DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.229/2011
Smt. Karuna Sharma
W/o Sh. Brahm Dutt Sharma
R/o 90/5, AB, 1st Floor,
Malviya Nagar,
New Delhi-110017 ….Complainant
Versus
National Insurance Co. Ltd.
through its Branch Manager
E-13, Hauz Khas Market,
New Delhi-110016 ….Opposite Party
Date of Institution : 05.07.11 Date of Order : 25.09.18
Coram:
Sh. R.S. Bagri, President
Ms. Naina Bakshi, Member
Ms. Kiran Kaushal, Member
ORDER
Member - Kiran Kaushal
Briefly stated facts of the complaint are that:
1. The complainant Ms. Karuna Sharma, had taken a mediclaim insurance policy for herself and her family from General Insurance Company hereinafter referred to as OP on 09.03.2006. The complainant had been availing the services of the OP for the last five years and getting the said policy renewed timely and regularly. The premium of the policy was paid as and when it became due and payable. The said policy was again renewed on 09.03.2010 for a period of one year valid from 15.03.2010 to 14.03.2011 vide policy no. 360902/48/09/8500002888 on which premium of Rs.19,448/- was paid to the OP.
1.1 Complainant’s husband Mr. Bhrahm Dutt Sharma got a cataract surgery done from Sita Ram Bhartiya Institute of Science & Research on 08.09.10. An Intra Ocular Lens was planted on his left eye under local anesthesia and after dressing was discharged on the same day. The complainant states that Rs.25,154/- was incurred on the said operation. The complainant further submits the complainant husband visited Dr. Umesh Bareja on 09.09.10, 11.09.10, 14.09.10, 18.09.10 and 27.09.10 for review and post hospitalization treatment. Copy of the OPD card and prescription with respect to the aforesaid review and post hospitalization treatment has been annexed as Annexure C-11.
1.3. The complainant averred that post her husband’s surgery, she remained very busy in taking care of her husband and visiting the doctor frequently for review. On 15.10.10 the complainant filed the total claim for Rs.26,347.97p and submitted the claim form along with the list of documents to the OP. But to her utter shock and grief her claim was repudiated by the OP vide letter dated 07.12.10. OP stated that her claim was inadmissible and hence not payable under clause 11 of the policy because the claim has been lodged after one month and 7 days of hospitalization.
1.4 It was on receiving the repudiation letter that the complainant was constrained to come to this forum with the following prayer.
- Direct the OP to process the claim of the complainant and pay Rs. 26.347.97p.
- OP be directed to pay sum of Rs. 25000/- toward physical, mental agony, harassment and loses caused to the complainant
- Cost of litigation to be awarded in favour of the complainant and any other relief which this forum deems fit.
2. OP resisted the complaint by filing the written statement stating that the OP is a General Insurance Company engaged in the business of insurance and are governed by rules and regulation framed. OP further states that whenever the mediclaim policies are issued all the terms and condition are brought to the knowledge of the insured in writing and are also explained verbally to make the insured understand their rights and obligations under the said policy.
2.1 OP averred that the husband of complainant went in for cataract operation which is done with laser technology, wherein the patient is discharged on the same day. The post hospitalization treatment required after such operation is precautionary and only to avoid any uneventful disorder. OP further submits that as per the terms and conditions of the policy under reference, the complainant should have raised her claim within one month from the discharge of her husband from hospital. Admittedly the patient was discharged on 08.09.11 and complainant filed her claim form on 15.10.10, which is beyond limitation.
2.2 OP alleges that the complainant also had cashless facility available to her but the complainant neither chose to opt for the same nor sent any prior notice or intimation to OP within prescribed time limit in regards to availment of benefits of the policy under reference.
2.3 OP reiterates the fact that the complainant filed her claim form beyond the prescribed time limit and the complainant cannot be allowed to take advantage of her own wrong. It is further stated by the OP that they have rightly repudiated the claim as per the terms and conditions laid down and agreed by the complainant on the grounds of filing the claim form beyond the time limit prescribed in the rules. Hence, the complaint is not tenable in the eyes of law and is liable to be rejected out rightly with cost.
3 No rejoinder was filed to the written statement on behalf of the complainant.
4. Complainant filed her evidence by way of affidavit. In support of her evidence, complainant has filed the mediclaim insurance policy, copy of bills, OPD card, discharge summary, repudiation letter, legal notice etc.
5. Affidavit of Mr. S.K. Soni Deputy Manager of National Insurance Co. was filed on behalf of the opposite party.
6. Written arguments have been filed on behalf of the parties.
7. After hearing the counsels and perusing the records, it is observed that the complainant has purchased mediclaim policy for herself and her family from OP. Later it is admitted that when her husband got his cataract surgery done, the complainant filed her claim which was repudiated stating that her claim was inadmissible and hence not payable under clause 11 of the policy because the claim has been lodged after one month and seven days of the hospitalization. Before we proceed further it is pertinent to reproduce the rejection letter, which is the matter of record as follows
“While Scrutinizing the claim documents of the aforesaid claim, it has been observed by the TPA that the expenses incurred during hospitalization for the disease being inadmissible under clause 11 of the policy as the claim has been lodged after one month and seven days of hospitalization.
We have perused the claim file and are in agreement with the decision of the TPA in this regard.
You are therefore, by this letter, being informed that your aforesaid claim is inadmissible and hence not payable.”
8. It is noticed that the discharge summary placed on record is dated 08.09.10 and the claim is stated to be filed on 15.10.10. Therefore, the delay in filing the claim form by the complaint is just of seven days which could have been easily considered and waived off by the OP. However, the case of the complainant with respect to delay in lodging the claim rests upon the circular no. IRDA/HLTH/ MISC./CIR/216/09/2011 DATED 20.09.2011, issued by Insurance Regulatory and Development Authority (IRDA). The said circular, to the extent it is relevant, reads as under:-
“The Authority has been receiving several complaint that claims are being rejected on the ground of delayed submission of intimation and documents.
The current contractual obligation imposing the conditions that the claims shall be intimated to the insurer with prescribed documents with a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.
The insurers’ decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such intimation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to exercise litigation.
Therefore, it is advised that all insurers needs to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers, should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time.”
9. Perusal of the aforesaid circular supports the view earlier expressed by the Forum that repudiation of the claim was apathetic and gross violation of IRDA circular which envisages condonation of justifiable delays. It is further the case of the complainant that the claim was filed well within time but as per the clause 11 of the mediclaim policy “final documents along with the hospital receipted original Bills/Cash memos/reports, claim from and list of documents as listed below should be submitted to the Company/TPA within 30 days from the date of discharge from the Hospital and where post-hospitalization treatment, is not completed, it shall be within 30 days from the date of completion of Post- hospitalization treatment.”
10. Complainant submits that the post- hospitalization a Taper treatment was done on 27.09.10 and the claim papers were filed on 15.10.10. Therefore the claim was well within time.
11. But the OP contends that the cataract operation being a common operation is done by laser technology wherein the patient is discharged on the same day. The post hospitalization treatment required after such an operation is precautionary and only to avoid the uneventful disorder. But to a prudent and reasonable person ‘post-hospitalization’ would mean follow-ups to the doctor post surgery and treatment of any ailment related to surgery which was Taper treatment in this case.
12. OP further contends that the cashless facility was available to the complainant which was not availed of. Nowhere in the mediclaim insurance policy has it been mentioned that it is mandatory to avail the cashless facility. Therefore, it was purely a matter of choice of the complainant to avail the cashless facility which she chose not to.
13. For the reasons stated hereinabove it is a clear cut case of gross deficiency in service on the part of the OP. Hence, OP is directed to pay Rs.26,348/- alongwith interest @ 9% per annum from the date of the filing of the claim i.e. 15.10.10. In addition to above payment OP is also directed to pay Rs.10,000/- towards physical and mental agony and harassment to the complainant within 30 days of receipt of copy of this order.
Failing which OP will be liable to pay Rs.26,348/- alongwith interest 12% per annum from the date of the filing of the claim i.e. 15.10.10 till the date of realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 25.09.18.
