O R D E R
K.S. MOHI, PRESIDENT
The complainant has filed the present complaint against the O.Ps u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant had taken a mediclaim policy (Family Group Medi-claim-policy) bearing No.354100/48/09/8500002859 valid for the period from 05.02.2010 to 04.02.2011 from the O.P-1. It is alleged that complainant’s daughter namely Surbhi Modi suddenly and unfortunately fell ill and was admitted in the St. Stephen’s Hospital, Delhi on 15.07.2010 and was discharged on 22.07.2010 during this period she was examined, investigated and treated in the hospital by Dr. Anoop Kumar Bangroo. It is further alleged that the said Hospital charged Rs.8,523/- on account of their hospital bill, the original discharge memo and bill with original receipts of Rs.8,523/- were sent to O.P by the complainant vide letter dated 03.08.2010 which was duly received by the O.P. It is alleged that complainant had also submitted all the original receipts of payment showing purchase of medicines and other expenses to the tune of Rs.6,628/- vide letter dated 03.08.2010. It is further alleged that the complainant paid total sum of Rs.15,151/-. It is alleged that the complainant has been repeatedly reminding and requesting the O.Ps to reimburse the amount paid by him but of no avail. Complainant has also sent a legal notice dated 08.11.2010 but all in vain. On these facts complainant prays that O.Ps be directed to pay the mediclaim amount of Rs.15,151/- alongwith interest and also to pay cost and compensation as claimed.
2. O.Ps appeared and filed its written statement. In its written statement O.Ps have not disputed that complainant had taken policy refer to above. It is alleged that the complainant had filed the claim and was diagnosed for Mild acute Pancreatitis was said to be Gall Stone Induced which could not have been paid without ascertaining the history and duration of treatment. It is further alleged that complainant/ insured was required to submit all the claim related documents to the TPA for the reimbursement of the claim. It is alleged that the complainant did not submit the certificate from the treating doctor regarding duration of illness and past treatment papers to the O.P-2 so as to the process the claim and as such the O.P-2 was unable to process the claim of the complainant. It is further submitted that the O.P-2 wrote a number of letters dated 06.08.2010, 18.08.2010 and 25.08.2010 regarding the submission of documents. Since the complainant did not submit the complete papers to the O.P-2, the O.P-2 had no choice but to close the file vide letter dated 10.09.2010. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit affirming the facts alleged in the complaint. He has also proved documents exhibited as Ex. CW-1/1 to CW-1/11. On the other hand Sh. D.K. Sagar, Sr. Divisional Manager has filed his affidavit on behalf of OP-1 and Sh. R.K. Kachroo, Executive Director & CEO has also filed his affidavit on behalf of the O.P-2, testifying all the facts as stated in the written statements. Parties have also filed their respective written submissions.
4. We have carefully gone through the record of the case and have heard submission of Ld. Counsel for the O.P.
5. In the present case the main contention of the O.P is that the insured was required to submit all the claim related documents to the TPA for the purpose of reimbursement of the claim, however, complainant did not submit the certificate of the treating doctor regarding duration of illness and past treatment papers, as a result the O.P was unable to process the claim of the complainant. It is further submitted that the O.P-2 wrote a number of letters dated 06.08.2010, 18.08.2010 and 25.08.2010 regarding the submission of documents to the complainant but all in vain. Ultimately the O.P had no choice but to close the file vide letter dated 10.09.2010. It is true that complainant is supposed to submit all the relevant documents relating to his illness/ medicines to the insurance company, so that the claim is process and considered. In the present case the record indicates that the complainant submitted all the relevant documents including the medicine bill, treatment papers/ discharge slip indicating the kind of illness suffered by him and the treatment. It will not be out of place to mention here that duration of admission period has been very much mentioned in the final bill. The date of admission is indicated as 15.07.2010 at 14:18 P.M and date of discharge as 22.07.2010 at 14:11 P.M. The insurance company has not indicated any specific condition or term of policy which required the certificate by treating doctor to be a pre-condition for assessment of medical claim. We feel that all the relevant documents of illness and medicine were already submitted by the complainant to the O.P but the O.P for the reasons best known to him did not process the claim for ulterior motive, therefore, we find there is deficiency in the service of O.P and hence the claim is allowed.
6. Keeping in view the discussion above the O.P repudiate the claim on frivolous grounds, therefore, deficiency in service. We award a sum of Rs.15,151/- with interest @ 6% from the date institution of the complaint till payment, the further award of Rs.3,000/- towards harassment mental agony loss of time and Rs.1,500/- towards litigation cost.
Copy of this order be sent to the parties as per rules.
Announced this 20th day of January, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
