Date of filing :22.6.2017
Judgment : Dt.5.4.2018
Mrs. Balaka Chatterjee, Member
This petition of complaint is filed under section 12 of C.P.Act, 1986 by Sanjay Diwan alleging deficiency in service on the part of the opposite parties namely (1) Star Health and Allied Insurance Company Limited and (2) The Manager Customer-Service.
Case of the Complainant in brief is that the Complainant in 2015 had availed a Health Insurance Plan under Family Health Optima Insurance Plan issued by the OP Insurance Company Ltd. having unique identification No. being UIL:IRDA/NL-HLT/SHAI/P-H/V.11/129/14-15 and policy No.P/191117/01/2016/006020 by paying the premium of Rs.15,436/- through the authorized agent of the OPs and the said policy became in force on and from 14.11.2015 till the midnight of 13.11.2016 covering the Complainant along with his spouse and daughter namely Mrs. Alka Diwan and Avani Diwan respectively with assured sum of Rs.15,00,000/-. The Complainant has further stated that on 26.10.2016 his wife Mrs. Alka Diwan having customer ID No.4726625-2 was admitted to the C. K. Birla Hospitals, the Calcutta Medical Research Institute due to acute onset cough with shortness of breath. However, she received treatment therefrom 1day and she was discharged therefrom on 27.10.2016. The Complainant has further stated that the total expenses in the treatment of his wife was Rs.59,181/- and thereafter post hospitalization expenses was Rs.2,305/- and summing up those amount it has become Rs.61,486/-. Accordingly, the Complainant submitted the claim stating detail of the said treatment and expenses involved and the said claim form was duly received by the Inward Zone of the said Insurance Company but till date the OPs have not taken any step to disburse any amount towards expenses of the said treatment by adopting false, frivolous, baseless and lame excuses violating the Insurance guidelines. It is specifically stated by the Complainant that as per the guidelines framed by the Insurance Regulatory and Development Authority as well as the terms of the said Insurance Policy issued in favour of him the Complainant is legally entitled to get the insured value incurred for treatment of his wife. It is also stated that the Complainant served a demand notice upon the OPs through his Ld. Advocate on 23.5.2017 but even receiving the same the OPs are sitting tight over the entire issue and thereby depriving the Complainant from his legitimate demand. According to the Complainant all such above mentioned act on the part of the OP amount to unfair trade practice adopted by them. The Complainant has prayed for direction upon the OPs to disburse the claim amount of Rs.61,486/- towards claim to pay Rs.25,000/- towards cost of litigation and Rs.1,00,000/- towards compensation.
OP contested the case by filing written version denying and disputing all the material allegations made out in the petition of complaint stated inter alia, that the Complainant was asked to file relevant document by a letter dt.20.02.2017 issued by the OPs and subsequently by two reminders dt.08.03.2017 and subsequently, on 24.03.2017 to which the Complainant did not respond rather informed that he was not in a position to file the same though the same would not debar him to get his claim. It is further stated by the OPs that Clause 4 of the Insurance policy runs as “The insured person/s shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require I n dealing with the claim”.
and the same is binding upon the parties and as per the said terms (Clause 4) the Complainant was under obligation to furnish the documents which he was asked to file vide letter dt.20.2.2017 for settlement of his claim. The OPs have further stated that in absence of the said documents which the Complainant was asked to furnish they considered the claim furnished by the Complainant as ‘No claim’ and, accordingly, informed the same to the Complainant vide letters dt.11.04.2017 and 04.05.2017. According to the OP they have no deficiency in providing, therefore, the Consumer Complaint is liable to be dismissed. The OPs have further submitted that the patient did not disclose the same in the proposal form at the time of obtaining the policy and the same was synonymous of suppression of material. It is also stated by the OP that the Insurance policies are issued on utmost good faith and therefore suppression of material fat violates the principle of utmost good faith and, hence, no claim is admissible to them who suppress the material fact.
Both parties adduced evidence followed by cross examination and reply thereto.
The Complainant annexed several documents including policy schedule, customer ID card, premium receipt dt.14.11.15, clinical report, Pathological report of the patient, money receipts and final bill and Advocate’s letter dt.23.5.2017, track report.
The OP annexed Family Health Optima Insurance Plan.
Points for determination
- Whether there is deficiency in providing service on the part of the OPs.
- Whether the Complainant is entitled to the relief as prayed for.
Decision with reasons
Both points are taken up together for comprehensive discussion and decision. Admittedly, the Complainant obtained an Insurance Policy issued by the OP Insurance Company covering the Complainant along with his wife Alka Diwan and daughter Avni Diwan as insured. It is also admitted that wife of the Complainant Alka Diwan fell ill and admitted to C. K. Birla Hospitals, the Calcutta Medical Research Institute on 26.10.2016 and discharged on 27.10.2016. The Complainant has stated an amount of Rs.59,181/- has been spent as to hospitalization charges and an amount of Rs.2,305/- was spent as post hospitalization expenses and submitted claim for reimbursement of Rs.61,486/- to the OP. The Complainant in support of his claim annexed copy of final bills dt.27.10.2016 issued by the CMRI and pharmacy bill dated 27.10.2016 issued by CMRI. It is the specific allegation made by the Complainant is that the OP did not disburse the claim amount so far.
The OP Insurance Company, in defence has stated that the patient Alka Diwan was suffering from S.O.B. more than 4 years but did not disclose the said fact in the proposal form while obtaining the Insurance Policy, moreover, as the OP stated that they have served letter dt.20.02.2017 requesting the Complainant to furnish certain documents like-
- Complete set of ICP
- As per ICP there is H/O SOB 4 yrs. Back. Previous reord.
- A letter from treting doctor stating any past history of asthma or COPD, if so provide its duration.
- Definitive diagnosis for present admission – probable cause for SOB.
- All consultations with investigation for cough done prior to admission.
- All past and present PFT report.
but the Complainant did not file the same.
It appears from the letter issued by the Complainant that the patient Alka Diwan for first time was detected such illness for which she was admitted to the said Nursing Home.
On perusal of the letters dt.20.2.2017, 9.3.2017 and 24.3.2017 it appears that the OPs requested the Complainant to submit –
(1)Complete set of Indoor Case papers
(2)As per ICP, history of SOB 4 years back kindly provide the documents.
(3)Letter from treating Doctor stating (a) Any past history of Asthma or COPD, if so, provide its duration, (b) Definitive diagnosis for present admission (c) Probable cause for SOB.
(4)All consultation papers with investigation reports for cough done prior to admission.
(5)All past and present PFT reports.
The insured patient by a letter to the claim Manager stated that as per her ICP there is no past medical illness regarding those diseases and it is first time detected and therefore she could not submit any papers, report, prescriptions, or any letter from any treating doctor.
Be that as it is claimed by the insured patient as to the effect that she had no past history for such illness but she must have the Indoor case papers (ICP) in respect of which she had been admitted to C. K. Birla Hospitals, which she did not file. The Complainant has furnished claim for reimbursement of the expenditure incurred for that and thus filed the bills issued by the said clinic but failed to file the Indoor Case Papers. The Complainant has alleged that the OP Insurer has been sitting tight over the matter and as such did not disburse the claim amount. It is duty on the part of the Complainant to show that the OPs due to invalid ground did not settle his claims. But in the instant case the Complainant failed to substantiate that the OPs on very much frivolous ground by alleging suppression of material fact sitting tight over the claim.
Under such circumstances, we are inclined to hold that the Complainant by not providing Indoor Treatment papers to the OPs violated the terms of the policy of Insurance. Hence, he is not entitled to get his claim settled.
In the result, the Consumer Complaint does not succeed.
Hence,
ordered
that the Consumer Complaint being No.CC/337/2017 is dismissed on contest but without any order as to costs.
