1 Perusal of file shows that there is no repudiation letter on the file either submitted by the complainant or opposite party, infact, the opposite parties have taken objection in Para No. 12 of Preliminary objections that the present complaint is legally not maintainable and liable to be dismissed for want of any cause of action and being pre mature in nature, as neither the complainant intimated about his alleged hospitalization nor has filed any reimbursement of his claim till date, therefore, the present complaint is liable to be dismissed. The opposite party has pleaded in Para No. 14 of Preliminary objection that the complainant should provide all the documents for processing of claim on merits basis mentioned below
- Discharge Summary
- Investigation reports with X-ray films, Scan reports ,etc.
- Main Hospital bills, Payment receipts with break-up
- Prescriptions, Medical bills, Investigation bills, Receipts
etc...
- Earlier treatments records, if any......
- If the claim is admitted, admissible amount will be transferred to the account of insured, if he so desire, he will have to provide a cancelled cheque also along with the foregoing documents.
- Mandatory Documents: As per the provisions of the Anti- Money Laundering Act (AML), the insured is required to submit a copy of his PAN which is mandatory in case his claim is of value one lakh Rupees and above.
2 On this during the course of arguments, Ld. Counsel for the complainant has made the following statement:-
“Stated that the complainant will supply the documents to the opposite parties as mentioned in Para No. 14 of Preliminary Objections of the Written version for processing of claim on merits detail of which is as follows:-
- Discharge Summary
- Investigation reports with X-ray films, Scan reports ,etc.
- Main Hospital bills, Payment receipts with break-up
- Prescriptions, Medical bills, Investigation bills, Receipts
etc...
- Earlier treatments records, if any......
- If the claim is admitted, admissible amount will be transferred
to the account of insured, if he so desire, he will have to provide a cancelled cheque also along with the foregoing documents.
- Mandatory Documents: As per the provisions of the Anti- Money Laundering Act (AML), the insured is required to submit a copy of his PAN which is mandatory in case his claim is of value one lakh Rupees and above.”
3 The claim has not been decided so far and is still pending due to non providing of documents. In case Balu Waman Kadam vs. ICICI Lombard General Insurance Co. IV (2013) CPJ 16A (CN) (Mah.), the matter was similar, wherein the Insurance Company was asking the complainant to submit the documents again and again and the complainant was alleging that he had already submitted the requisite documents to the Insurance Company. In such circumstances, the Hon’ble State Consumer Disputes Redressal Commission Maharashtra disposed of the matter, by directing the Insurance Company to reconsider the claim of the complainant within one month on receipt of the required documents from the complainant. While relying upon the above said authority, the Hon’ble State Commission, Punjab, Chandigarh passed the similar orders in case M/s Trends, through its Proprietor vs The Oriental Insurance Company Limited & Anr. Consumer Complaint No.245 of 2015 decided on 04.08.2017; and M/s Gurbir Rice Mills v. United India Insurance Company Ltd. & Ors. Consumer Complaint No.404 of 2016, decided on 09.10.2017, directing the Insurance Company to reconsider the claim of the complainant after submission of requisite documents by the complainant to it.
4 In view of our above statement and discussion as well as keeping in view the ratio of above said judgments, we are of the opinion that the ends of justice would be met, if the Insurance Company be directed to decide the claim of the complainant, after the complainant submit all the requisite documents as detailed above.
5 In view of the above discussion, the present complaint is disposed of with the direction to the complainant to submit the above said documents mentioned in Para No. 14 of the written version (mentioned in statement of complainant) to the opposite parties for deciding the claim within a period of 30 days from the date of receipt of copy of order and on approaching the complainant for supplying the requisite documents, the opposite parties will issue proper receipt acknowledging the same to the complainant. The opposite parties shall decide the claim of the complainant within a further period of 45 days therefrom and in case of failure on the part of the opposite parties the claim case of the complainant deemed to have been accepted. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.
Announced in Open Commission.
12.11.2024
