By Sri.P.K.Sasi, President
The case of the complainant is that he is a family health optima policy holder of the opposite party. The policy coverage is extended to his wife and two children. On 16/07/12 complainant’s wife admitted at Mother Hospital due to True Umbilical Hernia. He has submitted a claim for getting the treatment expenses from the opposite party. The admission at Hospital and details of treatments were immediately informed to the insurance agent one Mr. Raghu E.V. who canvassed the policy. The claim is submitted as per his direction with all the treatment records. For the treatment expenses and vehicle rent he has incurred an amount of Rs.70,187/-. Even after several repeated enquiries made by the complainant the opposite party neither repudiated the claim nor allowed the claim. Atlast they offered Rs.40,000/- as a favour. As per the policy the complainant is entitled to get Rs.1,00,000/- the denial of the genuine claim without cogent reason amounts to deficiency in service on the part of opposite party. Hence this complaint is filed for getting relief.
2) Being noticed on the complaint opposite party entered appearance through counsel and filed detailed version. In the version the policy is admitted as well as the claim submitted by the complainant is also admitted. According to the opposite party the complainant has submitted claim only after the laps of 12days of the occurrence of the event. According to the opposite party the complainant has denied an opportunity to satisfy whether the person who underwent treatment is the same person who is covered under the policy. Since the complainant had not intimated the hospitalization within 24 hours of admission in the hospital the claim falls outside the scope of cover. The opposite party further stated that as per policy condition No.3 specifically states that “upon the happening of any event which may give rise to a claim under this policy, notice with full particulars shall be sent to the company within 24 hours from the date of occurrence of the event”. As per the terms and conditions of the policy, it is the duty of the insured to intimate the claim within the stipulated time hence the claim was rejected on the ground of violation of condition No.3 of the policy and that was informed to the complainant on 01/10/2012. The opposite party further submitted that they have not committed any sort of deficiency in service towards the complainant and prayed for the dismissal of the complaint with cost.
3) Then the case was posted for evidence and the points for consideration was that
1) Whether there was any deficiency in service
happened on the part of opposite parties ?
2) If so, what cost and relief ?
4) From the side of complainant he has appeared before the Forum and submitted proof affidavit in which he has affirmed and explained all the averments stated in the complaint in detail. He was also examined as PW1 and thoroughly cross examined by counsel for the opposite party. He produced 5 documents which are marked as Ext. A1 to A5. Ext. A1 is the policy with terms and condition issued by the opposite party; Ext. A2 is the photocopy of letter of undertaking; Ext. A3 copy of lawyer notice dtd.01/03/2013; Ext. A4 A/D card and Ext. A5 is the reply notice received from opposite party.
5) From the side of opposite party Executive Officer one Mr. Manu Mohan appeared before the Forum and submitted counter proof affidavit in which he has affirmed and described all the contentions raised in their version in detail. He also produced 6 documents which are marked as Ext. R1 to R6. Ext. R1 is the authorization letter; Ext. R2 Family Health Optima Insurance Plan Policy; Ext. R3 is the copy of Discharge Summary; Ext. R4 is the copy of Medical Certificate; Ext. R5 is the copy of Claim form and Ext. R6 is the copy of Repudiation Letter. He was examined as RW1 and vehemently cross examined by the counsel for the complainant. Both sides filed detailed argument notes and we heard in detail also.
6) According to the complainant the opposite party has denied a genuine claim without cogent reason. Whereas the opposite party contented that the claim falls under condition No.3 hence they rejected the claim. We have gone through the contents of affidavits, evidences and perused the documents produced from both sides. The policy details are produced from both sides. Here the question to be considered is that, whether the claim falls under the condition No.3 of the policy or not. We would like to reproduce the policy condition No.3 of the available policy documents before us. “3. Claim must be filed within 15 days from the date of discharge from the Hospital. Note: Conditions 2 and 3 are precedent to admission of liability under the policy. However the Company will examine and relax the time limit mentioned in these conditions depending upon the merits of the case”. “2. Upon the happening of any event which may give rise to any claim in this policy notice with full particulars shall be sent to the company within 24 hours from the time of occurrence of the event”. On the perusal of these two conditions we could understand that as far as the hospitalization cases are concerned claim has to be filed within 15 days from the date of discharge from the hospital. The condition No. 2 is not applicable to the hospitalization cases. It is applicable only to other events except hospitalization. If the condition No. 2 is applicable to hospitalization cases there is no need for condition No.3. The claim is repudiated as per condition No.3. It is admitted by the opposite party that the complainant has submitted the claim only after laps of 12 days from the admission in the hospital. The case of the complainant is that he has submitted the claim as per the directions of the insurance agent who had canvassed this policy. The policy condition No.3 would go to show that the insurance agent has rightly advised them to submit a claim within 15 days. Accordingly the complainants submitted claim within 15 days before the opposite party. Here the opposite party committed deficiency in service by rejecting the claim based on a hospitalization under the head of condition No.3 applying the conditions of No.2 which is not applicable in this case. Considering these points discussed hereinabove we are of the opinion that the complainant is entitled to get the treatment expenses reimbursed by the opposite party as per the policy. By denying that, the opposite party has committed deficiency in service towards the complainant.
In the result, we allow this complaint and the opposite party is directed to pay Rs.70,187/- (Rupees Seventy thousand one hundred and eighty seven only) with 9% interest to the complainant from the date of complaint within one month from receiving copy of this order. Failing which, the complainant is entitled to get 9% interest till realization.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum this the 17th day of June 2017.
