FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER
This is an application u/s.35 of the C.P. Act, 2019.
The complainant is an employee of Indian Bank, Russel St. Branch, Kolkata – 700071 and is a beneficiary of the Tailor made Group Mediclaim Policy of the OP No. – 2 issued to his employer. The policy no is 500100/48/15/41/00000429 which was valid for the period from 01.10.2015 to 30.09.2016. The eligible sum assured was Rs.3,00,000/- and the beneficiaries were the complainant himself, his wife and two children. There was also a provision of benefit in the name of Corporate Buffer subject to approval of the employer when the maximum eligible amount of Rs.3,00,000/- got exhausted. The wife of the complainant got admitted to Amri Hospital, Kolkata on 06.09.2016 for treatment and was discharged from the said Hospital on 12.09.2016. The bill for the treatment was Rs.43,253/- which was paid by the complainant at the time of discharge of the patient. The bill was placed before his employer on 27.09.2016 for consideration. Since the limit of Rs.3,00,000/- was already exhausted the complainant was asked to apply for sanction of the buffer fund to the Indian Bank Authority. Accordingly application was submitted on 20.11.2016. The photocopy of the claim form was already received by his office on 27.09.2016. The approval of the competent authority for sanctioning Rs.43,253/- from the buffer fund was finally obtained vide letter dated 21.12.2016 and after completion of all formalities all documents were submitted to the OP1 for settlement vide letter dated 06.05.2017. The OP 1 vide letter dated 19.05.2017 addressed o the employer of the complainant asked for documents in the matter of delay filing and also the e mail id. of the complainant. The reply of the Bank Authority was received by the OP 1 on 07.06.2017. The OP 1 was silent since then. After series of follow up through mails for several times the OP 1 finally replied on 31.01.2019 that the claim is already closed on 14.03.2018. But it was neither communicated to the complainant nor to his employer Indian Bank at any point of time. It is the responsibility of the OP 1 to communicate the decision positively by assigning reason which they have not done which definitely tantamount to deficiency of service and adoption of unfair trade practice. As per IRDA Guidelines the claim is either to be settled or to be rejected within a period of 30 days from the date of receipt of the last necessary documents in accordance with the provisions of Regulation 27 of IRDAI (Health Insurance) Regulations,2016. The OP 1 did not perform their statutory duties for the reason best known to them by violating the terms and conditions of the policy and the IRDA Guidelines for which the complainant approached the Commission for justice with the prayers as mentioned in the complaint petition.
Points for Determination
In the light of the above pleadings, the following points necessarily have come up for determination.
1) Whether the OPs are deficient in rendering proper service to the Complainant?
2) Whether the OPs have indulged in unfair trade practice?
3) Whether the complainant is entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos. 1 to 3 :-
The above mentioned points are taken up together for the sake of convenience and brevity in discussion.
We have travelled over the documents placed on record. The complainant has submitted his evidence supported by affidavit. The Complainant has also submitted BNA. The case is heard on merit.
Facts remain that the wife of the complainant got admitted to Amri Hospital, Dhakuria, Kolkata on 06.09.2016 for treatment and released on 12.09.2016 during the period when the policy no.500100/48/15/41/00000429 in which she was the beneficiary was in force. The bill amount for the treatment was Rs.43,253/-. Since the maximum limit of reimbursement of Rs.3,00,000/- was exhausted the complainant has to comply the formalities to avail the benefits of the Buffer Fund. The formalities of the complainant as well as his employer was finally completed and all documents got deposited on 06.05.2017 to the OP 1 as per usual procedure. The OP 1 on receipt of the documents on 06.05.2017 sent one letter dated 19.05.2017 to the Bank Authority asking further documents which was submitted to them by the Bank authority vide letter 01.06.2017. The said documents were received by the OP 1 on 07.06.2017. But the OP 1 took no action either settled or rejected the claim within 30 days from the date of receipt of the documents. This is very much against the guidelines of IRDA ( Protection of Policyholders’ Interests ) Regulations,2017. As per the said Guidelines “ The Insurer shall settle the claim within 30 days from the date of receipt of last necessary document in accordance with the provisions of Regulation 27 of IRDAI ( Health Insurance ) Regulations,2016. In the case of delay in payment of a claim, the insurer shall be liable to pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate 2 percentabove the bank rate. “
While perusing the documents submitted by the complainant it is observed that several follow ups have been made by the complainant and his employer Bank with the OP 1. But to our utter surprise the OP 1 did not bother to respond those communication rather sat tight over the claim. They remained silent without any decision on the impugned claim. The claim is neither settled nor rejected. No formal intimation to the insured complainant regarding the decision has been sent. This itself tantamount to deficiency in service. Sitting idle over the issue for an indefinite period is a concrete example of unfair trade practice. We do not find any reason why the OP 1 had withheld the genuine claim without assigning any reason for a long period specially when IRDA has specific guideline in the matter of claim settlement. An indirect intimation of closing the impugned insurance claim without assigning any reason specially when the claim has been recommended by the competent authority of employer Bank and the Insurance company is arbitrary, meaningless, unreasonable, having no jurisprudence and defective in the eye of law and non cognizable one. In the given circumstances Ld. Advocate for the complainant has cited three relevant judgments
- (1996) 6 SCC 428 United India Insurance Company Vs. – MKJ Corporation – Supreme Court of India. – Insurance Company is liable to settle the insurance claim within two months.
- II(2006) CPJ 333 (NC) National Insurance Company Ltd. Vs. – Sukhdev Singh – Complaint filed after 7 years – No limitation – continue cause of action unless settlement of insurance claim.
- (2017) 5 SCC 776 – Civil Appeal No. 3883 of 2007 National Insurance Company Ltd. – Vs. – Hindustan Safety Glass works Ltd. – Provision of limitation in the Act (Consumer Protection Act ) cannot be strictly construed to disadvantage a consumer – paragraph no. 18.
Considering the above submission, we are of the opinion that the complainant has able to establish the case against the OP 1 & 2. All the points under determination are answered in the affirmative. There is no order against the OP 1 being the processing authority of the Insurance Company.
In the result, the consumer complaint succeeds.
Hence,
Ordered
That the complaint case be and the same is allowed ex parte against the OP No. 2 and dismissed against the OP No. 3 with the following directions.
- The OP No 2 is directed to reimburse the complainant a sum of Rs.43,253/- with interest at the rate of 6 percentfrom 07.08.2017 till the date of payment.
- The OP 2 is further directed to pay a sum of Rs.20,000/- to the complainant as compensation towards harassments and mental agony caused to the complainant.
- The OP 2 is also directed to pay a sum of Rs.10,000/- as litigation costs to the complainant.
The above order is to be complied within a period of 30 days from the date of the order in default the complainant will be at liberty to put the order into execution.
The judgment be uploaded to the website of this Commission forthwith for perusal of the parties.
