposite party being the TPA for the same. While the 2nd opposite party admits the policy claim itdenies the averment that all relevant documents were submitted to the 2nd opposite party. Asper the documents the complainant’s wife was admitted in the hospital on16.10.17 and after LSCS she was discharged 23.10.17. Though the complainantsubmitted a claim he did not submit the USG report, original detailed summaryand all original investigation report relevant to the bills inspite of repeatedreminders. As per the policy – request for quote no.7, the time limit forsubmission of maternity claims is 180 from the date of discharge. But thecomplainant failed to submit the necessary documents within the period of 180days. Therefore the complainant’s claim could not be processed for the saidreason. As per the letter dated 15.09.18 issued by the complainant and receivedby the TPA 25.06.18 it is specifically stated that he is sending the requireddocument on 15.09.18. It was not the complainant but the TPA who had beenconstantly reminding the complainant to submit the required documents. But hedid not send it within time. There is no deficiency in service on the part of the firstand second opposite parties.
The 3rdopposite party in his version has contented that the 3rd opposite party is an unnecessaryparty to the complaint. So the complaint is bad for mis joinder of unnecessaryparty. There is no cause of action against the 3rdopposite party. The complainant was theemployee of the 3rd opposite partyand his service was terminated on 11.01.2018. Thecomplaint is filed without any bonafides. There is no deficiency in service onthe part of the 3rdopposite party. The 3rd opposite party is not liable.The complaint is liable to be dismissed.
The evidence part of the case comprises proof affidavit along with Ext.A1
to A4 from the part of the complainant and proof affidavit along with Ext. B1 and B2 from the part of the 2nd opposite party. The 3rd opposite party has not adduced any evidence.
Though the 1st opposite party received notice, did not turn up to contest the case.
On a detailed evaluation of the pleadings and evidence on record, wewould like to frame the following issues.
- Whether the denial of policy claim on a sole ground of delay in the
submission of required documents amounts to deficiency of service?
2. If so, what are the reliefs the complainant is entitled for?
Pont No.1 and 2
The complainant, who was a staff of the 3rd opposite party had submitted aninsurance claim with the 2nd opposite party for the treatment of his wife being theinsured for LSCS. Even after submission of all the requireddocuments the 2nd opposite party did not approve the claim and later on enquiryhe was informed that they did not receive the required documents sentby him.
The second opposite party in its version and proof affidavit has stated that theyhad received the documents and the letter sent by the complainant on15.09.2018 only on 25.09.2018.
The Ext.B2 is a letter dated 15.09.2018 sent by the complainant tothe 1st opposite party stating that he was sending the required documents videcourier service admittedly received by the opposite party on 25.09.2018.
Ext.A3 and A4 are receipts issued by DTDC Express Ltd. which supportthe claim of the complainant that he had sent the documents. The 2 opposite party has not disputed the submission of the documents but it is the delaycaused which is beyond the time limit for the submission of maternityclaim of 180 days from the date of discharge is the ground forrejection.
In exhibitB2, II special conditions cl.7 “Claim submission timelinewithin 120 days fromthe date of discharge and Maternity claims upto180 days from date of discharge. Claim intimation not mandatory.”
The 2nd opposite party being the insurer has not informed thecomplainant through a repudiation letter or any other means that hisclaim was rejected due to the delay in submission of the documents.
The stipulated period of 180 days is a contractual necessity. Undercertain circumstances the period can be waived for the benefit of theinsured because he had been paying the premium required withoutdefault.
Moreover, there is no dispute regarding the treatmentpattern, the hospital expenses or submission of documents. Theonly contention of the 2nd opposite party is that the complainant has delayed thesubmission of the documents. But the complainant himself as swornin his affidavit that he was regularly contacting the 1stand 2nd opposite party but noreasonable reply was given by them.
Clause 7 in Ramesh Yadavvs The New India Assurance Company ... on 3 April,2014 the Honourable state commission,Haryana has held thatThe circular dated September 20th, 2011 (Annexure-A) issued byINSURANCE REGULATORY AND DEVELOPMENT AUTHORITY is as under:-
INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY
Ref.
IRDA/HLTH/MISC/CIR/216/09/2011 Date: 20.09.2011 CIRCULAR To:All life insurers and non-life insurers Re:
Delay in claim intimation/documents submission with respect to i.
All life insurance contracts and ii.
All Non-life individual and group insurance contracts The Authority has
been receiving several complaints that claims are being rejected on theground of delayed submission of intimation and documents.
The current contractual obligation imposing the condition that the claimsshall be intimated to the insurer with prescribed documents within aspecified number of days is necessary for insurers for effecting variouspost claim activities like investigation, loss assessment, provisioning,claim settlement etc. However, this condition should not preventsettlement of genuine claims, particularly when there is delay inintimation or in submission of documents due to unavoidablecircumstances.
The insurers decision to reject a claim shall be based on sound logic and
valid grounds. It may be noted that such limitation clause does not workin isolation and is not absolute. One needs to see the merits and goodspirit of the clause, without compromising on bad claims. Rejection ofclaims on purely technical grounds in a mechanical fashion will result inpolicy holders losing confidence in the insurance industry, giving rise toexcessive litigation.
Therefore, it is advised that all insurers need to develop a soundmechanism of their own to handle such claims with utmost care andcaution. It is also advised that the insurers must not repudiate such claimsunless and until the reasons of delay are specifically ascertained, recordedand the insurers should satisfy themselves that the delayed claims wouldhave otherwise been rejected even if reported in time.
The insurers are advised to incorporate additional wordings in the policy
documents, suitably enunciating insurers stand to condone delay on meritfor delayed claims where the delay is proved to be for reasons beyond thecontrol of the insured.
9. It is very clear from the above circular that the insurancecompany cannot repudiate the bonafide claims on technical grounds likedelay in intimation and submission of some required documents. Thedecision of insurers to reject a claim of the claimant should be based onsound logic and valid grounds. The limitation clause does not work inisolation and is not absolute. One needs to see the merits and good spiritof the clause, without compromising on bad claims. Rejection of claimson purely procedural grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise toexcessive litigation. It has been further advised in the above said letterthat the insurers must not repudiate such claims unless and until thereasons of delay are specifically ascertained, recorded.
10. What is the spirit of Insurance Policy, should be kept in mind by theofficials dealing with the genuine claims of the sufferers and the sameshould not be rejected on methodological grounds in a mechanicalmanner. The tendency of Insurance Companies in rejecting genuineclaims is the reason of increasing litigation between the insurers and theinsured’s/their legal heirs.
As held by the Honourable Supreme court in M/s. Galada Power &Telecommunication Ltd. v/s United India Insurance Co. Ltd. & Anotherthat mere delay cannot be raised as ground for repudiation.
Moreover, the opposite parties even after the elapse of 2 years, have notcommunicated about any repudiation to the complainant. This itself is adeficiency of service. The opposite parties are legally bound to intimatethe complainant about the repudiation if done. As no such intimation wasgiven, the complainant was waiting for the reimbursement of the amount. Hence after the sufferings due to decease and hospitalisation, the complainant had to suffer severe mental agony and hardships. So he is entitled to be compensated.
Hence in the light of the above discussion we are of the view to allow the
complaint vide the following order:
1. The opposite party is directed to pay Rs.38,975/- being the medicalexpenses to the complainant with interest at the rate of 9% from thedate of 23.10.17 the date of discharge till realisation.
2. The opposite party is directed to give Rs.10000/- towards compensationand Rs.5000/- as litigation cost.
Order shall be complied within 30 days from the date of receipt of Order. If not complied as directed, the compensation amount will carry 6% interest from the date of Order till realization.
Pronounced in the Open Commission on this the 22nd day of March, 2022
Smt. Bindhu R. Member Sd/-
Sri. Manulal V.S. President Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 –Copy of insurance card with terms and conditions
A2 – Copy of courier receipt
A2 (a) – Copy of courier receipt
A3 - Receipt (Consignment No.R28341809) issued by opposite party
A4 – Receipt (Consignment No.F11050256) issued by opposite party
Exhibits marked from the side of opposite party
B1 – Copy of policy with terms and conditions
B2 – Copy of letter dtd.15-09-18 by petitioner to 1st opposite party
By Order
Assistant Registrar
