DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No. 259/2019

QUORUM:      

Order By: Ms. Rashmi Bansal (Member)

JUDGMENT

By the present judgement, the commission is disposing of the complaint of the complainant against OP alleging deficiency of services in repudiating his medical insurance claim.

Initially the complaint has been filed against 3 OPs, however, vide order dated 24.10.2019, OP1 and OP 2 were deleted from the array of parties and only current OP remained against which complainant has claimed his relief.

1. It is the case of the complainant that he has opted for a medical policy, for a period from 13.08.2016 to 12.08.2017 from OP. His wife was admitted in AIIMS for the period from 07.11.2016 to 22.11.2016, for her treatment and thereafter, the complainant has preferred a claim of Rs.1,88,729/- along with all the required documents, submitted to OP on 02.01.2017. OP vide his letter dated 13.02.2017 again asked the complainant for more details which were also provided by the complainant on 14.02.2017, duly acknowledged by the OP, however, despite submitting all the required documents, OP did not pay the claim amount to the complainant till date andon checking the status of his claim on mobile phone through SMS on 08.08.2019 and 10.08.2019, claim is shown in progress.
2. Complainant submits that on account of deficiency of services on the part of OP in not paying his legitimate claim, he has suffered mental tension, harassment, financial loss for which he claims a compensation of Rs.3 lakhs along with payment of his claim amount of Rs. 1,88,729/-.
3. Upon notice, OP has appeared and filed its reply admitting issuance of the policy however, taking objection with respect to the limitation of two years after cause of action has arisen, that is, repudiation of the claimvide letter dated 28.07.2017 and the present complaint is filed in October 2019. It was also submitted that the last communication between the parties took place on 14.02.2017 and thereafter no communication has ever taken place between them, which clearly suggest that the present complaint is not maintainable and is liable to be dismissed being time barred as per provisions of law.
4. OP denied the supply of the required documents by the complainant, submitting that even otherwise the veracity and correctness of the claim has to be ascertained by the TPA of OP and when the complainant fails to submit the required documents, it impliedly prove that claim was filed by the claimant against the terms and conditions of the policy and said claim is not be payable being false claim.
5. OP further submits that the complainant has failed to deposit its documents despite OP’s letters dated 24.02.2017, 14.04.2017 and 22.03.2017, therefore, OP had no option but to close the claim of the complainant as ‘no claim’ vide letter dated 28.07.2017. OP further submits that even with the reply dated 14.02.2017 by the complainant in response of OP letter dated 13.02.2017, the complainant did not provide the documents and since then no further communication took place between OP and the complainant. OP has also denied the SMS alerts as mentioned by the complainant.
6. Complainant has filed his rejoinder denying the averments of OP and specifically denied receipt of any letter dated 24.02.2017, 14.04.2017, 22.03.2017 and 28.07.2017 from the OP and stated that such documents have never been acknowledged by the complainant and OP has to be put on strict proof with respect to supply of such documents to the complainant.
7. Both the parties have filed their respective evidences.
8. In support of his case, complainant has relied upon the copy of insurance policy, copy of discharge summary, claim form along with documentsduly acknowledged by OP, authorisation slip, letter dated 13.02.2017 of OP and reply dated 14.02.2017 by the complainant, SMS alert of OP.
9. OP has filed copy of the policy, copies of the letter dated 24.02.2017, 14.04.2017, 22.03.2017 and 28.07.2017.
10. The Commission has heard the arguments and perused the record.
11. Before deciding the matter on merits, the objection of the OP with respect to filing of the complaint beyond limitation is to be dealt with. The SMS alert dated 08.08. 2019 and 10.08.2019, filed by the complainant mentions “current status of your claim, 1378 3962 at all India Institute of medical sciences from 17.11.201 6–22.11.2016 is in progress. Claimed amount 1,88,729”. This SMS alerts,though denied by the OP, but without any evidence in support of it showing that these SMS alerts are not from them, and this leaves no doubt that at the time of filing the complaint, the cause of action was running. Therefore, the complaint is within limitation and the contention of the OP is rejected.
12. Further, the fact that , complainant’s wife has taken treatment from AIIMS, the claim amount of Rs. 1,88,729/- is also not disputed by OP. The basic defence of the OP is that the complainant has not submitted the requisite documents and has not cooperated with the OP. This is also observed that the claim of the complainant has been repudiated on the ground of non-receipt of the required information/documents and the claim was closed as no claim, whereas in evidence, OP contended, that in the absence of the documents the claim is not payable being the false claim as the correctness and voracity of the claim could not be ascertained and was rejected. Both the contentions of the OP are not acceptable as there is no reason why the complainant would not provide the required documents for his claim and further, OP failed to establish that he has not received the required documents or that the letters / reminders dated or that letters dated 24.02.2017, 14.04.2017, 22.03.2017 and 28.07.2017 were served upon the complainant or filed any acknowledgement to that effect. It is matter of record that the complaint/Paper Book was served upon the OP and OP had not asked any document from the Commission if they were deficient.  Fact otherwise is well proved that the complainant has filed all the necessary documents along with the complaint and exhibited all the documents.  Therefore, it appears to the Commission, that the contention of the OP that the complainant did not co-operate or did not furnish the document /details appear to be an after thought.  The OP should have demanded such document from the Commission but it did not ask any document meaning thereby the document were not deficient. 
13. Therefore, there is deficiency on the part of OP in not reimbursing the claim of the complainant.  Therefore, the Commission hereby orders as follows:

• OP would pay Rs.1,88,729/- to the complainant with interest @ 9% p.a. from the date of filing the complaint till date of realization along with compensation of Rs.7,500/- and Rs. 5,000/- towards litigation expenses. 

This order be complied with within 30 days from the date of receipt of the order failing which the OP would pay interest @ 12% p.a. on the entire amount of Rs.2,01,229/- from the date of filing the complaint till actual payment. 

Copy of the order be supplied / sent to the parties free of cost as per rules.

File be consigned to Record Room. 

Announced on 10.01.2024.