Haryana

Yamunanagar

CC/163/2014

Jayanti Parkash Goenka S/o Nand Kishore - Complainant(s)

Versus

OIC Ltd. - Opp.Party(s)

Raj Kumar

27 Oct 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA   NAGAR AT JAGADHRI.

 

                                                     Complaint No.163 of 2014.

                                                     Date of institution: 26.03.2014.

                                                     Date of decision: 27.10.2017.

Jayanti Parkash Goenka son of Sh. Nand Kishore Goenka, age 65 years, R/o H.No.777, Old Hamida, Tehsil Jagadhri, Distt. Yamuna Nagar.

                                                                                                  …Complainant.

                           Versus

1. The Oriental Insurance Co. Ltd., Oriental House, Asaf Ali Road, New Delhi, through its Managing Director/Chairman.
2. The Oriental Insurance Co. Ltd., 2^nd Floor, Jeevan Jyoti Building, Jagadhri Road, Ambala Cantt., through its Regional Manager.
3. The Oriental Insurance Co. Ltd., Opposite Madhu Cinema, Jagadhri Road, Yamunanagar through its Divisional Manager. 

 

….Respondents.

BEFORE SH. SATPAL, PRESIDENT

                SH. S.C.SHARMA, MEMBER.

                SMT.VEENA RANI SHEOKAND, MEMBER.

 

Present:     Sh. Raj Kumar Sharma, Advocate, for complainant.   

                  Sh. Rajiv Gupta, Advocate for the OPs.

               

                ORDER

         

(SATPAL, PRESIDENT)

                The complainant-Jayanti Parkash Goenka has filed this complaint under section 12 of the Consumer Protection Act 1986, as amended up to date (hereinafter respondents will be referred as OPs). 

2.             Brief facts of the complaint, as alleged by the complainant, are that he had taken a Joint Medical Claim Policy from the Op No.3 in his name as-well-as in the name of his wife bearing policy No.261700/48/2013/1499 and this policy was continuing since 20.11.1996 in respect of which, due payments had been made.  It is alleged that on 03.04.2013, the complainant slipped in his house and fell down on the ground and sustained injuries.  It is further alleged that the complainant was admitted to J.P. Hospital, Yamuna Nagar where he got treatment from 03.04.2013 to 07.04.2013 and incurred Rs.29,514/- on his treatment.  It is further alleged that the complainant lodged the claim with the Ops and submitted all the required documents but the Ops did not settle the claim of complainant.  So, it is a clear cut case of deficiency in service on the part of Ops and prayed for acceptance of complaint with the direction to Ops to pay Rs.29,514/- to the complainant alongwith interest @ 18% p.a. and further to pay Rs.10,000/- as compensation for harassment and mental agony as-well-as Rs.11,000/- as litigation charges.  Hence, this complaint.

3.            Upon notice, the OPs appeared and filed their written statement raising preliminary objections with regard to locus-standi; maintainability; cause of action; jurisdiction; that the claim papers were submitted by the complainant to the Op No.3, which were forwarded by the Op company to the TPA Vipul Medcorp TPA Private Ltd. for processing of the claim.  The TPA processed the claim and on processing, certain shortcomings were found and the TPA vide its letter dt. 17.07.2013 requested the complainant to provide some documents and a reminder was given by the TPA to the insured vide letters dt. 12.08.2013 and 13.09.2013 but the complainant had failed to provide the necessary information and documents and finding no alternative, the TPA sent a final letter dt. 17.10.2013 requesting the complainant to provide the necessary information within 15 days.  Since the complainant failed to submit the necessary documents and the information to the answering Ops, therefore, no claim was payable to the complainant under the policy in question; that there is no deficiency in service on the part of Ops.  On merits, the pleas taken in the preliminary objections are reiterated and so, prayed for dismissal of complaint.

4.             Ld. Counsel for the complainant tendered in evidence affidavit of complainant as Annexure-CW/A and documents Annexure-C1 to Annexure-C10 and closed evidence on behalf of complainant. 

5.             On the other hand, ld. Counsel for the Ops tendered in evidence affidavit of Sh. Gurmej Singh, Deputy Manager, Annexure-RW/A alongwith documents Annexure-R1 to Annexure-R5 and closed evidence on behalf of Ops.

6.             During the course of arguments, ld. Counsel for complainant has filed an application for permission to produce additional evidence i.e. letter dt. 10.06.2013 sent by the complainant to the Ops as the same is an important piece of evidence for just decision of the instant case.  The complainant could not produce copy of this letter by mistake in his evidence and the mistake is an unintentional one.  Reply to application filed by the Ops, wherein they have opposed the application on the ground that the complainant has not relied upon the letter dt. 10.06.2013 in his complaint and without pleadings, no evidence can be led and prayed for dismissal of application.  Heard on the application.  The document sought to be placed on record is an attested copy of letter dt.10.06.2013 sent by the complainant to Ops.  No prejudice will be caused to the parties in case this copy is placed on record.  The same is ordered to be marked as Annexure C-11.            

7.             We have heard the ld. Counsel for both the parties and perused the record carefully and minutely.

8.             The foremost question which requires adjudication is whether the complainant is entitled to re-imbursement of the amount of Rs.29,514/- as claimed by him in the complaint?

                Ld. Counsel for the complainant contended that the complainant  had taken a joint-medical policy from Op No.3 in his name as-well-as in the name of his wife, which is continuing since 20.11.1996 to 30.04.2013, the complainant slipped in his house and fell down on the ground and due to this accident, the complainant sustained injuries and was admitted in J.P.Hospital, Yamuna Nagar where he remained and got treatment from 03.04.2013 to 07.4.2013.  The complainant applied for medical claim with the Op No.3 and claimed Rs.29,514/- as total expenditure incurred on medicines and treatment in J.P.Hospital, Yamuna Nagar.  But the same has not been paid by the Ops till date and is being delayed on the one pretext or the other which amounts to deficiency in service on the part of Ops.

                On the other hand, ld. Counsel for the Ops contended that the claim papers were submitted by the complainant to Op No.3, which were forwarded by the Op company to the TPA Vipul Medcorp TPA Private Ltd. for processing of the claim, who after processing the same found some shortcomings in the claim papers and requested vide letter dt. 17.07.2013 to provide certain documents information/documents but the complainant failed to provide the necessary information despite issuance of reminders dt. 12.08.2013, 13.09.2013 and 17.10.2013.  Moreover, the complainant has failed to provide receipt of Rs.19,500/- regarding payment made to the hospital and has failed to provide the reasons for late submission of the claim documents. 

                It is admitted that the complainant was insured with the Ops-insurance company.  We have perused the document Annexure c-2, which is a medical bill dt. 07.04.2013 for a sum of Rs.19,500/- issued by J.P.Hospital, Yamuna Nagar for treatment taken by the complainant from 03.04.2013 to 07.04.2013.  The complainant has also tendered this bill in his evidence on 24.07.2015.  The bills of medicines incurred by the complainant from 03.04.2013 to 07.04.2013 are to the tune of Rs.7274/- and as such, the complainant incurred Rs.26,774/- for taking his treatment. 

                Further, from perusal of letter dt. 10.06.2013, written by the complainant to Op No.3, it is crystal clear that the complainant, who is a senior citizen, had humbly submitted that he was not aware of the condition prescribed for submission of the claim papers within 7 days and had further requested for condonation of delay. Further, about providing certificate relating to the circumstances of injury and the alcoholic status of the treating patient at the time of injury from the treating doctor.There is Annexure C-9 issued by Dr. Amit Goyal of J.P.Hospital, Yamuna Nagar, which reads as under:-

        “Patient J.P.Goenka was admitted in J.P.Hospital on 03.04.2013 with H/O fall at his home by slipping & falling down on ground.  He was fully conscious and not under effect of alcohol at the time of admission”.

      From the facts and circumstances of the case, it is clear that the Ops company made “no claim” on the ground that the complainant failed to submit the necessary document/information.  However, the complainant had submitted reply of querry vide document Annexure C9, which is report of treating doctor and also explained delay vide letter Annexure C-11, wherein the complainant explained his position regarding delay for submitting the claim form and as such, the complainant has fulfilled all the requirements as raised by the Ops.  Hence, we are of the considered view that as per I.R.D.A. instructions, the genuine claim should not be rejected on the technical ground.  The claim in respect of medical treatment of complainant should have been settled by the Op on the basis of the guidelines of non-standard settlement.  In this regard, reliance can be placed upon authority titled as United India Insurance Co. Ltd. Vs. Gian Singh reported in II(2006) CPJ page 83 (NC), wherein it has been held by Hon’ble National Commission that in case of violation of condition of policy as to nature of use of the vehicle, the claim ought to be settled on non-standard basis.  In the authority titled as Mohammad Ejaj Vs.UII, 2014(4) CLT page 161 (Hon’ble State Commission, Haryana), it has been held that Insurance Claim-Repudiation-On the ground that there was delay of 15 days in lodging the F.I.R. and 36 days in giving intimation to the Insurance Company-IRDA have given direction to the Insurance Companies not to reject genuine claims simply because of late registration of F.I.R. and late intimation to the Insurance Company-Held-IRDA is the controlling authority of all Insurance Companies and being a statutory body, is competent to frame guidelines and issue instructions to Insurance Companies which are binding upon them-Appeal accepted.  In the authority cited in 2016(2) CLT page 434 (Hon’ble State Commission, Haryana) titled as Future General India Insurance Co. Ltd. Vs. Satbir, where in the head-note, it is mentioned that Insurance claim-Theft of insured tractor-Prompt FIR-Delay of 66 days in intimation to insurance company-Held-In the Circular Ref:IRDA/HLTH/MISC/CIR/216/09/2011 dated September 20, 2011 issued by ‘IRDA’, it has been mentioned that genuine claims should not be rejected on account of delay in intimation, and that, the insurer’s decision to reject a claim must be based on “sound logic” and “valid grounds”-Insurance company is liable to indemnify the loss suffered by the complainant-Appeal dismissed.

9.     Thus, as a sequel of above discussion, we allow the complaint of complainant and direct the Ops to pay 75% of the total expenses of Rs.26,774/- (Medical bill of hospital + Bills of medicines during the treatment) incurred by the complainant on his treatment on non-standard basis.  Let the order be complied with within 30 days from the date of communication of this order, failing which, interest @ 9% p.a. shall be payable on the afore-mentioned amount.  A copy of said order be supplied to the parties free of cost.  File be consigned to record-room after due compliance.      

Announced in open court:

Dated: 27.10.2017.

 

                                                            (SATPAL)

                                                            PRESIDENT.

 

 

(VEENA RANI SHEOKAND)         (S.C.SHARMA)

MEMBER                                            MEMBER