PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

  1)        The Complainants by this complaint have prayed that the Opposite Parties be directed to pay Rs.33,711.30 to the Insured Complainant No.2 with interest @ 15% p.a. from the date of closer of claim i.e. 22/07/2009 till realization.  It is also prayed that the Opposite Parties be directed to pay penal compensation of Rs.15,000/- to the Complainant No.2 for the harassment and mental tension caused to him and cost of Rs.10,000/- towards this proceedings. 

 2)        This complaint is filed by Voluntary Consumer Organization on behalf of the Complainant No.2 who is the actual aggrieved consumer in respect of his insurance claim.  The Opposite Party No.1 is the Insurance Company with whom the Insured Complainant No.2 is covered under a Group Mediclaim Policy of his employers Godrej & Boyce Mfg. Co. Ltd.  The Opposite Party No.2 is Third party administrator appointed by Opposite Party No.1 to process insurance claim. This complaint is filed for deficiency in service and unfair trade practice to process the claim lodged by the Insured Complainant No.2.    

 3)        It is alleged that the Group Mediclaim Policy obtained by the employer of Complainant No.2 was inforce and valid from 01/04/2009 to 31/03/2010.  The said policy was issued to the employer of Complainant No.2 and hence, the copy of the same is not available with the Complainants.  The policy details which are available with the Complainants are filed as Exh.‘A’. The copy of the card issued by the Opposite Party No.1 in respect of the Complainant No.2 as poof of insurance coverage is marked as Exh.‘B’.

 4)        During the policy period on 06/05/2009 the Complainant No.2 while working at Godrej Boyce Mfg. Co. Ltd. and was feeding iron sheets in the sharing machine met with an accident and his right hand finger got injury and badly crushed in the pinch roller of the said machine known as CTL3.  The Complainant No.2 was taken to the hospital where it was told that as right hand finger was badly crushed it would have to be imputed. The Complainant No.2 wanted to avoid imputation.  Therefore, he was taken to Hinduja Hospital for expert opinion.  In Hinduja Hospital it was told that an attempt could be made to save his finger. The Complainant No.2 was therefore, admitted to Hinduja Hospital and placed under the care of Dr. Rajveer Chinoy (Orthopedic Surgeon).  Dr. Anil Tiberewala (Plastic Surgeon) was also consulted.  Thereafter, Dr. Rajveer Chinoy carried out a reconstructive surgery upon the Complainant No.2 on 07/05/2009 and he was discharged on 09/05/2009.  Copy of discharge summary of Hinduja Hospital is marked as Exh.‘C’. 

 5)        After discharge the Complainant No.2 submitted the claim form alongwith all original bills and other supporting documents and medical reports to the Opposite Party No.2 of the total amount of Rs.33,711.30 paise.  The copy of the claim form retained by the Complainant No.2 is marked as Exh.‘D’.  The claim status was being checked periodically online which showed as being “Under Process”.  However, on 22/07/2009 when the claim status was checked it came to know that all the amounts were shown as “0” and as “Claim Closed”.  Copy of the said claim status is marked as Exh.‘E’.  The Complainant No.1 on behalf of Complainant No.2 then on 23/07/2009 sent e-mail to the Opposite Parties and their respective officer Incharge protesting against the claim being closed without being processed.  The copy it is marked as Exh.‘F’.  According to the Complainants, the Opposite Party No.1 ignored the e-mail dtd.23/07/09, however, the Opposite Party No.2 sent reply dtd.27/07/2009 to the Complainant No.1 which is marked as Exh.‘G’, wherein it was informed that the claim has been closed because it could not be processed due to “want of certain documents’.  It is alleged that the said reply does not specify which were those certain documents.  It is the case of the Complainants that even then the Opposite Parties would have called upon Complainant No.2 asking for those documents but no such letter has been sent to the Complainant No.2 by the Opposite Parties till the date of filing of the Complainant.  By the said reply it was also not informed by the Opposite Parties that the claim has not been repudiated but would be processed further on receipt of the documents.  According to the Complainants, the Opposite Parties with ulterior motive and malafide intention failed to process the claim because they do not want to settle it, but cannot find any excuse to repudiate it. The approach of the Opposite Parties amounts to deficiency in service for which penal and deterrent compensation should be awarded.  The Complainants therefore prayed for the reliefs as mentioned in para 1 of this order.  

 6)        The Opposite Party No.1 contested the claim by filing written version.  It is contended that the complaint is false, frivolous, mischief and bad-in-law and is liable to be dismissed with cost.  According to the Opposite Party No.1, the Complainants have suppressed the material facts and have not come with clean hands.  The claim is filed by the Complainants to take disadvantage of their own wrongs.  It is not disputed that Godrej & Boyce Mfg. Co. Ltd., had taken Group Mediclaim Policy for its employees as alleged by the Complainants.  It is also not much disputed that the Complainant No.2 have submitted the claim with Opposite Party No.2 for the claim settlement.  It is however, contended that the Complainant No.2 had thereafter taken back all the documents submitted for the claim settlement and even inspite of demands made by the Opposite Parties and the employer of Complainant No.2 has not submitted the same and filed this complaint. It is contended that therefore, the complaint is not maintainable.  It is alleged that the Opposite Parties have made the follow up for the settlement of the claim of the Complainant No.2 and had sent several e-mails to the concerned officers of the Complainant No.2.  The concerned officer has made it clear that after returning documents by the company the Complainant No.2 had not turned up to submit the documents and hence, the claim is not settled for want of information and clarification as well as original documents.  It is contended that there is no fault of Opposite Party No.1 and the employer of the Complainant No.2.  The Complainant No.2 is negligent and had avoided to give the documents to settle the claim, the complaint is therefore, liable to be dismissed with cost.  The Opposite Party No.1 denied all other allegations made by the Complainants and contended that there is no cause of action to file this complaint.  The Opposite Party relied e-mail of Mr. Godrej B. Sachinwala, dtd.16/06/2011 issued to the Opposite Party No.2. It is contended that there is no deficiency on the part of the Opposite Parties and the complaint be dismissed with compensatory cost.

 7)        The Opposite Party No.2 though served remained absent the complaint therefore, proceeded ex-parte against Opposite Party No.2. The Complainant No.2 has filed his affidavit of evidence.  The Divisional Manager of the Opposite Party No.1 Rajiv Mehta has also filed his affidavit of evidence.  The Complainant and Opposite Party No.1 filed their written arguments. We heard Mr. Jehangir Gai, the Representative of Complainants and Mr. Sanjay Mhatre, Ld.Advocate for the Opposite Party No.1. Shri. Jehangri Gai pointed out that in the affidavit of Complainant No.2 he has specifically stated that for the first time the Opposite Party No.1 has come up with a unique defence that the claim file had been retuned to Complainant No.2.  He also pointed out that in the e-mail at Exh.‘E’ there is no such mention.  He also pointed out that in the letter of Opposite Party No.2 at Exh.‘G’ to the complaint dtd.27/07/09.  On the contrary it was informed to the Complainant No.1 that “In this regard we would like to convey that the aforesaid Insured submitted the claim file with us which was forwarded to medical scrutiny team. The concerned doctor during his corporate visit has personally informed the Insured that the file is deficient and the said file cannot be processed further due to want of certain documents.  Once the said documents is retrieved the claim will be processed further.”   He also pointed out that in the said letter the Opposite Party No.2 have informed that they have not repudiated the claim but have just close the claim due to non availability of certain documents.  Shri. Jehangir Gai, thus submitted that the stand taken by Opposite Party No.1 in its written version is totally contradictory to the communication of Opposite Party No.2.  He made submission that the Complainant No.2 had submitted all the bills of Hinduja Hospital to the Opposite Party No.2 is supported by the document filed alongwith the affidavit of Complainant at Exh.‘I’.  He also pointed out that the Opposite Party No.1 had acknowledged the said documents as per Exh.‘H’ filed with the affidavit of Complainant No.2.  He also pointed out that in Exh.‘J’ filed with the affidavit of the Complainant No.2 it is specifically mentioned that all the documents are being submitted in original except X-Ray Plates of injured fingers as these will be required at the time of obtaining the disability certificate on completion of healing and also for obtaining workmen compensation, if any. He made submission that thus, the defence taken by the Opposite Party No.1 is totally inconsistent with the documents placed on records.  He also pointed out that affidavit of the Divisional Manager of Opposite Party No.1 is not anyway helpful for disallowing the claim as he had no personal knowledge of the incident.  He submitted that in view of the observations in the case of United India Insurance Co. Ltd. V/s. Smt. Kusumben J. Badiani, II (1995) CPJ 109 (NC), the contentions in the affidavit of Divisional Manager of Opposite Party No.1 cannot be accepted.  He also submitted that the original claim form, medical documents and bills were submitted by the Complainant No.2 to the Opposite Party No.2. He further submitted that the said Opposite Party No.2 remained absent and did not contest the claim, on the other hand in the communication made by the Opposite Party No.2 vide letter at Exh.‘G’, dtd.27/07/09 the Opposite Party No.2 has specifically accepted that the claim papers were received by it, but the file was deficient.  He made submission that in the said letter there is no mention that the Complainant No.2 had taken back the original documents and file. Shri. Gai, submitted that the Opposite Party never informed that what deficient documents were required for settling the claim.  He thus, submitted that the defence raised by the Opposite Party No.1 is totally unacceptable and therefore, the claim made in the complaint may be allowed. 

 8)        Shri. Mhatre, Advocate for the Opposite Party No.1 relied the e-mail filed with written version sent by Mr. Godrej Sachinwala and submitted that as per the said e-mail the officer of the Complainant No.2 had informed that the Complainant No.2 had approached said Godrej Sachinwala and requested to give the original claim documents and accordingly he has handed over the whole original claim file to him as per his request and thereafter he had not returned to submit the documents.  Shri. Mhatre, Advocate thus, submitted that the Opposite Party No.1 is not guilty of deficiency of service and the Complainant No.2 himself is at fault, as he had taken the original documents from his employer as per the e-mail placed on record. Shri. Mhatre thus, made submissions that the Complainants have not proved there claim and the same is liable to be rejected.