PER SHRI. S.S.PATIL - HON’BLE MEMBER :
1) This is the complaint regarding the deficiency in services as non settlement of mediclaim of the Complainant by the Opposite Parties.
2) The facts of the complaint as stated by the Complainant are that he has been taking Mediclaim Policy form Opposite Party No.1 since 2004 and he has not submitted any claim ;since the inception of the 1st policy till 27/01/2010. during the validity of Mediclaim Policy No.111400/34/09/11/00003407 (valid from 13/05/09 to 12/05/2010) he was hospitalized and treated for Acute Viral Hepatitis A in Surgicare Hospital at Andheri (W) from 04/01/2010 to 08/01/2010. The Complainant then submitted his claim of Rs.30,250.65 on 27/01/2001, however, the claim was rejected vide letter dtd.11/11/2010 under Clause 5.5 of the policy giving reason as follows –
“The shall be null and void & no benefit shall be payable in the event of misrepresentation, misperception or non disclosure of any matter fact/ particular if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on his behalf.”
3) The Complainant has further stated that the above repudiation of the claim done by the Opposite Party was ambiguous. Therefore, he wrote several letters to the Opposite Parties but in vain. The legitimate claim of the Complainant was repudiated on frivolous ground and thus, there is a deficiency in service on the part of Opposite Parties. Therefore, the Complainant has prayed for the following reliefs –
a) To reimburse the medical expenses of Rs.30,250.65 to the Complainant with interest.
b) Compensation of Rs.1 Lac for mental agony and physical inconveniences.
c) Cost of the complaint, etc.
4) The Complainant has attached the xerox copies of the following documents in support of his complaint -
Policy documents 2006-2007, 2007-2008, 2008-2009, 2009-2010, 2010-2011, Claim Form dtd.27/01/2010, Policy documents 13/05/09 – 12/05/2010, Receipts No.1068 dtd.25/01/2010 & other medical papers, letter of Opposite Party No.2 dtd.03/11/2010 repudiating the claim, Letter dtd.11/11/2010, Letter dtd.01/12/2010, Letter under RTI Act, Letter dtd.04/03/2011, Appeal under RTI Act, Letter dtd.20/04/2011, RTI Reply dtd.20/04/2011.
5) The complaint was admitted and notices were served on the Opposite Parties. Opposite Parties appeared through Ld.Advocate Smt. Kalpana Trivedi. She filed the written statements of the Opposite Parties wherein the allegations of deficiency in service on the part of Opposite Parties are denied. However, it is admitted that the Complainant has availed the mediclaim facility from the Opposite Party No.1 and has filed the claim of Rs.30,250.65, but it was rejected as per clause 5.5 as fraudulent claim as there were various discrepancies in the claim documents and information collected by the Opposite Party on personal verification. Hence, there is no deficiency in service on their part.
6) Thereafter, both the parties have filed their affidavits of evidence and written arguments wherein they have reiterated the facts mentioned in the complaint and written statement respectively.
7) The Opposite Parties have given a pursis that their written argument be accepted as the oral argument. Accordingly we heard the Ld.Advocate for the Complainant, perused all the papers filed by both the parties and our findings are as follows –
8) The Complainant has taken Mediclaim policy No.111400/34/09/0002407 from Opposite Party No.1 valid from 13/05/09 to 12/05/2010 for Rs.1 Lac. During the validity of this policy the Complainant was admitted in Surgicare Hospital at Andheri (W), Mumbai from 04/01/2010 to 08/01/2010 i.e. for 5 days for Viral Hepatitis A under the medical treatment of Dr. Santosh Nagre, M.D. The Complainant has produced the necessary medical papers in this respect showing that he was admitted in the hospital under the treatment of medical practitioner and incurred an expenditure of Rs.30,250.65.
9) However, despite the hospital papers, the Opposite Party has repudiated the claim on the ground of clause 5.5 of the mediclaim policy. Clause 5.5 stipulates as –
“The policy shall be null & void and no benefit shall be payable in the event of misrepresentation, misdescription or non disclosure of any material fact/particular if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on his/her behalf.”
10) We have carefully gone through this repudiation letter of Opposite Party No.2. There is nothing more than the contents of clause 5.5. The Opposite Party No.2 has not clarified as to how the claim filed by the Complainant is fraudulent or what is misrepresented by the Complainant or what material fact is not declared by the insured or some other person on his behalf.
11) The Complainant has tried his level best to know what was the misrepresentation the Opposite Party No.2 had found in his mediclaim, why his claim was rejected under clause 5.5 of the policy by applying RTI Act, 2005 also but, the Opposite Parties did not give any plausible reason for repudiation the claim and did not answer the genuine queries of the Complainant. Only in written statement of the Opposite Party, they have clarified that there are discrepancies in the medical reports submitted by the Complainant and information collected by them personally but the Opposite Parties have miserably failed to point out what are these discrepancies. Therefore, if is crystal clear that the Opposite Parties have not given any plausible reason for repudiating the insurance claim and thus adopted unfair trade practices to repudiate the genuine mediclaim of the Complainant.
12) The Complainant has rightly taken objection in his written argument that the Opposite Party has singed the written statement but it is not verified as there is no verification clause. Hence, it should not be considered as Opposite Party’s defence. Inspite of this objection, we were also curious about the reason to know the grounds which attracted clause 5.5 of the policy. But the Opposite Parties did not explain the ground and only stated that there were discrepancies without mentioning those discrepancies. This certainly indicates that the Opposite Parties have not applied their mind in repudiating the claim of the Complainant and rejected the eligible mediclaim of the Complainant only quoting the stipulation under clause 5.5 of the policy.
13) Thus, there is a deficiency in service as well as the Opposite Parties have adopted unfair trade practice in repudiating the claim and hence, they are liable to reimburse medical expenditure incurred by the Complainant and they are also liable to pay compensation to the Complainant for his mental agony and harassment undergone by him due to the deficiency in service on their part and unfair trade practice adopted by them. The Complainant is entitled for the cost of this complaint. Therefore, in view of the above observations we pass the following order –
O R D E R
1. Complaint No.199/2011 is partly allowed.
2. The Opposite Party No.1 & 2 are directed to reimburse jointly and/or severally Rs.30,251/- (Rs. Thirty Thousand Two Hundred Fifty One Only) to the Complainant alongwith interest @ 9 % p.a. from 28/01/2010 till payment.
3. The Opposite Party No.1 & 2 are also directed to pay jointly and/or severally Rs.10,000/- (Rs. Ten Thousand Only) to the Complainant as compensation for mental agony caused to the Complainant.
4. The Opposite Party No. 1 & 2 are also directed to pay jointly and/or severally Rs.5,000/- (Rs. Five Thousand Only) to the Complainant towards the cost of this complaint.
5. Opposite Parties are directed to comply with this order jointly and/or severally within 30 days from the receipt of copy of this order.
6. Certified copies of this order be furnished to the parties.
