By Sri. MOHANDASAN.K, PRESIDENT
The complaint in short is as follows:-
1. The complainant and family was having insurance policy of the opposite party and the complainant remitted insurance premium regularly without failure. During the valid period of the insurance policy she has got complaint of bleeding and subsequently under gone DNC Procedure. The complainant was consulted with a doctor and as per his advice he was treated as inpatient in ARMC AEGIS hospital, Perintalmanna. The said hospital was not having tie-up with the opposite party insurance company, the husband of the complainant was directed to remit the hospital bills and to submit claim before the opposite parties. The complaint met an amount of Rs. 30,021/- for her treatment in the hospital.
2. The complainant submitted her claim before the opposite party, but the opposite party did not allow the hospital expenses stating various reasons. The complainant submitted account details of herself, the daughter and the account details of her husband on various occasions. But the opposite parties repeatedly demanded account details of the daughter of complainant. The complainant submitted that she met the hospital expenses with the expectation that the opposite party will pay the amount duly. But the opposite party did not pay the amount without any valid reason and thereby caused inconvenience, hardship and mental agony. Hence the complainant pray for the treatment expense of Rs. 30,021/- along with interest at the rate of 12% per annum. The complaint also prayed compensation of Rs. 2, 00,000/- and cost of Rs. 25,000/-.
3. On admission of the complaint notice was issued to the opposite parties and the opposite parties entered appearance and filed version denying the entire averments and allegations in the complaint.
4. The oppose parties submitted that they were always ready and willing to settle the claim filed by the complainant for her treatment and they never denied the claim of the complainant. The opposite parties admitted that the claim of the complainant dated 01/12/2020 is for reimbursement medical expenses and the same was received by the opposite parties on 10/12/2020.
5. The opposite parties submitted that the insurance industry has shifted to payment by NEFT mode for settling all claims. The same is in line with the Government Policy of going digital and also because there were many complaints of loss in transit of cheques and also instances were cheques landed in wrong hands. For settlement by NEFT mode it is standard practice of the insurance Industry to request for NEFT details,
6. The opposite party submitted that they issued letter on 22/12/2020 requesting the proposer i.e. Fathima Dilshana, daughter of the complainant to submit any of the documents for NEFT that is cancelled cheques/ bank passbook with band stamp/ bank statement with stamp of the bank, bearing printed name for proposer with her signature and IFSC code. The letter was addressed to Fathima Dilshana since she is the proposer of the policy by which the insured is covered by the opposite parties. Since there was no reply reminder was sent on 15/01/2021 and thereafter on 17/3/2021. But so far no reply has been received.
7. The complainant has admitted in the complaint that she has received first two letters. But no explanation has been given in the complaint as to why the complainant has not replied to the letter or why the complainant has not produced the documents request for.
8. The opposite parties submitted that the amount will be transferred to the account of the proposer or complainant within 10 days of receipt of the NEFT details. It is further submitted that if the complainant wants to exercise the option of receiving the payment by cheque then the complainant can express the intention in writing and the cheque will be produced in court within 15 days or sent to the complainant if so directed by the Commission. Hence the submission of the opposite party is that they have not committed any deficiency in service. But the complainant unnecessarily dragged the matter to this Commission instead of simply writing a letter to the opposite parties either enclosing the NEFT details or requesting for payment by cheque. Hence it is submitted that the complaint is frivolous one and so liable to be dismissed with cost to the opposite parties.
9. The complainant and opposite parties filed affidavit and documents. The documents on the side of complainant marked as Exts. A1 to A14 and the documents on the side of opposite parties marked as Ext. B1 series. Ext. A1 is copy of Courier receipts issued by DTDC Courier Service dated 05/12/2020 and 25/02/2021. Ext. A2 is copy of letter issued by the HDFC Ergo General Insurance Company Limited to Fathima Dilsana dated 22/12/2020. Ext. A3 is copy of letter issued by the HDFC Ergo General Insurance Company Limited to Fathima Dilshana 16/02/2021. Ext. A4 is copy of consultation bill dated 20/11/2020 of ARMC AEGIS Hospital, Perinthalmanna. Ext. A5 is copy of procedure bill dated 20/11/2020 issued by ARMC AEGIS Hospital. Ext. A6 is copy of lab bill dated 20/11/2020. Ext. A7 is copy of cash receipt of registration fee issued from ARMC AEGIS Hospital dated 20/11/2020. Ext. A8 is copy of pharmacy bill dated 21/11/2020 of ARMC AEGIS Hospital. Ext. A9 is copy of lab bill dated 21/11/2020. Ext. A10 is copy of pharmacy bills dated 23/11/2020 (6 Nos.). Ext. A11 is discharge bill issued by dated 24/11/2020. Ext. A12 is copy of pharmacy bill dated 24/11/2020.Ext. A13 discharge summary dated 24/11/2020. Ext. A14 is copy of receipt to show the consignment delivered to the opposite party dated 10/12/2020. Ext. B1 series copy of letters issued by the opposite party to the Fathima Dilshana dated 15/01/2021 and 17/03/2021.
10. Heard complainant and opposite parties. Perused affidavit and documents. The following points arise for consideration:-
- Whether there is deficiency in service on the part of the opposite parties?
- Relief and cost?
11. Point No.1 and 2 :-
The case of the complainant is that she has got insurance coverage with the opposite parties and thereby the complainant approached the opposite parties for the reimbursement of medical expenses met by her. The opposite party did not allow the claim stating non submission of account details which is baseless one. Hence the complainant filed this complaint seeking direction to allow the medical expenses met by her in the hospital along with interest, compensation and cost.
12. The opposite parties submitted version contenting that they are prepared to allow the claim of the complainant subject to production of account details to effect payment through NEFT. The contention of the opposite party is that the complainant failed to provide the account details and so there is no any sort of deficiency in service on the part of opposite parties.
13. The complainant produced Exts A1 to A14 to establish the claim of the complainant. The opposite party produced Ext. B1 series to prove the case of the opposite parties.
14. It can be seen that the complainant filed this complaint on 22/07/2021 to allow the insurance claim which is an admitted fact. But the opposite party so far not turned to pay the admitted claim to the complainant. The opposite party have no case that the complainant did not submit claim details except the account details. If that be so the opposite party is not barred from producing the admitted insurance amount before the Commission. The complainant submitted that the claim details and the account details were submitted to the opposite parties and the same was received by the opposite party. The complainant produced Ext. A1 series and Ext. A14 document to substantiate the contention of the complainant. The complainant admitted the issuance of Ext. B1 series. But the fact remains the opposite party so far not paid the amount to the complainant. The opposite parties are not restrained from effecting payment through the cheque instead of NEFT. In the light of above facts and circumstance we find that there is deficiency in service on the part of opposite party. The complainant is entitled the medical expenses with interest as stated in the complaint. It is also relevant to note that the complainant approached the opposite party duly with documents, but the opposite party did not consider the claim in due time. As per Ext A4 the opposite party received the documents as part of claim on 10/12/2020. Since the opposite party failed to honour the claim within reasonable time, resulted much inconvenience and hardship to the complainant. Hence the complainant is entitled a reasonable amount of compensation and that we fix as Rs. 25,000/-. The Complainant is also entitled cost of proceedings Rs. 10,000/-.
15. In the light of above facts and circumstances, we allow this complaint as follows:
- The opposite parties are directed to pay Rs. 30,021/-(Rupees Thirty thousand and twenty one only) to the complainant towards the medical expenses.
- The opposite parties are directed to pay Rs. 25000/- (Rupees Twenty five thousand only) as compensation to the complainant.
- The opposite parties are directed to ay Rs. 5000/- (Rupees Five thousand only) as cost of the proceedings.
- It is clarified that if the documents already submitted by the complainant to the opposite party is not sufficient to effect NEFT transaction the opposite parties are directed to pay the amount through cheque in favour of the complainant.
The opposite parties shall comply this order within one month from the date of receipt of copy of this order, failing which the entire above amount will carry interest at the rate of 9% per annum from the date of filing this complaint to till realization.
Dated this 30th day of April, 2024.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A14
Ext. A1 : Copy of Courier receipts issued by DTDC Courier Service dated 05/12/2020
and 25/02/2021.
Ext. A2: Copy of letter issued by the HDFC Ergo General Insurance Company Limited
to Fathima Dilsana dated 22/12/2020.
Ext. A3: Copy of letter issued by the HDFC Ergo General Insurance Company Limited
to Fathima Dilshana 16/02/2021.
Ext. A4: Copy of consultation bill dated 20/11/2020 of ARMC AEGIS Hospital,
Perinthalmanna.
Ext. A5: Copy of procedure bill dated 20/11/2020 issued by ARMC AEGIS Hospital. Ext. A6 : Copy of lab bill dated 20/11/2020.
Ext. A7 : Copy of cash receipt of registration fee issued from ARMC AEGIS Hospital
dated 20/11/2020.
Ext. A8: Copy of pharmacy bill dated 21/11/2020 of ARMC AEGIS Hospital.
Ext. A9: Copy of lab bill dated 21/11/2020.
Ext. A10 : Copy of pharmacy bills dated 23/11/2020 (6 Nos.).
Ext. A11 : Discharge bill issued by dated 24/11/2020.
Ext. A12 : Copy of pharmacy bill dated 24/11/2020.
Ext. A13: Discharge summary dated 24/11/2020.
Ext. A14: Copy of receipt to show the consignment delivered to the opposite party dated 10/12/2020.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1
Ext. B1: Series copy of letters issued by the opposite party to the Fathima Dilshana
dated 15/01/2021 and 17/03/2021.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
