Heard learned counsel for the parties. The officer concerned of the National Insurance Co. Ltd. is present.
2. Captioned appeal is filed u/s 15 of the erstwhile Consumer Protection Act, 1986 (hereinafter called the ‘Act’). Parties to this appeal shall be referred to with reference to their respective status before the District Forum.
3. The case of the complainant in nutshell is that complainant has purchased Mediclaim Policy vide Policy No. 163401/48/08/8500000025 from opposite party for the period from 15.7.2008 to midnight of 14.07.2009. It is alleged inter alia that the complainant went for piles operation at Gupta Nursing Home, Burla on 1.12.2008 and was discharged on 4.12.2008. Being the beneficiary of the policy complainant forwarded a claim for reimbursement of total expenditure incurred in aforesaid operation and claimed a sum of Rs. 16737.29 paisa by filling up the prescribed form.
He has submitted the entire relevant documents in original on 29.12.2008. In spite of submission of all document, the opposite party slept over the matter. Further, it is alleged that since the opposite party failed to take any action on the said documents, the complainant filed the complaint case alleging deficiency in service on the part of opposite party.
4. On issuance of notice, the O.P. appeared through counsel but failed to file any written version and he was set ex parte on 10.5.2010, but later on he appeared and got the ex parte order set aside. Then counsel for the opposite party filed written version stating that the insurance policy has been issued and they have received the claim application. As the complainant has failed to produce the relevant documents, the opposite party was compelled to close the file. There is no deficiency of service on the part of opposite party.
5. After hearing both the parties, learned District Forum passed the impugned and operative portion of the impugned order is as follows:-
“ xxxx Ordered that the O.P. is directed to pay a sum of Rs. 16,737.29/- paisa (Rupees Sixteen Thousand Seven Hundred Thirty Seven and Twenty nine paisa) along with 12% interest per annum from the date of filing of this case i.e. dt.16.2.2010 till the realization to the complainant and to pay a sum of Rs.5000/- (Rupees Five Thousand) only to the complainant towards mental agony and harassment within two month from the date of order. Both the parties are directed to bear their own cost and accordingly complaint petition is allowed.
The case is disposed of accordingly.”
6. Learned counsel for the appellant along with representative of the insurer submitted that learned District Forum passed the impugned order without considering the written version filed by the opposite party with proper perspectives. According to him, the complainant was required to file previous policy, money receipt and many other documents duly called for, but he did not submit the same. As per the norm, the complainant has to file all the documents to satisfy the insurer. Since the complainant did not file the documents, they have closed the file repudiating the claim of the complainant that he has no claim. Learned counsel for the appellant further submitted that Genins India TPA Ltd. to whom the policy has been obtained is not a party to this case. Therefore, he submitted to set aside the impugned order by allowing the appeal.
7. Considered the submissions, perused the DFR and impugned order. It is well settled that the complainant has to prove its case and about deficiency of service on the part of opposite party.
8. It is not in dispute that the complainant has purchased the policy from opposite party for the above period. It is also not in dispute that complainant was admitted for surgery of piles at Gupta Nursing Home, Burla on 1.12.2008 and discharged on 4.12.2008. It is also not in dispute that the complainant has claimed mediclaim policy towards the medical expenditure.
9. Now the question arises whether the repudiation of claim or closure of the claim by the opposite party is correct and whether the complainant has proved the deficiency of service on the part of opposite party.
10. The complainant stated to have sent all the documents to the opposite party. In support of that, he has filed a postal receipt RLAD No.2948 by registered post. Copy of the claim petition is also filed. Necessary documents as appears in their letter are original policy report, policy schedule, original medical bill, original discharge certificate of the hospital. To prove the documents along with the complaint petition, the complainant has possessed copies of the documents available with him with the policy schedule to the opposite party by registered post. Once a letter is sent by registered post, it is presumed that the same has reached the insurer. Therefore, the complainant has proved his case by filing the documents.
11. The opposite party in order to prove his submission has filed copy of the letter sent by Genins India TPA Ltd. where it is stated that to determine the claim of the complainant, Dr. Advice for admission for the 2nd Hospitalization, Previous all policy copies since inception, clinical test report original from Jehangir Ghandy Hospital and Money Receipt of Rs. 283/- from Jehangir Ghandy Hospital are necessary. Copy of the letter has been sent to the insurer. The opposite party relies on those documents because he has engaged expert to find out the relevance of the claim. When the original documents have been sent to the insurer, it is for the insurer- The Genins India TPA Ltd because the policy has been sold by the opposite party to the complainant. The Genins India TPA Ltd is not a necessary party. However, the letter to the opposite party as relied by opposite party should be taken into consideration. The certified copies of documents as asked for is necessary because it does not show what happened to documents already submitted by the complainant to the insurer. Once the policy has been purchased from the opposite party, it is for the opposite party -insurer to decide whether the claim to be allowed or disallowed, but cannot sit over the matter on that ground. The Genins India TPA Ltd. has called for some documents.
12. In our considered opinion, action of respondent- opposite party is nothing but a unfair trade practice as per Section-2(r) of the Consumer Protection Act, 1986. Since they sat over the matter and closed the matter, it amounts to repudiation of claim. It is also proved by the documents relied on by the complainant there is deficiency of service on the part of the opposite party. We rely on the decision of the Hon’ble Supreme Court of India in Gurmel Singh vs. Branch Manager, National Insurance Co. Ltd. disposed of on 20th May, 2022 in which their Lordships have held in para 4.1.
“4.1. xxxxxxx While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control.”
13. With reference to the aforesaid decision, we are of the view that the repudiation or sitting over the matter, or rejection of claim of the claimant by opposite party is a clear deficiency in service on the part of opposite party. Therefore, we find no reason to interfere with the impugned order and as such the impugned order is confirmed.
14. In the result, the impugned order is confirmed and the appeal is allowed.
DFR be sent back forthwith.
Supply free copy of this order to the respective parties or the copy of this order be downloaded from Confonet or Website of this Commission to treat same as copy supplied from this Commission.
