ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Ms. Nipur Chandna, Member
Complainant is the medicalim policy holder of the OP company vide policy no. 212703/48/2011/442 w.e.f. 6.5.2010 to 5.5.2011.
It is alleged by the complainant that his wife was admitted on 20.10.2010 is Bagga Nursing Home and was discharged on 24.10.2010. It is further alleged by the complainant that he had spent a sum of Rs.10,744/- on the treatment. Complainant lodged the claim with the OP company for the reimbursement of the aforesaid amount. The OP company vide its letter dated 21.11.2011 informed the complainant that as he had failed to submit the required information, his claim file was closed.
It is alleged by the complainant that the OP company had not paid his claim under the pretext of non-supply of the document this act of OP amounts to deficiency in service on its part, as he had already supplied the required information to it twice, firstly with the claim from and secondly vide letter dated 19.7.2011.
The complainant therefore approached this Forum for the redressal of his grievance.
Complaint has been contested by the OP. OP company has filed its W.S. Para No. 6 of the reply on merits is relevant for deciding the present complainant and is reproduced as under:-
6. That the contents of the Para under reply are denied as stated. It is denied to the knowledge and information of the answering opposite party that the complainant has furnished the documents as stated in the Para under reply vide its letter dated 19.7.2011. So far as the previous policies are concerned it has already been informed to the complaint through reply to the legal notice got issued by the complainant through it’s counsel. It is submitted that the complainant obtained insurance policy for the first time from the opposite party no. 2 valid from 6.5.2010 to 5.5.2011 on production of earlier policy no. 272401/48/2010/77 issued by its BO Palwal for a period from 6.5.2009 to 5.5.2010 and the complainant has failed to produce any other policy prior to the one issued by it’s Palwal office. As per the record furnished by the complainant policy under which the claim has been filed was running in the second year and as such the claim for the specified disease was not payable under the terms and conditions of the policy. It is submitted that the complainant has not furnished the details of the previous policies to the respondent and without getting the details the respondent cannot verify the authenticity of the policies from concerned offices of the respondent the rest of the averments made in the Para under reply are wrong and the same are specifically denied
Both the parties have filed their evidence by way of affidavits.
We have heard arguments advanced at the bar and have perused the record.
The counsel for the complainant has contended that the complainant had already supplied the required documents/information to the OP company alongwith claim form on 28.10.2010. The complainant again vide letter dated 19.7.2011 supplied the necessary information sought by the OP company vide its letter dated 2.6.2011 to the OP co. The counsel for the complainant has placed on record the copy of claim form alongwith documents, letter dated 2.6.2011, letter dated 19.7.2011 and the copy of letter dated 21.11.2011 vide which the OP company has closed his claim file in support of his contention.
The counsel for the complainant has stated that the OP company had closed its file a false and flimsy ground for non supplying of documents/information. This act of OP amounts to deficiency in service.
We are in agreement with the contention of the counsel for the complainant. The counsel for the OP has taken the plea that as the complainant had failed to supply the Insurance documents to the TPA, his claim file was closed. The counsel for the complainant had drawn our attention to the copy of claim form, which clearly shows that the complainant had already submitted the original receipt of Rs.8200/- as ______by the TPA with the claim form on 28.10.2010. Hence, the question of supplying the original receipt does not sustain.
The counsel for the OP has taken the plea in its W.S. that “the policy of the complainant was running in second year and as the claim for the specified disease has not payable under the terms and condition of the policy. He has however, failed to place on record any document which shows that he wife of the complainant was suffering from any such disease which was specifically excluded as per the terms and condition of the policy.
In view of the above discussion, we are of the considered opinion that the OP had closed the claim file of the complainant on false and flimsy ground.
We, therefore, hold OP guilty of deficiency in service and direct it as under:-
- To pay to the complainant a sum of Rs.10,744/- (Ten thousand seven hundred forty four only) alongwith interest @ 10% from the date of filing of complaint till payment.
- To pay to the complainant a sum of Rs.5,000/-(Rupees Five Thousand only ) for pain and mental agony suffered by him.
- Pay to the Complainant a sum of Rs.5,000/- (Rupees Five thousand only ) as a cost of litigation.
The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. If the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule.
File be consigned to record room.
Announced in open sitting of the Forum on ___________
