Haryana

Karnal

505/2012

Balkishan Gupta S/o Bishambar Dass - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

Vishal Goel

02 Aug 2016

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.   

                                                              Complaint No.505 of 2012

                                                             Date of instt.:17.10.2012

                                                               Date of decision 2.8.2016

 

Bal Kishan Gupta son of Shri Bishambar Dass resident of House no.2370, Sector 13, Urban Estate Karnal.

 

                                                                   ……..Complainant.

                                      Vs.

1. Divisional Manager, The Oriental Insurance Company Ltd., near Bus Stand, G.T. Road, Karnal

2. Managing Director, The Oriental Insurance Co. Ltd., Registered office Oriental House, A-25/27, Asaf Ali Road, New Delhi.

3. Vipul, MEDCORP TPA Pvt. Ltd. (TPA for Oriental Insurance Co. Ltd.) 515, Udyog Vihar, Phase-V, Gurgaon.

 

                                                                 ………… Opposite Parties.

 

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Sh.Anil Sharma…….Member.

 

Present:-      Shri Vishal Goel Advocate for complainant.

                    Shri Suresh Khanna Advocate for opposite parties no.1 and 2.

                   Opposite party no.3 exparte.

 

                                       

 ORDER:

 

                   This complaint has been filed by the complainant u/s 12 of the Consumer protection Act 1986, on the averments that he obtained a mediclaim policy bearing no.261300/48/2011/844 dated 6.9.2010 valid from 10.9.2010 to 9.9.2011 from opposite party no.1. He and his wife Smt. Kamlesh Gupta were insured and covered under the aforesaid policy. He met with an accident on 8.8.2011 and remained admitted in the hospital of Dr.Ashok Gupta, Karnal from 8.8.2011 to 12.8.2011. Operation was performed to fix the fractured ankle. Even after discharge from the hospital, he visited the concerned doctor as an outdoor patient. An amount of Rs.31,146/- was spent on his treatment. He submitted genuine claim of expenses incurred on his treatment to the opposite parties. Opposite party no.3, who was acting as TPA for opposite parties’ no.1 and 2, vide letter dated 10.3.2012 and 13.09.2011 put some queries, which were replied by him and the required documents were submitted. He explained to opposite party no.1, vide letter dated 15.3.2012 that he could not submit the claim after discharge from the hospital as due to accident he was not in a position to move and inform the concerned authority, regarding hospitalization. Moreover, his wife became victim of Malaria and got treatment from 5.9.2011 to 8.9.2011 from Noor Medical Centre, Sector 6, Urban Estate Karnal. Therefore, he could not submit the requisite claim and could not inform the opposite parties regarding his hospitalization. However, vide letter dated 29.3.2012 his claim was repudiated on the ground that the reply to the queries was not sent whereas he had duly replied all the queries. Ultimately, he sent legal notice dated 6.6.2012 to opposite parties no.2 and 3, but the same also did not yield any result. In this way, there was deficiency in service on the part of the opposite parties, which caused him mental pain, agony and harassment apart from financial loss.

2.                Notice of the complaint was given to the opposite parties. Opposite parties no.1 and 2 filed joint written statement controverting the claim of the complainant. It has been submitted that the complainant never intimated the opposite parties regarding his accident or admission/treatment in hospital, whereas according to terms and conditions of the policy, he was bound to intimate within 48 hours of his admission or from discharge from the hospital. The complainant even did not send the relevant documents of his accident/admission within stipulated period as per condition of the policy in question. Since no feedback was provided by the complainant within time, his claim was repudiated. Therefore, no liability can be fastened upon the opposite parties. The other allegations made in the complaint have been denied.

3.                None appeared on behalf of opposite party no.3 on 24.9.2014, therefore, exparte proceeding initiated again it.

4.                In evidence of the complainant, his affidavit Ex. CW1/A and documents Ex.C1 to C30 have been tendered.

5.                On the other hand, in evidence of the opposite parties, affidavit of R.S.Behlan Sr. Divisional Manager Ex.O and documents Ex.O1 to O5 have been tendered.

6.                We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.                The complainant had obtained a mediclaim policy from the opposite party no.1 which was valid from 10.9.2010 to 9.9.2011. During the subsistence of the policy, he met with an accident and suffered fracture of ankle. He remained admitted in the hospital of Dr.Ashok Gupta Karnal from 8.8.2011 to 12.8.2011 and thereafter got treatment as outdoor patient. He lodged claim with the opposite parties for reimbursement of the amount spent by him on his treatment but his claim was repudiated.

8.                Learned counsel for the opposite parties laid emphasis on the contention that as per policy condition the complainant was required to intimate the opposite parties regarding accident or his admission/treatment in hospital within 48 hours of his admission or before discharge from the hospital, but he did not give such intimation. Moreover, relevant documents relating to his accident and admission in the hospital were also not submitted despite letters Ex.O1 to O4, therefore, his claim was rightly closed by the opposite parties as ‘No Claim.’

9.                Admittedly, the complainant had not given any intimation to the opposite parties regarding his accident and admission in the hospital within 48 hours of the admission or before discharge from the hospital. However, he submitted reply to the queries put  by the opposite party no.3 in the letter dated 10.3.2012, vide his letter dated 15.3.2012, the copy of which is Ex.C6. It was submitted that after the accident he was not in a position to inform the concerned authority regarding his hospitalization. As soon as he was able to do so, he had informed the opposite party no.3 and documents were sent to Gurgaon office for process of the claim, that except the x-ray of copy of all the documents were submitted earlier and the same were being sent again. The complainant again submitted reply dated 13.4.2012, the copy of which is Ex. O5 to the queries put by the opposite parties, vide letter dated 29.3.2012. He clarified in his letters that the previous letter sent by the opposite parties were not received by him due to which there was delay in sending the documents and replies at his end.

10                A perusal of the letters of the opposite parties, the copies of which are Ex.O1 to Ex.O3 and Ex.C8 show that the opposite parties have admitted that the complainant submitted the documents and claim 28 days after discharge from the hospital. The complainant has produced Ex.C12 to Ex.C26, the copies of treatment record, bills paid by him and the medicines purchased for his treatment. When the complainant can produce all such documents in his evidence, it cannot be believed that he did not produce the same before the opposite parties alongwith his claim. Even if, some documents were not produced, the opposite parties could ask for the same from him after his letters dated 15.3.2012 and 13.4.2012, the copies of which are Ex.C6 and Ex.O5 respectively. Therefore, the opposite parties were not justified in making the claim of the complainant as ‘No Claim’ on the ground of non-production of documents.

11.              The other ground on which the opposite parties made the claim of the complainant as ‘No Claim’ is that he did  not give intimation to the opposite parties regarding his accident and admission within 48 hours or before discharge from the hospital. The question arises whether the opposite parties were justified to repudiate the claim of the complainant on technical ground of delay in intimation.

12.               Insurance Regulatory and Development Authority issued circular dated 20.9.2011, which is reproduced as under:-

“ To: All life insurers and non-life insurers.

  Re: Delay in claim intimation/documents submission with respect to

i.        All life insurance contracts and

ii.       All Non-life individual and group insurance contracts.

          The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.

         The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.

          The insurers’ decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good ‘spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.

          Therefore, it is advised that all insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time.

          The insurers are advised to incorporate additional wordings in the policy documents, suitably enunciating insurers’ stand to condone delay on merits fort delayed claims where the delay is proved to be for reasons beyond the control of the insured.

          J.Harinarayan

          CHAIRMAN.”

 

13.              It is clear from the above circular that insurance company cannot repudiate the theft claim on technical grounds like delay in intimation and submission of some required documents. The decision of insurer to reject a claim of the claimant should be based on sound logic and valid reasons. The limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holder losing confidence in the insurance industry, giving rise to excessive litigation. It has further been advised in the said letter that the insurer must not repudiate such claims unless and until the reasons for delay are specifically ascertained, recorded.

             What is the spirit of insurance policy, should be kept in mind by the officials dealing with the genuine claims of the sufferers and the same should not  be rejected on methodological grounds in a mechanical manner. The tendency of insurance companies in rejecting genuine claims is the reason of increasing litigation between the insurers and the insureds/their legal heirs. In this context reference with advantage may be made to orders of the Hon’ble State commission in  Shriram General insurance Company limited Versus Rajesh Kumar 2014(2) CLT 290 and Shriram General Insurance Company Limited Vs. Manoj 2014(3) CLT 447 as well as order of Hon’ble National Commission in National Insurance Co.Ltd. Versus Kulwant Singh IV (2014) CPJ 62 (NC).

14.              In the instant case, it is not the case of the opposite parties that the complainant had not suffered any injury in the accident and he did not remain admitted in the hospital. Neither it has been alleged nor there is any evidence worth the name, which may show that the claim of the complainant was not genuine. The complainant had suffered fracture of ankle, he remained admitted in the hospital from 8.8.2011 to 12.8.2011 and thereafter got treatment as outdoor patient. When the insured was admitted in the hospital he could not be expected to intimate the insurance company about his accident immediately, while admitted in the hospital or immediately after discharge from the hospital. Uniting of fracture might have taken sufficient time and in such a situation he could not be able to move and give written intimation to the opposite parties regarding his admission in the hospital. Under such circumstances, repudiation of the claim of the complainant by the opposite parties was contrary to the spirit of the letter of Insurance Regulatory and Development Authority, because intimation to insurance company after delay of 16 days was not significant in genuine claim of the complainant. Therefore, repudiation of genuine claim of complainant on sole ground of delay in intimation amounted to deficiency in service on the part of the opposite parties. The complainant has claimed an amount of Rs.31,146/- as expenses spent on his treatment. He has produced the copies of the bills regarding payment made to the hospital and for purchase of medicines and there is no reason to doubt the genuineness of the same.

15.              As a sequel to the foregoing discussion, we accept the present complaint and direct the opposite parties to pay Rs.31,146/- to the complainant  alongwith interest thereon @ 9% per annum from the date of filing of complaint till its realization. We further direct the opposite parties to pay Rs.5500/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 02.08.2016

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

                             (Anil Sharma)

                               Member