Delhi

New Delhi

CC/824/2014

Gopalan Krishan - Complainant(s)

Versus

M/S. The Oriental Insurance Company Ltd. - Opp.Party(s)

03 May 2018

ORDER

 

CONSUMER FISPUTES REDRESSAL FORUM-VI

(DISTRICT NEW DELHI,  M-BLOCK, 1^ST FLOOR,

VIKAS BHAWAN, I.P. ESTATE. NEW DELHI-1100001.

 

C.C.No.824/2014

 

Mr. Gopalan Krishnan,

GT 1/7B, Gurgaon One,

Mullahera, Sec.22,

Gurgaon, Haryana-122015.                                             …..Complainant.

Vs.

 

The Oriental Insurance Co. Ltd.,

Oriental House, A-25/27, Asaf Ali Road,

New Delhi-110002.                                                         ….Opposite Party.

 

 

NIPUR CHANDANA, MEMBER

 

O R D E R

 

 

The complainant has filed the present complaint against the O.P under section 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant  was  the mediclaim policy holder of OP Insurance Co. for last several years. It is alleged by the complainant that he had taken mediclaim insurance  policy  bearing No.215601/48/2011/1149 for his mother Late Smt. Rukmani Gopalan from the O.P. which was valid for one year commencing from 4/6/2010 and expiring at the midnight of 3/6/2011.  It is alleged that on 2/7/2010, the mother of the complainant was hospitalized at Calcutta Medical Research Institute, West Bengal, due to sudden pain and weakness. The pre-authorization request form and documents were sent by hospital to Third Party Administrator (TPA) who on reviewing the documents initially gave the approval of Rs. 50,000/- to the Hospital but failed to pay the same, although the claim was cashless, the complainant was forced to pay a sum of Rs.35,000/- to the hospital. It is alleged by the complainant that vide letter dated 9.7.10 he filed a claim with the OP Insurance Co. for reimbursement and despite his continuous follow-up and several letters and e-mail nothing has been done by the OP to settle his genuine claim, hence this complaint.

2.     Complaint has been contested by OP.  OP filed its written statement in which it denied any deficiency in services on its part and has taken the preliminary objection regarding the maintainability of the complaint on the issue of limitation.    It is further stated by the OP that as per clause  5.5 of the terms and conditions of the Insurance Policy the complainant failed to submit the claim form and original documents within 15 days of the reminder issued by the OP vide its letter dt. 13.10.2010, hence the claim of the complainant was rightly closed.

3.     Complainant has filed the rejoinder to written statement filed by the OP and stated that the present complaint is within limitation as the continuous correspondence was going on between the complainant and TPA.  The TPA vide its letter dated. 27.2.2013 asked the complainant to send the scanned copy of cancel cheque so that payment could be remitted in his account. 

4.     Complaint has filed his evidence by way of affidavit. He has also placed on record photocopy of Policy, photocopy of payment receipts, photocopy of a no. of letters, e-mails, copy of Medical Certificate and copy CCMRI Hospital Final Bill. On the other hand Ms. Beena Dhawan, Divisional  Manager has filed her affidavit in evidence on behalf of OP testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.

5.     We have carefully gone through the record of the case and have heard submissions of the Ld. Counsels for the parties.

6.      It is argued on behalf of OP that the present complaint is not maintainable on the ground of limitation as the OP Insurance Co. had closed the claim file of the complainant in the year 2010 by way of letter dated 13.10.2010 and the same may be treated as accrual of cause of action.  The complainant has filed his complaint in the year 2014. The period of filing of complaint from the date of accrual cause of action is of 2 years,  in the present complaint the date of accrual of the cause of action is 13.10.2010, complainant ought to have filed the present complaint in 2012 but the same is filed in year 2014, hence the same is hopelessly barred  by limitation. It is further argued by the OP that as per clause  5.5 of the terms and conditions of the Insurance Policy the complainant failed to submit the claim form and original documents within 15 days of the reminder issued by the OP vide its letter dt. 13.10.2010, hence the claim of the complainant was rightly closed.

 7.    It is argued on behalf of complainant that after denial of the cashless by the OP Insurance Co. he paid a total sum of Rs.32,119/- to the hospital and lodge a reimbursement claim to the OP but the same was also repudiated by OP on false and frivolous ground vide its letter dated 13.10.2010.  On the issue of limitation it is argued on behalf of complainant that the continuous correspondence was carried on by him with the   Genins India TPA Ltd. and   vide e-mail dt. 4.3.2013 Dr. Shirya, Chief Manager Medical Corporate Office had communicated to  Anu Khurana Officer of OP Insurance Co. that the claim of the complainant was processed as per policy terms and conditions and net amount payable as assessed by TPA is Rs.32,119/- hence, the continuous cause of action exist and the complaint is well within limitation.   In support of his contention, the complainant has drawn our attention towards the e-mail dated. 4.3.2013 sent by Dr. Shirya, Chief Manager Medical Corporate Office of Genins India TPA Ltd. to  Anu Khurana Officer of OP Insurance Co. the contents of which are reproduced as under:

        Details of payment receipts:

S.No.	RECEIPT DATE	PAYMENT RECEIPT NO.	AMOUNT
1.	2/7/2010	RCPA001376451	Rs.10,000/-
2.	2/7/2010	RCPA001376549	Rs.2,000/-
3.	4/7/2010	RCPA001378335	Rs.23,335/-

 

• Since the original claim file was not received from the hospital, the documents submitted by the insured were considered as a supplementary claim and filed accordingly.  The claim documents were registered vide our control number OR-1-153329.1.  Our claim processing unit on scrutiny of the documents submitted, sent letter to the insured for documents in support of the payment receipts submitted.

 

• The main claim documents were then received from the insured which were filed in another folder as a separate file.  On processing it found to be deficient in payment receipts and letter sent accordingly for the same.

 

• Due to unusual chronology of nature of documents submitted i.e. main claim documents were received subsequently and that it was considered primarily as a cashless case, erroneously the three folders could not be linked together and thus all the three claim files were closed due to incomplete documents.

 

• On receipt of the grievance from the insured, case manager was allocated for detailed investigation.  The documents available in the three folders were collated and reviewed in detail and the aforesaid facts were revealed.  Accordingly, it has been concluded that although it was a cashless claim as per our records, the entire hospitalization expenses had been borne by the insured.  It has therefore been registered as  per reimbursement claim vide our claim control no.or-1-153329 and processed as per policy terms.  Details are as under:-

 

Total claimed amount (Rs.)	Deduction Amount (Rs.)	Deduction Detail	Total payable amount (Rs.)
35335	3216	Rs.100/-mortuary sheet not payable Rs.2386/- service charge not payable Rs.65/- thermometer not payable.  Rs.95/- hand rub not payable. Rs.570/- under pad not payable.	32119

 

8.     The bare perusal of the e-mail dated 4.3.2013 reproduced above  shows that the claim of complainant was processed in the year 2013, as such, the present complaint is well within the period of limitation.  Well knowing the facts through e-mail date 4.3.2013 sent by Genins India TPA Ltd. to Anu Khurana Officer of OP Insurance Co. that the claim of the complainant is payable as per the terms and conditions of the policy,  OP Insurance Co. failed to reimburse the claim of the complainant and asked him to run from pillar to post. This act of OP amounts to deficiency in services.

9.     We, therefore, hold the OP guilty of deficiency in service and direct it as under:

i.      Pay to the complainant a sum of Rs.32,119/- along with 9% interest from the date of filing of complaint i.e 30.10.2014 till payment.

2. Pay to the complainant a sum of Rs.20,000/- towards compensation on account of harassment, mental agony and pain suffered by him along with a sum of Rs.10,000/- as  litigation cost.

The order shall be complied with within 30 days of the receipt of the copy of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 9% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post.

 

Announced in open Forum on __________. 

 

 

 

(ARUN KUMAR ARYA)

PRESIDENT

 

                             (NIPUR CHANDNA )                                                 (  H.M. VYAS)

                                  MEMBER                                                              MEMBER