IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 29th day of December, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 218/2020 (filed on 28/12/2020)
Petitioners : Shaji Francis
S/o. T.J. Francis,
Parapuram House,
Pampady P.O.
Kottayam – 686502
(Adv. Tom K. Jose)
Vs.
Opposite Parties : (1) Chairman-Cum-Managing Director,
HDFC ERGO General Insurance
Company Ltd. 1st Floor,
HDFC House, 165-166 Backbay
Reclamation, H.T. Parekh Marg,
Church Gate, Mumbai – 600 034.
(Regd and Corporate office)
(2) Branch Manager,
HDFC ERGO General Isnurance
Company Limited, 2nd Floor,
Safa Trading Centre,
Railway station road,
Kottayam- 686 001.
(For Op1 and 2, Adv. Lithin Thomas)
O R D E R
Smt. Bindhu R. Member
The complainant took a medi claim insurance policy under the name and style “My health Suraksha Policy” from the opposite parties as policy number 2952203364481100000 on 19-03-020. The period of the policy was from 19-03-2020 to 18-03-2022. Thus the complainant is a consumer of the opposite parties. The premium paid was 20,685/-. The sum insured was Rs.3,00,000/-. The proposal was sent through his mobile and the payment was made vide his credit card.
On 27.08.2020 the complainant met with an accident in which he sustained severe spinal injury and his C6 – C7 disc prolapsed with nerve root compression. Immediately after the accident he was taken to the Carithas hospital and was admitted and treated there as an inpatient for 5 days. He was discharged on 13-09-2020. The total expense was 43,281/- which was spent by the complainant himself. The accident was occurred within the insurance coverage period and the opposite party is bound to reimburse the amount. The complainant submitted a claim petition to the opposite parties no.RR-HS20-11353495(CCN). But the insurer denied the claim of the complainant stating some baseless reasons.
This denial of claim is deficiency of service and unfair trade practice of the opposite parties. The complainant is entitled to get the expenses of treatment reimbursed by the opposite parties. Hence this complaint is filed for the refund of Rs.43,281/- and for compensation of Rs.10,000/-with cost.
Upon notice the opposite parties appeared and filed version jointly admitting the policy and contending that the complainant underwent treatment of C6-C7 disc prolapse with nerve root compression on account of alleged fall with spine injury. The hospitalisation was for a period from 9/9/2020 till 13/09/2020 incurring a total medical expenditure of Rs.45,140/-.The insured underwent disectomy and fusion as treatment for the same. The complainant has submitted a claim. On perusal of the claim form along with the documents, the opposite party issued a query letter on 29/09/2020 seeking further information as relevant documents were not submitted along with the claim form. The documents demanded were
1 MLC/FIR copy, if any.
2. Treating doctor’s certificate mentioning whether the patient was under the influence of alcohol/any other intoxicating drug(s) at the time of incident.
3. Treating doctor’s certificate mentioning the circumstances that lead to the accident.
4. Original MRI bill against duplicate bill enclosed.
5. Advance paid receipt of Rs.27,000/-
6. All investigation reports against bill enclosed.
The opposite parties further contend that they issued reminder letters to the complainant on 14/10/2020,30/10/2020 and on 14/11/2020 but no reply. As there was no reply from the complainant, the claim was closed as per claim closure letter dated 14/11/2020. An act of the complainant to provide complete information required for verification and settlement of claim can by no stretch be termed as deficiency in service on the part of the this opposite party. The opposite party has relied on the Honourable supreme court in Ravneet Singh Bagga Vs KLM Royal dutch Airlines(2000)1 SCC 66. If there is any shortcoming imperfection, or inadequacy on the part of the insurance company, such fault etc. must be wilful. If the service provider has acted after considering all the material with them and the relevant facts has acted in a particular manner, then such acts will not amount to deficiency in service. Thus there is no deficiency in service on the part of the opposite party and the complaint is liable to be dismissed. The complainant has approached this commission without any bonafides and hence the complaint is liable to be dismissed.
Towards the evidence part the complainant has filed affidavit in lieu of chief examination along with documents which were marked as Exhibit A1 to A14 and the opposite party has no oral evidence and filed only documents which were marked as Exhibits B1 to B5.
On the basis of the pleadings and evidence the points to be framed are that whether the complainant has successfully established any deficiency of service on the part of the opposite parties and if so what are the reliefs?
Upon a thoughtful evaluation of the facts and circumstances of the complaint, it is understood that the complainant had an accident by falling from scooter and he got admitted in the hospital due to cervical spine injury & cervical disc prolapse on 9-9-20 as per the exhibit A10 and he underwent emergency C6 C7 discectomy and fusion as per Exhibit A2 discharge summary. Though the complainant submitted a claim to the opposite parties on time, he failed to submit the original documents within the time limit and hence the claim was closed by the opposite parties.
The opposite parties have not challenged the injury, hospitalisation bill amount etc. The claim is admitted. The only reason for the closure of the claim is the non-production of documents. Subsequently all the documents are produced before this Commission by the complainant. Hence the opposite parties can very well settle the claim on the basis of the said documents.
The complainant though alleges that he had produced the documents by way of email etc., has not produced any evidence to that effect. The original documents are produced before us.
Though the complainant has not made out a clear deficiency on the part of the opposite parties, it is admittedly evident that the complainant had a valid insurance and the claim is admissible. The only reason is the delay in submitting the original documents. As the opposite parties have received the premium amount from the complainant and the claim is admitted, they are bound to reimburse the insurance policy. The Consumer Protection Act aims at protecting the interest of the consumers and it being a beneficial legislation deserves pragmatic construction.
Hence allowing the complaint we direct the opposite parties to process the claim of the complainant as per the documents produced before this Commission within 30 days of copy of this Order.
Pronounced in the Open Commission on this the 29th day of December, 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 policy 2952203364481100000
A2 –Discharge summary dtd.13-09-20 issued by Caritas Hospital
A3- MRI scan report dtd.09-09-20 issued by Jeevan MRI Centre
A4- Bill dtd.09-09-2020 by Caritas hospital
A5-Duplicate bill dtd.09-09-20 by Jeevan MRI Centre\
A6 – Discharge bill dtd.13-09-20 by Caritas hospital
A7- Progressive bill dtd.09-09-20 by Caritas hospital
A8-Cash receipt dtd.09-09-20 by Jeevan Health care group
A9-Bill dtd.13-09-20 by Caritas Hospital
A10-Certificate dtd.01-10-20 by Dr.Saeesh Kumar
A11-Advance receipt dtd.13-09-2020 by Caritas hospital
A12-Claim form Part A and B by opposite party
A13-Copy of screen shot dtd.03-10-2020 and certificate u/s 65 B of Evidence Act
A14- Copy of screen shot dtd.18-11-2020 and certificate u/s 65 B of Evidence Act
Exhibits marked from the side of opposite party
B1 – Copy of claim form
B2 – Copy of discharge summary from Caritas hospital
B3 – Copy of letter dtd.23-09-20 by opposite party to petitioner
B4 – Copy of letter dtd.14-10-20, 30-10-20 and 14-11-20 by opposite party to petitioner
B5 – Copy of claim closure letter without prejudice dtd.14-11-20 by opposite party to petitioner
By Order
Sd/- Assistant Registrar
