Oriental Insurance Company V/S kamlesh Gupta W/o Balkishan Gupta - Consumer Court Case

Haryana

Karnal

493/2012

kamlesh Gupta W/o Balkishan Gupta - Complainant(s)

Versus

Oriental Insurance Company - Opp.Party(s)

Sh. Vishal Goel

18 Nov 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

Complaint No. 493 of 2012

Date of instt.: 9.10.2012

Date of decision:18.11.2015

Kamlesh Gupta wife of Sh.Bal KishanGupta r/o House no.2370, Sector 13, U.E.Karnal.

……..Complainant.

Vs.

1. Divisional Manager, The Oriental Insurance Co. Ltd. near Bus stand, GT Road, Karnal.

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

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

…..Opposite Parties.

Complaint u/s 12 of the Consumer

Protection Act.

Before Sh.K.C.Sharma……….President.

Smt. Shashi Sharma……….Member.

Present:- Sh.Vishal Goel Advocate for the complainant.

Sh.Gurmit Singh Advocate for OP no.1 and 2.

OP no.3 ex parte.

ORDER:

. The present complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986, on the averments that she obtained a mediclaim policy from the Opposite Party ( in short OP) No.1 bearing No.261300/48/2011/844 dated 6.9.2010 effective from 10.9.2010 to 9.9.2011. She and her husband Bal Kishan Gupta were assured under the said policy. She was hospitalized due to Malaria disease on 5.9.2011 in Noor Medical Centre, Sector – 6, Urban Estate, Karnal and remained admitted there upto 8.9.2011.An amount of Rs.9897/- was spent on her treatment. She submitted her claim as per medi claim policy with Ops, but the OP no.3, who was working as TPA for OP sno.1 and 2 vide letter dated 15.2.2011 put some queries. She replied all the queries in detail. She explained to Op no.3, vide letter dated 5.3.2012 regarding late submission of the claim as her husband had met with an accident and he was not able to move from bed. She submitted all the required documents to Op no.3 vide letter dated 2.3.2012. However, Ops repudiated her claim on the ground that intimation was not sent to Ops within seven days of the date of discharge. The act of the Ops repudiating the claim of the complainant was arbitrary and was not legally justified and the same amounted to deficiency in services, which caused mental harassment to her apart from financial loss.

2. Notice of the complaint was given to the Ops. OPs no.1 and 2 put into appearance and filed written statement disputing the claim of the complainant. Objections have been raised that complaint is not maintainable; that complainant is estopped by her own acts and conduct from filing the present complaint; that complainant has concealed the true and material facts and that this Forum has no jurisdiction to entertain and decide the present complaint.

On merits, it has been submitted that claim of the complainant was repudiated on valid ground as per terms and conditions of the insurance policy. The insurance policy and other record was not traced till filing of the written statement as the claim was not filed by the complainant within stipulated time and there was violation of terms and conditions of the policy of insurance therefore, her claim was rightly repudiated.

Notice to OP no.3 was sent through registered post but none appeared on its behalf on 2.5.2013. Therefore, ex parte proceedings were initiated against it.

3. In evidence of complainant, her affidavit Ex.C1 and documents Ex.C2 to Ex.C21 have been tendered.

4. In evidence of the Ops, affidavit of Sh.R.S.Balahan, Senior Divisional Manager Ex.R2 and documents Ex. R2 to Ex.R7 have been tendered.

5. We have heard the learned counsel for the parties and have gone through the case file very carefully.

6. In the written statement Ops No.1 and 2 submitted that insurance policy and other documents were not available, therefore, factum of mediclaim insurance policy of the complainant was not admitted. However, in the affidavit of Sh.R.S.Bahalan, Senior Divisional Manager Ex.R1 no dispute regarding issuing mediclaim policy to the complainant has been raised. It has been submitted that claim of the complainant was repudiated as intimation regarding claim was not given within 48 hours from the time of hospitalization. Even incomplete record of treatment was submitted after around fifteen days of the completion of treatment and remaining record was not submitted despite reminders. The copy of the letter of Ops regarding repudiation of the claim of the complainant Ex.R2 shows that claim of the complainant was repudiated on the ground “ Inspite of our repeated reminders, the reply to our query ahs not been received. We presume that you are not interested in the said claim. As such we are left with no alternative except to close the file as a no claim, which please note.” The ground regarding repudiation of claim is different in the affidavit Ex.R1 and the letter of repudiation Ex.R2.

7. The learned counsel for the OPs put a great thrust on the contention that notice regarding admission of the insured in the hospital was required to be given within 48 hours of the hospitalization or before discharge from the hospital and the claim should have been submitted to the company within seven days of the discharge from the hospital as per condition no.5.4 and 5.5 of the policy but the complainant gave intimation and submitted claim after about 15 days of the discharge of the hospital which amounted to violation of the condition of the insurance policy, therefore, the claim of the complainant was rightly repudiated.

8. Copy of the letter Ex.C13 and copy of the courier receipt Ex.C15 indicate that some documents were required by Ops from the complainant vide letter dated 14.3.2012 and the complainant had sent the required documents alongwith letter dated 22.3.2012. However, the Ops sent reminders Ex.R4 and Ex.R5 dated 1.8.2013 seeking reply to some queries from complainant as mentioned in the letter dated 26.3.2012, but the copy of the letter dated 26.3.2012 has not been produced by the OPs. Therefore, it is not clear as to which queries of the Ops were not replied by the complainant. Copy of the letter Ex.C20 dated 5.3.2012 and copy of the courier receipt Ex.C21 show that the complainant had furnished explanation for not submitting the claim within time. She gave explanation that her husband had met with an accident and he was not able to move from bed, due to which there was delay in informing the insurance company. In the said letter, it was also clarified that all the documents which were mentioned in the queries of the Ops were sent alongwith the said letter. In the affidavit of the complainant Ex.C1 also the reason for delay in informing the Ops and submitting the claim has been explained. Thus, from the evidence of the complainant it is amply established that she had furnished all the required documents, and replied to the queries raised by the Ops and even gave explanation for delay in informing the Ops and submitting the claim. If the Ops, were to avail condition no.5.4 and 5.5. of the policy, then there was no need to ask the complainant to reply to the queries and explain the delay in giving information and submitting the claim because the claim of the complainant could be straight way repudiated on the ground of delay in giving information and submitting the claim in view of the aforesaid conditions. Once the claim of the complainant was entertained and explanation was sought from her and queries were also raised, which were duly replied by her, the Ops were estopped from repudiating the claim on the ground of delay.

9. It is also worth pointing out that neither in the written statement nor in the letters Ex.R2, Ex.R4 and Ex.R5, it was mentioned that claim of the complainant was repudiated on the ground of delay in giving information of illness and submitting the claim. In the said letters, it was submitted that reply to the queries was not given by the complainant. Therefore, argument of the learned counsel for the Ops that claim was repudiated on the ground of delay in giving information regarding admission of the complainant and submitting the claim considering as violation of the conditions of insurance policy, cannot be accepted. It is also important to point out that in the letters Ex.,R2, Ex.R5 and Ex.R6 it was not clarified as to which queries were not replied by the complainant whereas the evidence of the complainant shows that all the queries were duly replied and required documents were provided to the Ops. The stand of the Ops is not clear, therefore, under such circumstances there is no reason to discard the evidence of the complainant.

10. In view of the foregoing circumstances, we have no hesitation in observing that a t of the Ops repudiating the claim of the complainant was not justified. Therefore, the same amounted to deficiency in services on their part.

11. As a sequel to the foregoing discussion, we accept the present complaint and direct the Ops to make the payment of Rs.9897/- to the complainant alongwith interest @ 9% per annum from the date of filing of the present complaint i.e. 9.10.2012 till its actual realization. The complainant shall also be entitled for a sum of Rs.5500/- for the mental agony and harassment caused to him and for the litigation expenses. The Ops shall make the compliance of this order within a period of thirty days from the date of receipt of the 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:18.11.2015

(K.C.Sharma)

President,

District Consumer Disputes

Redressal Forum, Karnal.

(Smt.Shashi Sharma)

Member.