Order dictated by:
Sh.Anoop Sharma, Presiding Member
1. Kapil Puri, complainant has brought the instant complaint under section 12 & 13 of the Consumer Protection Act on the allegations that complainant got Health Benefit Mediclaim Insurance for himself and his wife from opposite party covering the risk period 6.8.2010 to 5.8.2011. Complainant unfortunately fell ill and was to be hospitalized at Indraprastha Apollo Hospital,New Delhi from 9.5.2011 to 17.5.2011 and incurred an expenditure of Rs. 2,15,000/- on his treatment. Opposite party was duly informed about the said hospitalization and the treatment to be taken thereof as the said policy was issued on cashless basis. The sum insured of the medical benefit is for Rs. 1 lac. The complainant has paid the hospital expenses from his own pocket. Opposite party instead of making the said payment started sending frivolous letters for frivolous queries and the complainant responded to all the queries . The last query of the opposite party is made vide letter dated 29.10.2012 to which the complainant duly responded vide letter dated 17.4.2013 and thereafter the opposite party did not respond to the complainant and neither paid the genuine claim of the complainant . Complainant vide instant complaint has sought for the following reliefs:-
- Opposite party be directed to pay the amount of Rs. 1 lac alongwith interest @ 12% p.a. from 17.5.2011 till realization ;
- Opposite party be also directed to pay compensation to the tune of Rs. 50000/- alongwith adequate litigation expenses.
Hence, this complaint.
2. Upon notice, opposite party appeared and contested the complaint by filing written version taking certain preliminary objections therein inter alia that complaint filed by the complainant is barred by limitation. In this regard it was submitted that as per provisions of the Consumer Protection Act, the complaint should be filed within a period of two years from the date of cause of action. In the present case the date of cause of action is 9.5.2011 when the complainant fell ill and the complaint should have been filed on or before 8.5.2013, whereas the complainant filed the present complaint in the year 2016 i.e. after gap of more than three years ; that even if the cause of action is to be considered by this Forum from the date of decision of the company, then it is submitted that the decision conveyed to the complainant that if the requisite documents are not supplied, then the claim will be closed as No claim after 15 days . The said closure letter is dated 29.10.2012 and after giving period of 15 days, the date of cause of action qua the Insurance company comes to 14.11.2012 and the complaint should have been filed on or before 13.11.2014 whereas the present complaint has been filed in the year 2016. As such the complaint filed by the complainant is barred by limitation and the same is liable to be dismissed on this ground alone ; that the complainant is estopped by his own act and conduct from filing the present complaint as he had himself not fulfilled the obligation put upon him as it has been clearly agreed that if the complainant insured fails to fulfill the obligation put on him, then he becomes debarred from getting any relief under the policy. In this regard it was submitted that the case of the complainant was handled by Park Mediclaim TPA Pvt.Ltd on behalf of opposite party and the said TPA after examining the case of the complainant in the light of papers submitted by him to the said TPA, wrote letter dated 20.8.2012 to the complainant to supply the following documents:-
- Settlement report from Paramount TPA
- That on verification of IPD record , it has been observed that the patient has history of Psoriasis 5 to 6 years and dysponea on exertion for 5 to 6 months and for that purpose the complainant was called upon to submit all records of treatment taken by him in the past ;
- First consultation paper of diagnosis of diabetes with investigation reports.
Period of 15 days was provided to the complainant to supply these documents but he failed to supply these documents and thereafter first reminder dated 25.9.2012, second reminder dated 12.10.2012 and final reminder i.e. closure letter dated 29.10.2012 clearly stating that if the said documents are not supplied within 15 days, it will presumed that you are no more interest to persue the claim any further and would close the file as No claim. As the complainant did not make any compliance of this letter , therefore, claim file stands closed after 15 days from the date of closure letter dated 29.12.2012. Hence, the complainant has no cause of action to file the present complaint. While denying and controverting other allegations, dismissal of complaint was prayed.
3. In his bid to prove the case complainant tendered into evidence his duly sworn affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-13 and closed his evidence.
4. To rebut the aforesaid evidence Sh.P.N.Khanna,Adv.counsel for the opposite party tendered into evidence affidavit of Mr. Dheeraj Seth, Divisional Manager Ex.OP/1, affidavit of Dr. A.K.Batra, Medical Director Park Mediclaim TPA Ltd Ex.OP/2 alongwith documents Ex.OP/3 to Ex.OP/9 and closed the evidence on behalf of the opposite party.
5. We have heard the ld.counsel for the parties and have carefully gone through the record on the file .
6. On the basis of the evidence on record, ld.counsel for the complainant has vehemently contended that it is an admitted fact that the complainant got Health Benefit Mediclaim Insurance Policy for himself and his wife for the period from 6.8.2010 to 5.8.2011 with sum assured Rs. 1 lac, copy whereof is Ex.C-7 on record. It is also an admitted fact that the complainant fell ill and was to be hospitalized at Indraprastha Apollo Hospital, New Delhi from 9.5.2011 to 17.5.2011, copy of discharge summary is Ex.C-8 on record. It is further the case of the complainant that the complainant incurred an expenditure to the tune of Rs. 2,15,000/- on his treatment , copy of certificate issued by Indraprastha Apollo Hospital is Ex.C-9 on record. The complainant immediately informed the opposite party about the said hospitalization and the treatment to be taken thereof . But, however, opposite party instead of making the payment for the genuine claim started sending the frivolous letters to which the complainant duly replied to all queries raised by the opposite party. Opposite party again vide letter dated 29.10.2012 sought the same queries as raised earlier to which the complainant duly replied vide letter dated 17.4.2013. The complainant vide letters dated 8.8.2011, 7.7.2011 and 3.6.2011 has already sent the documents as demanded vide letter dated 29.10.2012. But even then the opposite party did not process the claim case and the claim was lying as it is with the opposite party .
7. But however, the plea of the opposite party is that complaint filed by the complainant is barred by limitation as in the present case the closure letter is dated 29.10.2012 and after giving period of 15 days, the date of cause of action comes to 14.11.2012 and the complaint should have been filed on or before 13.11.2014, whereas the present complaint has been filed in the year 2016. But, however, this plea of the opposite party that complaint should have been filed on or before 13.11.2014 as the opposite party sent closure letter to the complainant on 29.10.2012, is not tenable because the opposite party vide letter dated 29.10.2012 has demanded the documents which the complainant has already supplied to the opposite party vide letters dated 8.8.2011, 7.7.2011 as well as 3.6.2011, copies of which are Ex.C-2, C-3 and C-4 respectively. As the complainant has already sent the documents as demanded by the opposite party, so the plea of the opposite party that the complainant did not make compliance of the closure letter, therefore, claim file stands closed after 15 days from the date of closure letter dated 29.12.2012 ,is not justifiable. It is, therefore, contended that complainant has been able to prove his case before this Forum through evidence brought on record .
8. As the complainant has already submitted the documents as demanded by the opposite party , so the opposite party is liable to decide the claim case of the complainant . Consequently , the complaint stands disposed of accordingly. The opposite party is directed to decide the claim case of the complainant within 30 days from the date of receipt of copy of order. As the complainant has suffered harassment in the hands of the opposite party since the year 2011, as such the complainant is entitled to compensation. Opposite party is directed to pay compensation to the tune of Rs. 3000/- while litigation expenses are assessed at Rs. 2000/-. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated : 10.4.2017
