KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL No. 268/2020

JUDGMENT DATED: 22.11.2024

(Against the Order in C.C.153/2016 of DCDRC, Kasaragod)

PRESENT:

SRI. AJITH KUMAR D.                                                    : JUDICIAL MEMBER

SRI. RADHAKRISHNAN K.R.                                        : MEMBER

APPELLANTS:

1. Sreenivasa Iyyangar, Chief Operating Officer, Reliance Life Insurance Co. Ltd., Registered Office, H. Block, 1^st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra-400 710.

2. The Branch Manager, Reliance Life Insurance Co. Ltd., Land Mark Centre, Commercial Complex, New Bus Stand, Kasaragod-671 121.

          (By Adv. Sachin Daga and Adv. Suja Madhav)

RESPONDENTS:

1. Shaju V.D., Vathappallil District residing at G.L.P.S. Chalingal, Pullur, P.O. Haripuram, Hosdurg Taluka, Kasaragod.

2. Lucy Shaju, Vathappallil District residing at G.L.P.S. Chalingal, Pullur, P.O. Haripuram, Hosdurg Taluka, Kasaragod.

(By Adv. G.S. Kalkura and K.T. Sidhiq)

3. Customer Services Department, Medi Assist, India TPA Pvt. Ltd., Tower 5 D, 4^th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangakire-560 029.

4. Sheena M., Agent, Kanamkampil House, Kanamvayal P.O., Cherupuzha, (via), Kannur District-670 511.

JUDGMENT

SRI. RADHAKRISHNAN K.R.: MEMBER

This is an appeal filed by the 1^st and 3^rd opposite parties in C.C. No. 153/2016 on the files of the District Consumer Disputes Redressal Commission, Kasaragod (‘District Commission’ for short).  As per the order dated 17.02.2020 the District Commission allowed the complaint in part to the extent that the 1^st opposite party insurance company shall pay to the complainant a sum of Rs. 1,39,664/- towards settlement of the medical insurance claim of the complainant with 6% interest per annum from the date of complaint till realization.  The District Commission also directed the 1^st opposite party to pay an amount of Rs. 25,000/- towards compensation for the mental agony and harassment and Rs. 5,000/- as costs.  The appellants and respondents are referred as per their original status in the complaint.

2.  Brief details of the complaint are as follows: The complaint is regarding a claim under a health insurance policy for the treatment of the 2^nd complainant who is the wife of the 1^st complainant.  1^st and third opposite parties are the insurer, 2^nd opposite party is the Third Party Administrator (TPA) and 4^th opposite party is the Agent of the insurer. The complainant had taken an insurance policy called ‘Reliance care for you plan’ (a non-linked health insurance plan)  from the 3^rd opposite party for a sum insured of Rs. 2,00,000/-for a period of three years from 07.09.2013.  The complainants are covered under the policy No. 51054524.  The first instalment premium of Rs. 13,491/- and the subsequent premiums were paid regularly.  The 2^nd complainant was hospitalized at Father Mullars Hospital, Mangalore on 10.07.2015 for polypoidal growth sigmoid.  For better treatment she was discharged on 11.07.2015 and was admitted at MIMS Hospital on 23.07.2015 and after treatment she was discharged on 29.07.2015.  They had spent an amount of Rs. 10,205/- at Father Mullars Hospital and an amount of Rs. 1,29,459/- as medical expenses at MIMS Hospital, Kozhikode for the treatment of the 2^nd complainant. Thus they preferred a total claim of Rs. 1,39,664/-.  The complainant submitted all the required papers to the insurance company.  As they failed to pay the claim amount, this complaint was filed claiming Rs. 1,39,664/- towards treatment expenses and Rs. 2,00,000/- as compensation and Rs. 20,000/- as costs. 

3.  Notice was issued to the opposite parties.  The opposite parties 1 & 3 entered appearance and filed version stating that the complainants did not submit the essential documents which were required for the settlement of the claim.  They also did not reply to the letters sent by the second opposite party indicating the requirements.  The reminder letters were also not replied by the complainant.  They gave sufficient opportunities to the complainant to submit the relevant documents.  In the absence of the essential documents for the claim, the claim was closed as ‘No claim’.  The claim can be settled only after getting all the required documents as per the terms and conditions of the policy.  As the complainants had not produced the required documents the claim could not be settled. There was no deficiency in service on the part of the opposite parties 1 and 3.  The 2^nd opposite party who is the third party administrator and the 4^th opposite party who is the agent of the opposite party did not appear before the District Commission. 

4.  The evidence in the complaint consists of the oral evidence of the 1^st complainant as PW1 and Exhibits A1 to A6 were marked on his side.  The opposite parties filed proof affidavit and Exts. B1 and B2 were marked on the side of the 1^st and 3^rd opposite parties.  On the basis of the evidence adduced, the District Commission passed the impugned order.  Aggrieved by the said order, the 1^st and 3^rd opposite parties have filed this appeal.

5.  Heard the learned counsel for the appellants.  There was no representation for the respondents.  The learned counsel for the appellants submitted that the claim could not be paid by them as the respondent/complainant failed to submit the essential documents which are required for settlement of the claim.  The TPA sent several letters to the respondent/complainant for submitting the required documents like the original hospital bills, investigation report, discharge summary etc. vide their letters dated 25.08.2015, 04.09.2015, 17.04.2016 etc.  In the absence of the required documents the TPA could not proceed with the settlement of the claim.  The insurance policy is a contract between the policy holder and the insurer and the benefits under the policy is payable only as per the terms and conditions of the policy.  It is the duty of the complainant to provide each and every document required establishing their right to claim and if they failed to do so the claim is not to be considered as valid and genuine claim.  The claim could not be settled because of the non-co-operation of the respondent/complainant.  There is no deficiency in service on the part of the appellant and hence they prayed for allowing the appeal and dismissing the complaint.

6.  We have considered the submissions of the learned counsel for the appellants and perused the records.  This is a case of non-payment of insurance claim in connection with the hospitalization of the 2^nd complainant/2^nd respondent.  The respondents/complainants 1 and 2 have produced the policy issued to them and it was marked as Exhibit A1.  The policy and the coverage are admitted by the opposite parties.

7.  The only reason stated by the appellants/opposite parties for non-payment of the claim is non-submission of the relevant documents for processing the claim.  They have produced Exts. B1 and B2 letters sent to the respondent/complainant asking for certain documents required for settlement of the claim.  They further submitted that there was no response from the respondent/complainant to these letters sent by the TPA, Medi Assist India Pvt. Ltd.  In those letters, they have also referred their earlier letters dated 25.08.2015, 04.09.2015, 23.11.2015 and 03.12.2015 also.  However, copies of these letters are not produced before the District Commission.  We observe that both Exhibits B1 and B2, sent by second opposite party TPA are dated 14.07.2016. They have stated five requirements in Ext. B2 letter dated 14.07.2016 whereas there are only two requirements in Exhibit B1 which was sent on the same day.  In Ext. B1 the requirements were reduced to two and they wanted only the following documents:

“(1) provide all original pre-numbered paid receipts of hospital bill Rs. 1,29,459/- and

(2) We have received incomplete query reply.”

8.  From the above correspondence, it is clear that the only left out information to be received from the complainant was the hospital bill for Rs. 1,29,459/-. The complainant had produced the discharge bill for Rs. 1,29,459 (Ext A6) and for Rs. 10,000/- (Exhibits A2 and A4 ) totaling Rs. 1,39,614/- towards treatment expenses in both hospitals. These bills produced by the complainants before the Commission are not disputed by the opposite parties.  They have also stated that they have received ‘incomplete query reply’ which means that they have received a response from the complainant earlier.  It is not clarified by them as to which are the documents they have received from the complainant.  We observe that the communications said to be sent are by the second opposite party TPA.  The claim was not repudiated and closed as “No claim” by them.  They have not appeared before the Commission and filed their version and adduce any evidence.  The version is filed by 1^st and 3^rd opposite parties only. The documents marked especially the medical records and discharge bills are not disputed by the opposite parties and hence stand proved.  In the absence of any evidence on the side of the opposite parties regarding non receipt of documents, we are inclined to conclude that they have received the documents necessary for processing the claim.

9.  The 1^st complainant, the husband of the patient, was examined as PW1.  He deposed that he submitted all the relevant documents to the insurance company’s help desk at MIMS hospital.  These documents were returned by them and subsequently all these papers ie. original medical bills and hospital records, were submitted to the  3^rd opposite party at their Kasargod Branch.  He had also given the required reply to the letter sent by the insurance company.  There is no reason to disbelieve the complainant as it is his requirement to get his claim settled as soon as possible. From the above it is evident that the complainant had taken all efforts to submit the relevant papers to the appellant/insurance company for getting his claim.

10.  The respondent/complainant had produced Ext. A3 discharge summary from Father Mullars Hospital Mangalore and Exhibits A2 and A4 bills from the same hospital.  He has also produced the discharge summary (Ext. A5) and discharge bill (Ext. A6) for Rs. 1,29,459/-.  From this document it is evident that the patient was treated for polypoidal growth sigmoid and she had spent a total amount of Rs. 1,39,614/ towards treatment expenses.  She was treated in Father Mullars Hospital from 10.07.2015 to 11.07.2015 and at MIMS Hospital from 23.07.2015 to 29.07.2015.  The surgery was conducted on 24.07.2015.  The documents produced by the respondent/complainant are sufficient to conclude that she was treated for the illness and spent the amount claimed by her.  We concur with the finding of the District Commission that there is deficiency in service on the part of the opposite party.  Hence we are of the view that the complainants are entitled for the claim of Rs. 1,39,614/-. In our opinion the compensation and costs awarded by the District Commission are just and reasonable.

11.  For the foregoing reasons we do not find any valid ground for the appeal and hence the order of the District Commission is liable to be confirmed. 

12.  In the result, the appeal is dismissed and the order dated 17.02.2020 passed by the District Commission in C.C. No. 153/2016 is confirmed.  There shall be no order as to costs.

The statutory deposit made by the appellants at the time of filing the appeal shall be given to the respondents 1 & 2 to be adjusted/credited towards the amount ordered by the District Commission, on proper acknowledgement. 

AJITH KUMAR D. : JUDICIAL MEMBER

                                                                        RADHAKRISHNAN K.R.  : MEMBER

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