Jharkhand

Bokaro

CC/17/178

Ram Yash Ojha - Complainant(s)

Versus

M/s Universal Sompo General Insurance Co. Ltd. - Opp.Party(s)

Dadan Singh

11 Apr 2022

ORDER

1. Case is put up for order.Argument of Learned Counsels for the complainant and O.P. No.1 (M/s Universal Sompo General Insurance Co. Ltd.)has already been heard. Vide order dt. 04.10.2018 case is being proceeded Ex-parte against O.P. No.2.

2       Complainant’s case in short is that he being retired employee of Allahabad Bank has obtained Health Insurance Policy No. 2816/51338480/04/000 which was renewed time to time and was valid for the period from 01.04.2015 to 31.03.2016 covering the complainant himself  and his wife namely Chandrakanti Ojha. Further case is that the wife of the complainant was treated at BGH Bokaro from 08.08.2015 to 22.08.2015 in which he incurred Rs. 31065/- as medical expenses for which he submitted claim before the Bank but it was not settled hence he inquired the matter through RTI which was replied to approach the insurance co. directly, hence he approached the insurance co. but his claim was not settled. He also paid Rs. 257/- as extra expenditure in preparation of duplicate  copy of the treatment papers. Hence claim for Rs. 31322/- has been filed.

3.      W.S. has been filed by O.P. No.1 (M/s Universal Sompo General Insurance Co. Ltd.) mentioning therein that case is pre-matured because no claim has been made directly to the insurance co. Further reply is that it is true that complainant and his wife have obtained alleged insurance policy for the alleged period but they have not approached this O.P. directly nor they have fulfilled required criteria related to filing of claim form, submission of required treatment papers etc. Further it is reply that since no cause of action has arised hence case is pre-matured.

From perusal of the papers submitted by the complainant it appears that complainant has obtained insurance policy through the Allahabad Bank hence he has directly applied before the Bank for re-imbursement of the amount incurred into treatment of his wife along with all original papers to which Bank has forwarded to the insurance Co. As per insurance Co. some papers are wanting hence for want of fulfillment of legal criteria claim has not been processed.

In the given facts we are of the opinion that this case is liable to be disposed off with certain observations in the following manner:-

1. That the O.P. No.1 and 2 namely M/s Universal Sompo General Insurance Co. Ltd. Doranda Ranchi and Allahabad Bank Main Branch, B.S.City, Bokaro shall co-ordinate with each other in respect to transmission of all original papers (already submitted) within 45 days from today with intimation to this Commission.
2.  That in case of deficiency in any paper O.P. No.1 will intimate to the complainant within 60 days from today for filing of such paper which is more essential for taking decision on the matter related to payment of claim and on receipt of such intimation complainant will provide copy of required document to the O.P. No.1 within 10 days from the date of intimation. Further  the complainant shall file an affidavit before the O.P. No.1 with copy to O.P. No.2 mentioning therein that he is having no original papers in his custody for which he is submitting photo copy and on submission of such affidavit O.P.No.1 will process the claim on the basis of photo copy of the papers with affidavit as indicated above.
3. That O.P. No.1 M/s Universal Sompo General Insurance Co. Ltd. Doranda Ranchi shall settle the claim within 90 days from today as per above direction with intimation to this Commission.
4. That in case, grievance of the complainant is not settled then he will have liberty to file case afresh on fresh cause of action. Accordingly this case is being disposed off. Office to provide copy of this order to the parties concerned for strict compliance within stipulated period.