THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C. 413/2012
Dated this the 18th day of February 2016
(Smt. Rose Jose, B.Sc, LLB. : President)
Smt.Beena Joseph, M.A : Member
Sri. Joseph Mathew, MA, LLB : Member
ORDER
Present: Beena Joseph, Member:
This petition was filed on 28.09.2012 against the illegal repudiation of mediclaim of the petitioner. Petitioner states that he has taken a mediclaim insurance from 1st opposite party through the 2nd opposite party on 07.02.2011. Thereafter on 07.08.2011 during the insurance period he met with an accident and dislocation caused to his left shoulder. And he was admitted in Malabar Medical College hospital and he was discharged on 08.08.2011.He informed regarding the accident to the insurance Company through second opposite party. Later claim form submitted with all relevant documents through second opposite party. Instead of honouring the claim insurance authorities will fully repudiated the claim of the petitioner. Thus they committed service deficiency and cheating . So the petitioner seeks medical bill amount and compensation.
In this matter notice were issued to both parties. Both of them appeared. 1st opposite party filed version stating the following contentions. The complainant has got valid mediclaim policy during the policy period. But the claim form was lodged not in time as per the rules. Hence the 1st opposite party repudiate the claim on 31.10.2011 and issued letter to that effect. According to the 1st opposite party the hospitalization has to be intimated to the insurance company within 24 hours from the date of occurrence of the event. Like wise the claim form has to be submitted within 15 days from the discharge from the hospital. Above condition were not complied by the petitioner. Hence the repudiation of policy is proper and strictly according to the terms and conditions of the policy. So the repudiation is genuine. There is no service deficiency or cheating on the part of the opposite party.
In this matter complainant filed affidavit and examined as PW1 Ext.A1 to A5 were marked. A1 is the copy of policy. A2 is the copy of discharge summary, A3 is the copy of claim form A4 copy of repudiation letter. A5 copy of Lawyer notice.
Basing on the rival contention of the complainant and opposite party, the following issues are framed.
Points to be considered.
1)Is there any service deficiency or illegal trade practice adopted by opposite party?
2)If Yes, what are the awards to be passed.
In this matter the existence of policy and coverage of policy is not disputed by the opposite parties. Admittedly the accident was occurred on 07.08.2011 during the policy period. The opposite party has not disputed the accident, insurance, or the bill of the claim. The only one defence took up by them that the claim put forward is out of time due to that reason alone they repudiated the claim. So in this matter we have to consider whether the repudiation is proper or not. The claim of the respondent was that the accident has to be intimated within 24 hours and the claim has to be lodged within 15 days from the date of discharge. The petitioner herein deposed before the forum that he had intimated the accident within 24 hours to the opposite party through second opposite party who facilitated the policy to the complainant but the second opposite party absent. while verifying the claim form it is proved that there was delay on the part of complainant to lodged the claim. The petitioner deposed before the forum that the delay was caused due to the death of his father’s brother. The only point is to be considered is that whether the delay can be condoned or execused. Admittedly the accident took place in during the policy period and the delay was explained by the complainant, even then a small policy amount was declined by the opposite parties. In this matter we have to consider whether the amount took place is true or not and is it caused during policy period both these circumstances are in favour of the complainant. Repudiation of policy due to some hyper technical basis is against natural justice and contrary to the Law. In this matter the respondents acted in a mechanical manner. They ought to have taken it as a humanitarian ground because it is a beneficial to the policy holder. Denial of policy due to flimsy reason is improper. More over in this matter complainant explained the delay for submitting the claim form, above all he deposed that he intimated the incident to the 2nd opposite party which can not be ruled out.
In this circumstances mechanical repudiation of policy is improper and unsustainable. So it is held that opposite party mechanically repudiate the claim which amounts to illegal trade practice and service deficiency. In the result above petition is allowed in part.
We direct the opposite parties to pay Rs.6,164/-(Rupees six thousand one hundred and sixty four only) towards the claim and Rs.2,000/-(Rupees two thousand only) as cost of the proceedings. Comply the order with, within one month from the date of receipt of the copy of the order.
Dated this the 18th day of February 2016.
Date of filing:28.09.2012.
SD/-MEMBER SD/- PRESIDENT SD/- MEMBER.
APPENDIX
Documents exhibited for the complainant:
A1. Copy of policy No. P.181211/01/2011/005435 dtd.07.02.2011.
A2.Copy of Discharge card dtd.08.08.2011
A3. copy of claim form dtd.02.09.2011
A4. Copy of repudiation letter issued by the 1st OP dtd.31.10.2011.
A5. Copy of Lawyer Notice with postal receipt and acknowledgment dtd.11.06.2012.
Documents exhibited for the opposite party:
B1. Copy of the policy No.P/181211/01/2011/005435 issued to the complainant along with the
terms and conditions.
B2. Copy of the claim form submitted by the complainant to the first opposite party
dtd.05.09.2011.
Witness examined for the complainant:
PW1. Biraj (complainant)
Witness examined for the opposite party:
None
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
