BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.

Date of filing : 09/11/2010

Date of Order : 31/12/2011

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 591/2010

Between

And

O R D E R

Paul Gomez, Member.

1. The facts of this complaint lies within a narrow compass :

The complainant was holding Reliance General Insurance Policy with the 1^st opposite party insurance company to the tune of Rs. 1 lakh for one year. The 2^nd opposite party is the authorized agent of the 1^st opposite party and it was through them the policy was taken. In the currency of the policy, the complainant happened to be hospitalised for 16 days in an ayurvedic hospital for which Rs. 26,736/- was charged by the latter. The complainant was asked to produce certain documents pertaining to the claim application that had been submitted through the 2^nd opposite party before the 1^st opposite party. Eventhough the said documents were submitted, the claim application was dismissed. This complaint claiming various reliefs is consequent on dismissal of the above claim application.

2. The 1^st opposite party filed version wherein the allegations have been denied. The 1^st opposite party on receipt of the application had directed the complainant to submit certain relevant documents in relation to the settlement of the claim. But the claimant has hitherto submitted only one document despite repeated reminders. The 1^st opposite party is bound to allow the claim only in accordance with the terms and conditions of the contract of insurance and also subject to exclusions provided therein. Since the complainant had not cared to submit the documents, his claim was closed as no claim. Therefore, there is no deficiency in service on the part of the 1^st opposite party in this regard and urges upon the Forum to dismiss the complaint with costs.

3. The complainant was examined as PW1. Exts. A1 to A7 were marked for him. The 1^st opposite party filed version. No other steps in furtherance of the proceedings on their part. But parties were heard.

4. The points for determination are the following :

1. Whether the dismissal of claim as no claim is justified in the circumstances of the case?

2. Reliefs, if any allowable?

5. Point No. i. :- Ext. A3 policy schedule stands testimony to the contract of insurance. Ext. A4 discharge summary stands to show that the insured was under ayurvedic treatment for the medical infirmities mentioned therein for the period from 16-06-2009 to 02-07-2009. Undoubtedly, the treatment was taken during currency of the policy. Ext. A5 invoices set out the break-up of the charges incurred by the patient for various modes of treatments undergone there. Ext. A6 letters have been forwarded to the insured requesting him to submit certain documents which were considered as relevant for the settlement of the claim. While the 1^st opposite party states that except one, no other required documents have been filed by the complainant before them, the latter asserts that those documents have been submitted through the 2^nd opposite party. Ext. A7 receipts have been produced by the complainant in support of his stand. In his cross-examination in the Forum, he has reiterated the same stand. It is also pertinent to note that in the receipt dated 26-07-2010, some notings regarding some documents are made therein.

6. This is a case where in our view, the documents that have been produced before the 2^nd opposite party have not been forwarded to the 1^st opposite party. That has given rise to this misunderstanding between the parties and ultimately the insurance claim happened to be dismissed. In our view, the documents that have been submitted before this Forum, copies of which have been served on the 1^st opposite party are enough for a just disposal of the claim application. If at all anything is still need to be produced, they can be retrieved from the software system available with the opposite parties. There is no justification in further prolonging the matter. In that view of the matter, in the light of the discussion, we just had, the 1^st opposite party is directed to re-open the claim of the complainant and dispose of the matter expeditiously in a just and fair manner within a period of 2 months from the date of this order. In the facts and circumstances of the case, we refrain from ordering any other relief.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in open Forum on this the 31^st day of December 2011.

Sd/- Paul Gomez, Member. Sd/- A. Rajesh, President.

Sd/- C.K. Lekhamma, Member.

Forwarded/By order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :: Nil

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