BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 20 of 2019
Date of Institution : 22.01.2019
Date of Decision : 25.07.2019
Rajinder Kumar, aged 57 years, son of Shri Banarsi Dass, resident of village Goriwala, Tehsil Dabwali District Sirsa.
……Complainant.
Versus.
1. The Branch Manager, Life Insurance Corporation of India, Sirsa, District Sirsa.
2. The Senior Divisional Manager, Life Insurance Corporation of India, SCO-3,4,5 Sector 1, HUDA Rohtak.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI R.L. AHUJA…… PRESIDENT.
SHRI ISSAM SINGH SAGWAL……MEMBER.
MRS. SUKHDEEP KAUR……….MEMBER.
Present: Sh. Vishnu Bhagwan, Advocate for complainant.
Sh. K.K. Relan, Advocate for opposite parties.
ORDER
In brief, the case of complainant is that the complainant purchased a Joint Health Policy along with his wife Smt. Sushma bearing plan No.904, Policy No.179906340 on 24.07.2015 from the ops. The annual installment of the complainant was Rs.4,044-09, whereas, the annual premium of his wife was Rs.2,725-14. The date of proposal of this policy was 12.06.2015. The complainant continued making payment of the premium amount of this policy to the ops. It is further averred that on 4.5.2017, the complainant developed some heart problem and he was taken to Delhi Heart Institute and Multispeciality hospital, Bathinda, where he was admitted on 4.5.2017 and on 9.5.2017, the complainant was referred to Fortis, Mohali. A sum of Rs.2,04,620/- was incurred by the complainant for his treatment at Bathinda. That thereafter, on 9.5.2017, the complainant was taken to Fortis, Mohali where he was admitted on 10.5.2017 and underwent heart surgery and he was discharged on 16.5.2017. A sum of Rs.3,77,193/- was charged by the Fortis, Mohali as operation fee and other medicines expenses. The complainant lodged his claim with the op no.1 and submitted all the required documents for settlement for his claim. However, vide letter dated 15.9.2017, the complainant was required to submit more documents, which the complainant submitted vide his letters dated 3.11.2017 and 5.1.2018, but till date the claim of the complainant has not been settled/ decided by the ops. The complainant also got served a legal notice upon the ops on 14.9.2018 but of no use. That in this manner, the ops have committed gross deficiency in service and harassment to the complainant. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections regarding maintainability, complaint is premature, cause of action, concealment of true and material facts and that there is no deficiency in service on the part of the ops. On merits, it is submitted that as per the policy condition, claim payment does not depend upon the expenses incurred by the policy holder but defined benefits are to be paid. It is further submitted that it is wrong to say that the complainant submitted all the required documents for settlement of his claim as the discharge summary not yet submitted by him till date in spite of several reminders. It is further submitted that claim requirement letters dated 17.7.2017, 27.7.2017, 11.8.2017 and 26.8.2017 were sent to the policy holder at his residence for providing discharge summary only but the same was not provided by policy holder. The policy holder did not comply with the requirements called for and the claim was pending even after repeated reminders, hence the claim was rejected instead of keeping it open. Remaining contents of the complaint are also denied and prayer for dismissal of complaint made.
3. The parties then led their respective evidence.
4. We have heard learned counsel for the complainant and learned counsel for ops and have perused the record carefully.
5. The complainant in order to prove his case has tendered affidavit Ex.CW1/A in which he has deposed and reiterated averments made in the complaint. He has also produced documents i.e. Ex.C1 copy of policy schedule, Ex.C2 copy of medical examination confidential report, Ex.C3 copy of blood sugar report, Ex.C4 copy of Urine report, Ex.C5 copy of referral summary, Ex.C6 copy of hospital bill, Ex.C7 copy of discharge summary, Ex.C8 copy of operation notes, copies of medical record and bills Ex.C9, Ex.C10 and Ex.P11 to Ex.P14, copies of letters Ex.P15 to Ex.P17, copy of claim form Ex.P19, copy of repudiation letter dated 15.9.2017 Ex.P20, copy of legal notice Ex.P21 and copies of postal receipts Ex.P22, Ex.P23. On the other hand, OPs have tendered Ex.R1-affidavit of Rajender Singh Manager(Legal), Ex.R2 to Ex.R5 claim requirement letters, Ex.R6, Ex.R7 copies of medical reports of complainant, Ex.R8 copy of Cardiac Surgery form-II and Ex.R9 copy of repudiation letter.
6. Admittedly, the complainant had purchased a joint health policy alongwith his wife Smt. Sushma bearing plan No.904, policy No.179906340 on 24.7.2015 from the ops. The complainant developed some heart problem and was taken to Delhi Heart Institute & Multispeciality hospital, Bathinda and remained there from 4.5.2017 to 9.5.2017 and thereafter he was referred to Fortis Hospital, Mohali where he underwent heart surgery and was discharged on 16.5.2017. As per averments of complainant, he spent Rs.2,04,620/- on his treatment at Delhi Heart Institute and Multispeciality Hospital, Bathinda and he spent Rs.3,77,193/- on his treatment at Fortis Hospital, Mohali. Due intimation was given to the ops and claim was lodged, but however, same was not settled and paid rather claim file of the complainant was closed.
7. During the course of arguments, learned counsel for ops has strongly contended that despite best efforts of the ops and reminders, the complainant has not submitted summary of treatment taken by complainant at Delhi Heart Institute, Bathinda and nor he has submitted discharge summary of the Fortis Hospital, Mohali alongwith medical record, as a result of which the ops had no other option except to close the claim file.
8. Learned counsel for complainant has stated at bar that complainant has already submitted the requisite documents to the ops but despite that ops have not settled the claim of complainant. So, it will be in the fitness of things, if direction is given to the complainant to submit requisite documents which are necessary for the settlement of the claim and further ops are directed to examine the documents and thereafter settle the claim of complainant.
9. In view of above discussion, we partly allow the present complaint and complainant is directed to supply all the requisite documents which are required by the opposite parties for settlement of claim within 15 days from the date of receipt of copy of this order. The ops are directed to examine the documents so submitted by complainant and thereafter settle and pay the claim of complainant as per terms and conditions of the insurance policy within further period of 30 days. In case the documents submitted by complainant are not sufficient, the ops shall serve a seven days prior notice calling upon the complainant to submit the additional documents which they require for settlement of claim before passing any order of repudiation. Keeping in view the facts and circumstances of the case, no order as to costs. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum:Member Member President,
Dated: 25.07.2019 District Consumer Disputes
Redressal Forum, Sirsa.
