O R D E R

By Smt. Sreeja S. Member:

          The complainant subscribed SBI Life – Hospital cash annual health insurance policy bearing No. 46001835205 from opposite parties with sum assured as Rs.2,00,000/- and Rs.17,000/- as premium amount. The complainant admitted to Mary Immaculate Mission Hospital on 15/10/12 and discharged on 16/10/12. An amount of Rs.4,631.61/- was met by them towards medical expenses. Hence they preferred a claim before the opposite parties which was denied by them for want of further documents. All relevant documents including bills were sent to them but they did not pay the amount. Hence this complaint.

          2) On receiving complaint notice was issued to the opposite parties. The opposite parties appeared through their counsel and filed version. The contents of the version of opposite parties is as follows : The complaint is not maintainable. The company cannot assess the claim and decide the admissibility or otherwise of the claim of the complainant in the absence of the required documents. The complainant is misinterpreting the benefits under the policy and hence the complaint is liable to be dismissed on this ground only. The benefit payable under the policy is not based on the expenses incurred by the insured in the hospital. The same is based on the Sum Assured, the amount payable under Non ICU benefit, ICU benefit etc. which are clearly mentioned in the policy. The policy holders are required to abide by the terms and conditions of the policy bond. No cause of action has arisen for the complainant to file the present complaint because of onus of proving the genuineness of the claim of the complainant with supporting documents lies squarely on the complainant. There is no deficiency in the service. They admit that the complainant was the holder of policy bearing No.46001835205 with date of commencement as 04/10/2011 with daily hospital cash benefit of Rs.2,000/-, ICU benefit of Rs.4,000/- and Family Care Benefit of Rs.10,000/-.  This policy provides for the fixed Daily Hospitalization Cash Benefit as stated above to the policy holder with a ceiling up to the sum assured ie. Rs.2,00,000/-. Opposite parties have receivied the claim intimation from the complainant regarding hospitalization in Mary Immaculate Mission Hospital from 15/10/2012 to 16/10/2012 for injury. As per the definition of Day in the Policy Booklet, the number of days of hospitalization comes to 1 day. Accordingly, claim is for Non ICU Benefit, i.e. daily hospital cash benefit for 1 day i.e. Rs.2,000/- (Rs.2,000 X 1 day). The company has registered the said claim with claim ID No. 10021302979 and the claim was pending for following requirements.

1. Kindly provide all investigation reports in support of final diagnosis (X-ray films & reports)

          The TPA, E-Meditek had sent reminder letter dtd. 15/04/13 and a claim closure letter dtd. 14/01/14 was sent. Since the complainant did not comply with necessary requirements, the answering opposite parties are not able to examine the admissibility or otherwise of the claim. Still the answering opposite parties, the company is willing to examine the admissibility or otherwise of the claim of the complainant subject to the submission of the necessary documents as stated above. We will require the following documents. 1) copy of policy document    2) claim form 3) treating doctor’s Certificate 4) Discharge card and copy of all medical documents related to hospitalizations 5) any other document as the TPA / company may require depending on type / cause of claim 6) Identity Proof of the Policy Holder 7) Age proof of the Life Assured 8) Pan card copy of the Policy Holder (for online policies) 9) Direct Credit Mandate of the policy Holder. There is no deficiency in service on the part of the company and prayed for dismissal.

          3) Points for consideration

                   a) Whether there is any deficiency of service on the part of opposite

                       parties or not ?

                   b) If yes, relief and cost ?

           4) When the case was posted for evidence the complainant filed proof affidavit in tune with complaint and the documents produced by him were marked as Exts. P1 to P12. Ext. P1 is the Policy Document; Ext. P2 is the SBI Life Renewal payment notice dtd.20/08/13; Ext. P3 is the copy of Life Insurance Premium paid Certificate for the year 2012-13; Ext. P4 is the Admission & Discharge certificate issued by Mary Immaculate Mission Hospital dtd.01/03/13; Ext. P5 (series) are the Medical Bills issued by M.I. Mission Hospital; Ext. P6 is the ECG Report dtd.16/10/12; Ext. P7 is the copy of Reminder 1 dtd. 14/03/13; Ext. P8 is the copy of Reminder 2 dtd. 30/03/13; Ext. P9 is the Reminder dtd.26/02/13; Ext. P10 is the carbon copy of the letter dtd.15/04/13 issued by the complainant; Ext. P11 is the copy of Hospital cum Treating Doctor’s Certificate and Ext. P12 is the copy of ID card of Insurance Advisor. Two witnesses were examined as PW1 & PW2. From the side of opposite parties also filed counter proof affidavit in tune with counter and the documents produced by them are marked as Exts. R1 to R4. Ext. R1 is the  Policy Document; Ext. R2 is the copy of Claim form – Hospital cash; Ext. R3 is the Final Reminder Letter dtd. 15/04/13 and Ext. R4 is the copy of Claim closure letter dtd.14/01/14. One witness was examined as RW1. The Medical Record of the complainant issued by Daya Hospital was marked as Ext. X1.

          Points :

1. The case of the complainant is that he subscribed Ext. P1 health insurance policy issued by the opposite parties. He undergone Medical treatment in Mary Immaculate Mission Hospital, Engandiyoor and Ext. P4 Certificate issued in this regard. The complainant has preferred a claim in connection with the hospitalisation. All these facts are admitted by opposite parties. They contended that the claimant has to produce relevant documents pertaining to the treatment. The complainant further states that he has already delivered copies of all relevant records and the opposite partied did not process the claim with ulterior intention.

2. Ext. P1 is the policy and same is governed by policy conditions. Condition 10 deals with the manner in which claim is to be preferred. Clause 10.2 deals with the required documents to be produced along with the claim – clause 10.4 says that discharge card and all medical documents related to hospitalisation. Hence Ext. P1 invariably states about the documents need to be produced to process the claim. At this juncture Ext. P7, P8 and P9 carries due weightage. Ext. P7 is the reminder No.1, Ext. P8 is reminder No.2, Ext. P9 is the actual requisition of the document. Ext. P7 to P9 specifically deals with the particular documents called for to process the claim. The complainant adduced oral evidence to the extent that they have send all the documents needed to process the claim and PW2 complainant categorically states that no A/d card were attached along with the documents sent. The particular case of the opposite parties is that they are ready and willing to process the claim even at the later point of time subject to the submission of necessary documents as stated above. It is true that the complainant did not adduce the records or took any steps to produce the same before this Commission. Under such circumstances it is only to be inferred that there is latches from the part of the complainant and attempt to adduce oral evidence instead of documentary evidence turned to be futile exercise. But in the interest of justice and considering the readiness to process the claim by the opposite parties we are of the view that opposite parties may process the claim if the complainant produced originals of relevant documents as shown in the policy condition.

3. Considering entire evidence and pleading we are of the view that the complainant miserably failed to prove a tenable case before the Commission.

          In the result complaint dismissed without cost.

          Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Commission this the 30^th day of October 2021.

   Sd/-                                                                                            Sd/-

Sreeja S                                                                                   C.T. Sabu

Member                                                                                    President

                               Appendix

Complainant’s Exhibits :

Ext. P1 Policy Document

Ext. P2 SBI Life Renewal payment notice dtd.20/08/13

Ext. P3 copy of Life Insurance Premium paid Certificate for the year 2012-13 Ext. P4 Admission & Discharge certificate issued by Mary Immaculate Mission

             Hospital dtd.01/03/13

Ext. P5 (series) Medical Bills issued by M.I. Mission Hospital

Ext. P6 ECG Report dtd.16/10/12

Ext. P7 copy of Reminder 1 dtd. 14/03/13

Ext. P8 copy of Reminder 2 dtd. 30/03/13

Ext. P9 Reminder dtd.26/02/13

Ext. P10 carbon copy of the letter dtd.15/04/13 issued by the complainant

Ext. P11 copy of Hospital cum Treating Doctor’s Certificate

Ext. P12 copy of ID card of Insurance Advisor.

Complainant’s Witnesses :

PW 1Sindhu P.R.

PW 2 Satheesh Chandrabose.

Opposite Parties’ Exhibits :

Ext. R1 Policy Document

Ext. R2 copy of Claim form – Hospital cash

Ext. R3 Final Reminder Letter dtd. 15/04/13

Ext. R4 copy of Claim closure letter dtd.14/01/14

Opposite Parties’ Witnesses :

RW 1 Rajkumar.

Ext. X1 Medical Record of Complainant.

Id/-

Member