For Complainant : Sri Krutibas Rout, Advocate.
For OPs 1 & 2 : None
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1. The brief history of the case of the complainant is that he is a retired employee of OP.2 vide PB No.1425 and the OP.2 has provided health insurance cover to its retired employee under Master Health Insurance Policy bearing No.070300/26/16/PI/14937187 of United Insurance Co. under which the complainant is a beneficiary. It is submitted that the complainant was admitted in Baba Sri Lokanath Seva Sadan, Berhampur on 16.12.2017 for treatment of Cholecystitis and was discharged on 16.1.2018. It is further submitted that the complainant furnished health insurance claim bill amounting to Rs.158761/- before the OP.1 on 07.03.2018 with all relevant documents and the OP.1 being the service provider registered the claim vide No.16570840 against insurer claim ID 0703002817C185884001. After enquiry, the OP.1 asked the complainant to provide bank account details but again asked the complainant vide letter dt.08.05.2018 to further submit the treatment related documents. It is also submitted that the complainant has sent the documents by Registered Post on 07.05.2018 which was received by the OP.1 on 11.05.2018. The complainant has also sent the documents through email on 07.05.2018 but the OP.1 through a message dt.23.5.2018 intimated the complainant that they have closed the claim file due to non submission of required documents by the complainant. Thus alleging deficiency in service on the part of OP.1, he filed this case praying the Forum to direct the OPs to settle insurance claim at Rs.1, 58,761/- in favour of the complainant.
2. Both the Ops in spite of valid notice neither filed counter nor participated in this proceeding in any manner. We have heard the A/R for the complainant and perused the materials available on record.
3. In this case health insurance cover provided by the OP.2 to its retired employee under master health insurance policy bearing No. 070300/26/16/PI/14937187 of United Insurance Co. under which the present complainant is a beneficiary is an admitted fact in view of documents available on record. It is also a fact that the complainant was admitted in Baba Sri Lokanath Seba Sadan, Berhampur on 16.12.2017 for treatment of Cholecystitis and was discharged on 16.01.2018 as found from the documents on record. The said hospital has issued final bill amounting to Rs.158761/- and the complainant has lodged claim on 07.03.2018 with OP.1 by sending all required documents. It is also seen from the postal track shipment record that the OP.1 has received the claim documents on 15.03.2018 and also has registered the claim vide No.16570840 against insurer claim ID-0703002817C185884001.
4. The complainant submitted that the OP.1 visited the concerned hospital and thereafter sent a message to the mobile of the complainant on 24.03.2018 asking the complainant to provide bank account details but again on 08.05.2018 asked the complainant to submit required documents.
5. It is seen from the record that the complainant has sent required documents for the second time on 07.05.2018 as ascertained from the track shipment status filed by the complainant in support of his contentions. It is further seen that the complainant has also sent the above documents through email to the OP.1 on 07.05.2018. The Gmail document dt.07.05.2018 at 12.27 PM is also filed by the complainant in support of his case.
6. It is further seen that the complainant has filed a copy of message sent by OP.1 dt.23.05.2018 as Annexure-5. The OP.1 has intimated through that message that due to non submission of documents by the complainant for claim No.16570840, they have closed the claim file.
7. After going through the documents available on record, it is seen that the health insurance and treatment of the complainant is true and the complainant has furnished the treatment related documents from which it is noticed that he was undergoing treatment from 16.12.2017 to 16.01.2018 and a sum of Rs.158761/- has been incurred which is duly supported by bill with medicine details. The complainant has also furnished the treatment related documents before the OP.1 on 07.03.2018 which has been received by the OP.1 on 15.03.2018 vide claim No.16570840. Again as per advice of OP.1, the complainant has submitted the documents on 07.05.2018 which has been received by OP.1 on 11.05.2018. Further the Gmail document furnished by the complainant clearly shows that the complainant has sent the documents to OP.1 through mail on 07.05.2018. If any further document was required, the OP.1 could have asked the complainant to furnish the same but unfortunately without going through the documents sent by the complainant, the OP.1 has closed the claim file on 23.05.2018 which in our opinion is illegal and arbitrary.
8. In absence of counter and participation of the Ops in this proceeding, we had no scope to know anything from them and hence the allegations of the complainant duly supported by documents remained unchallenged. On summing up of the facts and circumstances of the case, we come to the conclusion that without going through the documents sent by the complainant, the OP.1 has closed the claim file which amounts to gross deficiency in service on the part of the OP.1 for which the complainant suffers.
9. In fine, we ascertained that the claim is genuine and duly supported by documents and hence the complainant is entitled to get his claim of Rs.158761/- with interest @ 12% p.a. from the date of filing (23.08.2018) of this case. In the peculiar circumstances of the case, we are not inclined to award any compensation and cost in favour of the complainant.
10. Hence ordered that the complaint petition is allowed in part and the OP No.1 being liable is directed to settle the health insurance claim at Rs.158761/- with interest @ 12% p.a. from 23.08.2018 in favour of the complainant within 30 days from the date of communication of this order. There is no case against OP No.2.
(to dict.)
