BEFORE THE DAKSHINA KANNADA DISTRICT  CONSUMER DISPUTES REDRESSAL FORUM,  ADDITIONAL BENCH, MANGALORE    

Dated this the 01^st March 2017

PRESENT

SRI. VISHWESHWARA BHAT D         : HON’BLE PRESIDENT

SRI. T.C. RAJASHEKAR                       : MEMBER

ORDER IN

C.C.No.347/2013

(Admitted on 21.12.2013)

M. Ibrahim,

S/o Late. B.Mohammad,

Aged about 60 years,

R/at Pangalai House,

Darbe Post,

Puttur, Taluk, D.K.

                                                                ….. COMPLAINANT

(Advocate for the Complainant: Sri SD)

VERSUS

The Manager,

National Insurance Co.Ltd,

Dharmasthala Building,

Main Road, Puttur, D.K.

                                                                   ….OPPOSITE PARTY

 (Advocate for the Opposite Party: Sri. ALS)

ORDER DELIVERED BY HON’BLE MEMBER

T.C. RAJASHEKAR:

I.   1. The above complaint filed under Section 12 of the Consumer Protection Act alleging deficiency in service against claiming, the Opposite Party to pay Rs.37,721/ to complainant with 12% interest from 08.01.2013 till payment, to pay Rs.20,000/ as compensation, to pay Rs.10,000/ as expenses.

2.       In support of the above complaint the complainant M. Ibrahim, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked at Ex.C1 to C9 as detailed in the annexure here below.  Opposite Party not any treated nil and produced document got marked at Ex.R1 as detailed in the annexure here below.

       The brief facts of the case are as under:

          We have perused the complaint and the version averments. The dispute is with regard to repudiation of insurance claim. The complainant alleges that he had purchased an insurance policy for his family and on 06.01.2013 to 08.01.2013 he was admitted for the left eye treatment and spent Rs. 37,721/ as hospital expenses for the treatment under gone. But the opposite party opposite party repudiated the claim on submission of claim form. Hence he alleges the deficiency in service on the part of the opposite party. The opposite party defended on the ground that as per policy condition the complainant/insured has to submit claim form within 30 days  after the completion of the treatment but the complainant delayed the claim more than 7 months. Hence the claim is rejected as per policy condition. These are being the facts of dispute in resolving it we consider the following 

POINTS FOR ADJUDICATION

          We have considered the documents produced and the evidence lead by the parties. The admitted facts are the issue of the insurance policy, the admissions to hospital and treatment taken and amount spent. It is also admitted that the complainant submitted the claim form and the claim was rejected on the ground the delay in submission of the claim form as per policy condition. It is denied by the complainant that the opposite party served the policy conditions to him. It id denied by the opposite party that there is deficiency in service on their part in repudiating the claim. Admissions and the denials reconciled and considered the following points for adjudication

1. Whether the complainant is a consumer under the consumer protection Act 1986?
2. Whether opposite party proves that the repudiation is proper and justifiable and there is no deficiency in service on their part.
3. Whether the complainant is entitled for the relief prayed for?
4. What order?

We have examined the evidence produced by the complainant and the documents produced are considered. The opposite party not filed his affidavit evidence. Notes of arguments considered and heard the party submissions and answered the above points as under

1. In the affirmative.
2. In the negative.
3. In the affirmative.
4. As per delivered order.

REASON

POINT NO.1: The complainant produced the policy copy Number 602301/48/11/b500001386 as EX C 1. This policy is issued in the name of the complainant herein. The opposite party not denied the complainant as consumer. Hence there established the relation of Consumer and the service provider between the complainant and the opposite party. Hence we answered the point No 1 in the affirmative.

POINT NO. 2: The opposite party after admitting the issue of policy and the treatment taken on admission to hospital by the complainant repudiated the claim submitted by the complainant on the ground of delay in submission of the claim form as per policy condition. Hence we have taken the point no 2 for consideration. The defense of the opposite party is that, as per policy condition No 6.3  in case of post hospitalization, treatment the all claim documents shall be submitted within 30 days after completion of treatment. But the complainant delayed the submission of claim form and the documents by 7 months and the claim is rejected justifiably.

2. It is admitted as true that the treatment was completed on 17.02.2013 and the complainant written letter(EX C 2) dated 16.05.2013 about the hospitalization with the details of name of the hospital, the disease treated, and date of admission to hospital and date of completion of treatment, the amount spent, and the letter also stated that the bill for Rs. 37,721/ is submitted with discharge summery details of drugs and other reports. The letter requested to acknowledge and settle the claim. EX C 3 is the letter dated 20.05.2013 addressed to the complainant which directs the complainant to submit the claim with the bills. This is the earliest stage where the opposite party should have taken the contention of delay in submitting the claim. But the opposite party instructs the complainant to submit the claim papers. Is it not the inference of condoning the delay in submission of the claim, as by this time already there is delay in submission of the bills and other documents? Can the opposite party take the same ground after once condoned and allowed to submit the claim form. The opposite party contention is not tenable.

EX C 9 is the letter purported to be repudiation letter cum reply to the complainants legal notice. In para 3 it is stated that further even though the doctor had cerified your treatment on 13.06.2013 still there is delay of nearly 3 months on receipt of your claim papers.  Again in last Para it is stated that unless we receive satisfactory explanation for the delay in submission of papers claim can hardly be considered. The combined reading of these two lines emanates that the opposite party admits the date of doctors certificate as date of condition within 30 days starts for the purpose of delay in claiming. We already seen the contents to the letter dated 16.05.2013 (EX C 2) in which all particulars with regard to treatment and papers and bill are submitted. The left over is only the formality of claim form submission. Also the last line manifests that the claim not yet been refused as it says it is hard to consider the claim if delay in not satisfactorily explained. So there is discretion with the opposite party in settling the claim if delay explained. As we already seen in previous Para that the delay already been condoned there is no reason to explain the delay.

3. On close scanning of the opposite party version, we have not found anywhere the opposite party has disputed the admission to hospital, treatment taken, the amount spent and the documents like discharge summery, payment bills, doctors certificate etc. When all the above facts are being admitted why the opposite party need the claim should be submitted within 30 days is not explained. Very condition in a contract will be based on some understanding. This condition also based on an opportunity shall be there for the opposite party to justify the claim by conducting some enquiry. But the opposite party case is not disputing the facts as above or an opportunity to enquiry into the instance. Only because there is condition and its breach occurred cannot be a ground for repudiation if consider it in the angle of natural justice. The opposite party shall state because of breach of condition what he has suffered or what opportunity he lost. In our opinion even if there is delay it is condonable and not worth of repudiation of claim.

4. The opposite party produced an authority New India Insurance co ltd V. Ram Avatar reported in I 2014 CPJ 29 and submitted that the delay in information of a fact is contravention of the policy condition. On conceiving the facts of the case, the authority is related to theft of a vehicle and the delay in information will lead to loss of opportunity to the opposite party in mitigating the loss. But the case on bench is not related to theft or it is not related to prior information before hospitalization. It is related to submission of bills and the claim form with in time stipulated in the policy as condition. Hence in our opinion the cited case cannot be applied mutatis mutandis  The complainant cited authorities as, IV (2015) CPJ 376 National Commission. It is held No evidence that Opposite parties ever supplied terms and conditions of group personal accident policy unfair trade practice proved. IV 2011 CPJ 390 National Commission. It is held technical objections like...not filing claim within 30 days will not make  a difference to the case of the complainants We saw there is specific contention by the complainant that the condition of the policy not supplied to them but the opposite party not disputed it either in their version or any suggestion in the interrogatories to the complainant. Also when there is no dispute with regard to admission and treatment the condition terms of the policy the claim shall be submitted within 30 days have a low profile and will not make any difference to the complainant case.

5. The opposite party has brought to our notice that another treatment at Puttur, and the claim made previous to the present treatment. We lost understand what relevance of this with the present case and the opposite party also not enlighten us and hence viewed lightly. In our considered opinion the opposite party has not proved his case as the repudiation of claim is  proper and justified it hence we answered the point no 2 in the negative.

POINT NO. 3 : We as per above discussion hold the breach of policy condition is not appreciated properly by taking facts and circumstances in to consideration and repudiated the claim on no acceptable ground and liable for deficiency in service. The complainant is entitled for the relief prayed for. The complainant is entitled for undisputed treatment expenses of Rs.37,721/ with an interest of 10 % per annum from the date of repudiation till the date of payment. There is negligence on the part of the opposite party in repudiation of the complainant claim and the complainant is entitled for an amount of Rs.10,000/ towards compensation and Rs.6,000/ as legal expenses.

POINT NO. 4: In the light of above discussion and adjudication of the above points we deliver the following

ORDER

         The complainant is allowed. The opposite party shall pay the complainant an amount of Rs.37,721/(Rupees Thirty seven thousand seven hundred twenty one only)   with an interest of 10 % per annum from the date of repudiation till the date of payment and an amount of Rs.10,000/(Rupees Ten thousand only) towards compensation and Rs.6,000/(Rupees Six thousand only) as cost within 30 days from the date copy of this order received.  

     Copy of this order as per statutory requirements, be forward to the parties free of costs and file shall be consigned to record room.

(Page No.1 to 10 directly typed by Member, revised and pronounced in the open court on this the 1^st March 2017)

            MEMBER                                              PRESIDENT

        (T.C. RAJASHEKAR)                        (VISHWESHWARA BHAT D)

  D.K. District Consumer Forum                D.K. District Consumer Forum

Additional Bench, Mangalore                   Additional Bench, Mangalore

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1  M. Ibrahim,

Documents marked on behalf of the Complainant:

ExC1: 07.02.2012: Copy of the policy.

ExC2:16.05.2013: O/c of the claim letter.

ExC3: 20.05.2013: Original reply of Opposite Party for the claim letter.

Ex.C4: 13.06.2013: Copy of the claim form.

Ex.C5: 06.01.2013 to 17.02.2013: Copy of the bills (8).

Ex.C6: 08.01.2013: Copy of the Discharge summary.

Ex.C7: 17.02.2013: Copy of the treatment certificate.

Ex.C8: 11.09.2013: O/c of regd. lawyers notice.

Ex.C9: 13.09.2013: Reply of the Opposite Party.

Witnesses examined on behalf of the Opposite Party:

Nil

Documents marked on behalf of the Opposite Party:

Ex.R1: copy of policy conditions.

Dated:  01.03.2017                             MEMBER