PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

1)        The Complainant has prayed that it be held that the Opposite Party is guilty of deficiency in service and unfair trade practices as per the provisions of the Consumer Protection Act, 1986 (hereinafter referred to as the Act).  The Complainant has further prayed that the Opposite Party be directed to pay Rs.30,313/- alongwith interest therein @ 18% p.a. from 15/06/2010 till the realization of said amount. The Complainant has also prayed that an amount of Rs.30,,000/- may be granted towards compensation for mental agony and Rs.30,000/- towards the litigation incurred by the Complainant for this complaint.

2)        According to the Complainant, she is permanent resident of Gujarat and earlier resided at Mumbai.  The Complainant had obtained Mediclaim Policy for the period 28/05/2009 to 27/05/2010 from the Opposite Party.  The copy of the said policy is at Exh.‘A’.  It is submitted that during the subsistence of the said policy the Complainant fell ill on or about 25/04/2010, so she approached Dr. Pinakin Dalal who advised for thorough check-up and after receipt of various reports the Complainant was prescribed required medicines.  It is alleged that however, as the health of the Complainant was deteriorated she was admitted to Diva Health Care Pvt. Ltd. at Ahmedabad, Gujarat on 28/04/2010 and she was treated for the illness for six days and was discharged on 03/05/2010.  The copy of the discharge card and hospital record is filed at Exh.‘B’.  According to the Complainant, she was bed ridden for some days after the discharge and as per the advice of the doctor she was taking bed rest and therefore, she lodged her claim on 15/06/2010 with the Opposite Party at their Divisional Office at Fort Mumbai alongwith the bills and other related documents.  The copy of the said claim form and other documents is at Exh.‘C’.  It is submitted that the Opposite Party’s Raksha TPA Pvt. Ltd. vide letter dtd.02/07/2010 repudiated the claim on the ground of delay in submitting the claim.  It is alleged that as the Complainant was bed ridden and there was delay of about 18 days which was explained by the Complainant by letter dtd.15/07/2010. The Opposite Party in view of the said letter ought to have granted the claim lodged by the Complainant.  It is submitted that the Complainant had made further correspondence as per Exh.‘D’ to which the Opposite Party did not give favourable response to it and repudiated the claim by letter dtd.03/08/2011 the copy of which is at Exh.‘E’.  It is submitted that the Opposite Party failed in its duty and is guilty of deficient in service by adopting unfair trade practice which resulted hardship and loss to the Complainant.  The Complainant has therefore, prayed the reliefs as mentioned in para 1 of this order. 

3)        The Opposite Party by filing written statement contested the claim and contended that as per the Condition No.11 as the Complainant has failed to produced the claim alongwith documents within 30 days of discharge from the hospital.  The Opposite Party/TPA has rightly repudiated the claim as the same was lodged after more than 18 days from the date of discharge of the Complainant on 03/05/2010.  The Opposite Party has thus, justified the repudiation of the claim.  The Opposite Party has denied all the parawise allegations made by the Complainant.  The Opposite Party has therefore, prayed for dismissal of complaint with cost. 

4)        The Complainant has filed affidavit of evidence.  The Opposite Party has filed affidavit of Shri. B.S. Gautam, Sr. Divisional Manager of Opposite Party.  Both the parties filed their written arguments.  We heard Shri. Ankush Navghare, Ld.Advocate for the Complainant and Smt. Kalpana Trivedi, Ld.Advocate for the Opposite Party.  We have perused the documents filed in the complaint.

5)        While considering the claim made by the Complainant in this complaint and the defence raised by the Opposite Party it is necessary to be considered that whether the repudiation communicated by the Opposite Party to the Complainant is justified or not. The Opposite Party by letter dtd.02/07/2010 and letter dtd.03/08/2011 has specifically come out with the case that as per the policy guidelines of company claim should be submitted within 30 days from starting of date of hospitalization.  It is informed to the Complainant that the claim filed by the Complainant falls outside the policy coverage and not tenable as per the clause 10 of the policy.  From the above facts it appears that the Opposite Party has not disputed that the Complainant was entitled to the claim lodged by her to the Opposite Party of Rs.30,313.33 but she is not entitled for the same because of non observation of the condition of submission of claim within 30 days.  The advocate for the Complainant in his argument submitted that the attitude of the Insurance Companies of rejecting the claim on the point of delay has been deprecated by Insurance Regulatory and Development Authority by its circular dtd.20/09/2011.  He made submission that as per the said circular the above authority had advised the insurers to incorporate additional wordings in the policy documents suitably enunciating insurers stand to condone delay on merit for delayed claims where the delay is proved to be for reasons beyond the control of the insured. Shri. Navghare Advocate thus, submitted that as the Complainant by letter dtd.15/07/2010 had specifically informed to the Opposite Party that her treatment was going and she was not aware that within 30 days from the discharge from the hospital the claim was required to be submitted and therefore, the delay may be condoned and her claim may be allowed was to required to be considered by the Opposite Party. He made submission that the Opposite Party has rejected the genuine and bonafide claim of the Complainant and caused mental harassment to her.  He thus, submitted that the claim made in this complaint needs to be allowed.  The said submissions made by the Complainant’s advocate in our view are justifiable in view of the observations of the Hon’ble Consumer Disputes Redressal Commission, Punjab, reported in 2009 CPJ 1308 in the case of Life Insurance Corporation of India V/s. Smt. Usha Ranii and in the case of Oriental Insurance Co. Ltd. V/s. Ozma Shipping Co., reported in 2009 CPJ 1887 of the Hon’ble Supreme Court. We hold that considering the observations in the aforesaid cases as the Opposite Party has wrongly rejected the claim on technical grounds and in view of the circular of IRDA, the Opposite Party is liable to reimburse Rs.30,313/- with interest @ 9% p.a. from 15/06/2010 till its realization to the Complainant.  The Opposite Party is also liable to pay Rs.8,000/- as compensation towards hardship and mental tension caused to the Complainant and cost of Rs.3,000/- to the Complainant. In the result we pass the following order –

O R D E R

i.        Complaint No.95/2012 is partly allowed against Opposite Party.

ii.        The Opposite Party is directed to pay Rs.30,313/- (Rs. Thirty  Thousand Three Hundred Thirteen Only) with interest @ 9% p.a.

           from 15/06/2010 till its realization to the Complainant. 

iii.       The Opposite Party is directed to pay Rs.8,000/-(Rs. Eight Thousand Only) as compensation to the Complainant towards

           hardship and mental tension caused to the Complainant and cost of Rs.3,000/- (Rs. Three Thousand Only) towards this

           proceeding.

iv.      The Opposite Party is directed to comply the aforesaid order within one month from the date of receipt of this order.  

v.       Certified copies of this order be furnished to the parties.