Order no. 7 Date 15/11/2007
The present case being no.56/2007 was filed by Sri Pradyot Kr. Bhattacharjee, S/o, Late Surendralal Bhattacharjee, 81/1/2, Kshetra Mitra Lane, Salkia, Dist. Howrah the petitioner to the petiton of complaint against the o.ps. viz (1) National Insurance Co. Ltd., Division-III, 1, Shakespeare Sarani, P.S. Park Street, 6th Floor, Kolkata-71, (2) The Senior Divisional Manager, National Insurance Co. Ltd., Division-III, 1, Shakespeare Sarani, P.S. Park street, 6th Floor, Kolkata-71 and (3) The Golden Trust Financial Services, 16, R.N. Mukherji Road, Kolkata-1before the forum u/s 12 of the C.P. Act, 1986 praying for various reliefs as specified at page 8-9 of the main petition.
The facts are in brief as follows :
That the complainant took Group Madiclaim Insurance coverage policy with the o.p. no.1 through the Golden Multi Services Club the o.p. no.3of Golden Trust Financial Services as member of that club. The policy being no.100300/46/01/8500/07/03/85/30044 was for the period from 15.10.03 to 14.10.04 (midnight) and the policy amount was Rs.30,000/-. In the month of May the petitioner was suffering from high fever and as per the advice of the physician the complainant took admission on 18.5.04 in the Alpha Medical Services (P) Ltd., 21/1, Dobson Road, Howrah-711101 and he was there for treatment from 18.5.04 to 23.5.04. Finding no improvement in his condition the petitioner was shifted to Dreamland Nursing Home, 2, Nayaratna Lane, Shyambazar, Kol-174 on 23.5.04 for better treatment and the petitioner was there from 23.5.04 to 26.5.04. For treatment and various test in connection with the treatment the complainant had to incur an expenditure of Rs.25,609/- on 3.7.04. The petitioner intimated about his hospitalization to the G.T.F.S. The o.p. no.3 who in turn requested the petitioners to submit the claim form along with related documents. On being advised the complainant submitted the claim forms on 6.8.04 to the o.p. no.3 who in turn on 20.8.04 transmitted the claim form to the o.p. no.1 for settlement of the claim of the petitioner. On 26.2.05 the o.p. no.1 intimated the petitioner that his claim attracts violation of condition no.5.3 and 5.4 of the policy and as such they have closed his claim as “No Claim’. On 15.3.05, 26.5.06 and 18.8.06 he petitioner made representation to the o.p. no.1 with a prayer to review evaluate and modify the decision and settle the claim but in vain. Finding no alternative, the petitioner approached the forum for justice the petitioner relied upon the annex-A-1 to A-8 in support of his claim.
The o.ps. have contested the case by way of filing w/v and affidavit denying therein very emphatically all the material allegation to the petition of complaint.
The o.p. no.3 stated in the w/v that the o.p. no.3 has got no authority to settle the claim of the petitioner and as such the proforma o.p. no.3 does not bear any responsibility for repudiation of the claim of the complainant by the o.p. no.1. Fact is that the complainant is a policy holder, fell ill and accordingly hospitalized for treatment incurred an expenditure for treatment submitted claim form to o.p. no.1 through the o.p. no.3 and the o.p. no.1 repudiated the claim of the petitioner citing the condition no.5.3 and 5.4 of the policy.
It appears that the petitioner could not intimate the o.ps. within seven days of his hospitalization and within 30 days from the date of discharge, he could not submit the claim form (policy condition no.5.3 and 5.4) and for that matter his claim was repudiated.
It is mere technicalities of the condition of the policy . Mere non intimation and non submission of claim form in the prescribed and stipulated time frame of the policy, could not be the sole ground for repudiation of the claim of the policy holder.
In practical world many unfortunate events happens for which no one can be blamed for non performing things in time. Here in this case the petitioner was fallen sick and under treatment and for that he could not submit the claim form in time and as he admitted, he was not aware of the nitty-gritty of the policy. The o.p. no.1 could have dealt the matter with a humane touch. Moreover, the o.p. no.1 in spite of having well oiled machinery failed to discharge its duty in time as it appears from the repudiation alter. The o.p. no.1 took more than six months to repudiate the claim of the petition.
The forum perused all the papers / documents, considered the arguments and submission of the parties and have come to conclusion that the petitioner has been able to prove his case to the hilt so as to get the benefit within the ambit of C.P. Act, 1986. The petitioner’s case is a genuine one and he suffered mental agony, harassment due to non action, negligence and deficiency on the part of the o.p. no.1. The o.ps. could not render service which the complainant is entitled to have as policy holder of the o.p. no.1. It is an established principle held by different forms in the country and the Hon’ble National Commission that mere non submission of claim form in time could not be the sole ground for repudiation of the claim of he petitioner. Having considered all the arguments so long discussed in detail, the forum have no hesitation in causing to conclusion that the action of the o.ps. smacks of dereliction of duty and deficiency and negligence in rendering positive service to the complainant’s claim. The complainant gave reasons for delay in submitting the claim form. The case succeeds on contest.
Hence
Ordered,
The o.p. no.1 is directed to reimburse the petitioner the claim amount of Rs.25,609/- (Rupees twenty five thousand six hundred nine) only as incurred by him during his treatment and also pay a sum of Rs.3000/- (Rupees three thousand) and Rs.1000/- (Rupees one thousand) respectively only as compensation and litigation cost for causing needless mental agony harassment to the petitioner through its negligence, inaction and deficiency. The o.p. is also directed to pay to the petitioner simple interest @ 8% p.a. beginning from the day on the aforesaid sums till full payment of the sums as ordered is made, if the o.p. does not pay such sums within that time as now given.
The payment should be made by the o.p. to the petitioner within 60 days from this date of the order.
The o.p. no.3 (GTFS) the proforma party has no liability for payment of the claim of the complainant.
The office will make available a copy of this order to the concerned parties free of cost as per rules.
Member President
