Madhya Pradesh

StateCommission

A/17/936

BR.MANAGER, LIC - Complainant(s)

Versus

SMT. MANJU KAKKAR - Opp.Party(s)

SH. SOMENDRA SAXENA

21 Feb 2023

ORDER

M. P. STATE  CONSUMER  DISPUTES  REDRESSAL  COMMISSION,                         

                             PLOT NO.76, ARERA HILLS, BHOPAL

 

                                      FIRST APPEAL NO. 936 OF 2017

(Arising out of order dated 25.04.2017 passed in C.C.No.44/2016 by District Commission, Chhatarpur)

 

1. BRANCH MANAGER,

    LIFE INSURANCE CORPORATION OF INDIA,

    CHHATARPUR-M.P.

 

2. DIVISIONAL MANAGER,

    LIFE INSURANCE CORPORATION OF INDIA,

    DIVISIONAL OFFICE- KRISHNA COMPLEX,

    KRISHNA NAGAR, SATNA-M.P.

 

3. M.D.INDIA HEALTH CARE SERVICE LTD.

    PUNE, MAHARASHTRA

    46/1, E SPACE, A WING, THIRD FLOOR,

    VEDGANGSAR, MAHARASHTRA                                                                        … APPELLANTS.

 

Versus

 

SMT. MANJU KAKKAR,

W/O SHRI SHAMBHUNATH KAKKAR,

R/O SHILPI STOLES,

BEHIND CHRISTIAN ENGLISH COLLEGE,

CHHATARPUR (M.P.)                                                                                               … RESPONDENTS.                                

                                 

BEFORE :

            HON’BLE SHRI JUSTICE SHANTANU S. KEMKAR   :  PRESIDENT

           HON’BLE SHRI D. K. SHRIVASTAVA                         :  MEMBER

            HON’BLE DR. (MRS) MONIKA MALIK                         :  MEMBER

                     

COUNSEL FOR PARTIES :

                Ms. Preetima Shrivastava, learned counsel for the appellants.

           Shri Mohan Chouksey and Ms. Pallavi Chouksey, learned counsel for the respondent.

                  

                                                  O R D E R

                                       (Passed on 21.02.2023)

                   The following order of the Commission was delivered by Dr.(Mrs) Monika Malik, Member:

           

                   This appeal by the opposite parties/appellants (hereinafter referred to as ‘appellants’) is directed against the order dated 25.04.2017 passed by the District Consumer Disputes Redressal Commission,

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Chhatarpur (for short ‘District Commission’) in C.C.No.44/2016, whereby the District Commission has partly allowed the complaint filed by the complainant/respondent (hereinafter referred to as ‘respondent’).

2.                Briefly put, facts of the case are that the respondent had obtained ‘Jeewan Arogya’ insurance policy no.357447416 on 28.03.2012 from the appellants. Before issuing the policy the respondent’s medical investigation was carried out by the appellants. On 25.01.2013, the respondent felt uneasiness and consulted in Christian Hospital, Chhatarpur from where she was referred to higher center. Thereafter she approached B.I.M.R. Hospital, Gwalior, Sir Gangaram Hospital, New Delhi and Shree Krishna Hospital & Medical Research Centre, Karamsad. The respondent was admitted and after thorough investigation she was found to be suffering from cancer. The respondent was treated and she sent claim form along with treatment bills to the appellants.  It is alleged that despite several reminders, the claim amount was not paid.   Therefore, alleging deficiency in service on part of appellants, she approached the District Commission seeking relief. 

3.                The appellants in their reply to the complaint before the District Commission stated that the respondent was asked to submit certain relevant documents but she did not supply the same to the appellants. Therefore, the claim could not be decided due to non-compliance by her.

 

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There has been no deficiency in service on part of the appellants. It was therefore prayed that the complaint be dismissed.

4.                The District Commission partly allowed the complaint and directed the appellants to pay the claim amount of Rs.2,11,778/- along with interest @ 9% p.a. from the date of filing of complaint i.e. 26.04.2016, till payment.  In addition compensation of Rs.5,000/- with another sum of Rs.2,000/- as costs is also awarded.  Hence this appeal.

5.                Heard.  Perused the record.

6.                Learned counsel for the appellants argued that upon receiving the claim request from the respondent, certain documents were demanded from the respondent, since it was required to be known as to when she was treated regarding her present illness, for the first time. The respondent did not comply with the directions and therefore, the claim is still pending with the appellants. The complaint filed by the respondent is pre-mature but the District Commission erred in allowing it. Therefore, the impugned order deserves to be set-aside. 

7.                Learned counsel for the respondent argued that the respondent had received treatment in the year 2013 and since then the claim was pending with the appellants. Various letters dated 05.04.2013, 25.05.2013

 

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and 15.06.2013 along with relevant documents had been sent to the appellants but the claim was still pending with the appellants for almost three

years, despite reminders for settlement of the same.  All documents, which were sent by the respondent to the appellants and are available in record as well, specify her health condition and treatment received by the respondent but the appellants-insurance company, in order to delay and avoid did not decide her claim request. The District Commission after considering the facts and circumstances of the case has rightly passed the impugned order and this appeal deserves to be dismissed.

8.                We find that the M. D. Health Care Service Limited (TPA) had asked from the respondent, the certificate of treating doctor mentioning previous history, regarding when the medical consultation first began, the photocopy of first consultation papers, photocopy of indoor case papers and day to day treatment chart from BIMR Heart Centre, Gwalior, City Hospital and Shree Krishna Hospital.

9.                The respondent in response has stated that she had never faced any such problem in the past. When she felt uneasiness in January-2013, she took consultation in Christian Hospital, Chhatarpur where she was admitted and thereafter referred to higher center.  She had thereafter consulted in BIMR Hearth Centre, Gwalior.  It is submitted by the respondent

 

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her’s is a genuine case as she had never taken any treatment in past for the diseases mentioned in the claim form. 

10.              The appellants vide letter dated 08.01.2016 had intimated the respondent that since she did not supply certain documents as demanded by TPA, her claim could not be paid.  The respondent has placed various documents on record viz. Christian Hospital, Chhatarpur Discharge Summary form, discharge summary of Shree Krishna Hospital & Medical Research Centre, discharge summary of Sir Gangaram Hospital, transfer summary of Sir Gangaram Hospital, case summary of BIMR Heart Centre. She has submitted that she had already provided those documents to the appellants as well. The District Commission has held that the appellants could have easily decided the claim on the basis of aforesaid documents instead of keeping the same pending for want of further documents.

11.              Admittedly, the appellants have not decided the respondent’s claim as we find that there is no rejection letter on record but they have expressed their inability to pay her claim. In our considered view, there has been deficiency on part of the appellants in not deciding the respondent’s claim. The fact is that when she was issued a health insurance policy and had subsequently filed a claim seeking reimbursement, the burden lies on the appellants-insurance company to find out and prove whether she is entitled for claim or not.

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12.              Therefore, in view of the foregoing discussion, we conclude that the District Commission has rightly passed the impugned order.  We do not find any ground for interference in the same.  

13.              This appeal, being devoid of any merit deserves to be and is hereby dismissed with no order as to costs.

 

(JUSTICE SHANTANU S. KEMKAR) (D.K.SHRIVASTAVA) (DR. MONIKA MALIK)                     

                  PRESIDENT                                MEMBER                MEMBER