MS. NIPUR CHANDNA, MEMBER
ORDER
07.03.2024
1. A complaint under Section 12 of Consumer Protection Act filed. In brief the facts are that complainant was having the mediclaim policy vide policy bearing no. 041202/48/13/06/00001794 for himself and his family members.
2. On 12.01 2015 , complainant while returning from the court sitting in the car suddenly started having chest pain, neck pain and sweating in the body as such his driver took him to Max Super Speciality Hospital, Shalimar Bagh, Delhi. On admission and after conducting various tests it was found that complainant was suffering from mild Hemichorea (left vescular) and was discharged from hospital on 13.01.2015. Complainant incurred total expenses to the tune of Rs. 62,265/-
3. After discharge from the hospital complainant lodged reimbursement claim with OP vide claim no. HH811602061. The OP Ins company reimburse an amount of Rs. 20577/- out of the total sum of Rs. 62265/- and arbitrarily deducted a sum of Rs. 41,688/-. Complainant wrote various letters for reimbursement of the balance claim but all in vain. It is also stated that on various occasion complainant submitted the duplicate medical bill to OP company for processing the claim but despite receiving the entire medical record as well as bills OP arbitrarily rejected the claim under the pretext of non receipt of the requisite documents. This act of OPs squarely covered under the deficiency in service, hence, this complaint.
4. Notice of complaint was sent to both the OPs.Despite opportunity OP-1 failed to file its WS. OP-2 filed its WS thereby denying any deficiency in service on its part. It is further stated that Op-1 sought necessary queries from the complainant and also requested for relevant documents for processing the claim. But the complainant never supplied the requite documents as such no cause of action ever arose in favor of the complainant and against OP-1. It is further stated that it is the hospital who has refunded Rs. 20577/- to the complainant and not the Ins. Co. It is further prayed that since the complainant failed to submit the requisite documents for processing the claim no case of deficiency in service can be made out against OP-1 and further requested that present complaint be dismissed with cost.
5. Complainant filed his evidence by way of affidavit and has placed on record the copy of treatment record as well as treatment bill, copy of letter dated 05.11.2015, 30.11.2015 and 05.01.2016 issued by OP-1. He has also placed on record the copy of letter dated 09.11.2015, 23.06.2016, 29.09.2017 address to OP-1 in support of his contention.
6. Sh. Satish Jagga Sr. Divisional manager of OP-2 Ins. Co. filed his evidence by way of affidavit.
7. The two questions for our consideration in the present complaint case is whether the complainant has submitted the requisite documents to OP-2 Ins. Co. and whether the non settlement of claim by OP is illegal or justified.
8. The complainant has placed on record the copy of letter dated 09.11.2015, 23.06.2016, 29.09.2017 address to OP-1. The bare perusal of the aforesaid letter makes it clear that on three occasions complainant has submitted the requisite documents to OP-1 for processing the claim. Moreover, the OP-2 Ins. Co. had not challenged in its written statement that complainant had not submitted the requisite documents to OP-1. Admittedly, there is a communication gap between OP-1 & 2 in respect to the submission of requisite documents resulting in the non processing of the claim of complainant. Whereas, the complainant has placed on record the copy of letter dated 09.11.2015, 23.06.2016, 29.09.2017 address to OP-1 which clearly establish that on each and every occasion complainant had submitted the requisite documents to OP-1 for processing the claim. Both the OPs failed to place on record any documentary evidence to establish that complainant failed to comply the directions of OPs . Along with its pleading OP-2 Ins. Co. has not placed on record any documentary evidence in respect to the non submission of the requisite documents by complainant. Moreover, OP-1 can easily procure the medical treatment record of the complainant to verify the truth from the hospital being TPA, but OP1 has not taken any steps. . Both the OPs under the pretext of non submission of the documents were trying to escape from the liability of indemnification. This act of OPs are totally unjust, illegal and arbitrary squarely covered under the definition of deficiency in service.
9. In view of the above discussion, we are of the considered opinion that both the OPs are guilty of deficiency in service. We therefore direct OP-2 Insurance Co. as under:-
i) pay to the complainant a sum of Rs. 41,688/- along with interest @6% from the date of filing of complaint i.e. 15.12.2017 till realization.
- Pay to the complainant a sum of Rs.15,000/- toward compensation for pain and mental agony suffered by him which will include the cost of litigation.
10. OP is directed to comply the order within 30 days from the date of receipt of this order failing which OP is liable to pay to the complainant interest @9% per annum from the date of non-compliance till realization.
Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving the application from the parties in the registry. Order be uploaded on www.confonet.nic.in.
Announced in open Commission on 07.03.2024.
SANJAY KUMAR NIPUR CHANDNA RAJESH
PRESIDENT MEMBER MEMBER
