BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 171 of 2015
Date of Institution : 1.10.2015
Date of Decision : 20.9.2016
Samiti aged about 27 years wife of Shri Anil Kumar, resident of H. No. 19/579 Gobind Nagar, Petrol Pump Wali Gali, Sirsa, Tehsil and District Sirsa.
….Complainant.
Versus
1. TATA AIG Mediprime Insurance Company A-50, 5th Floor, Building Number 4, Infinity IT Park, Dindoshi, Malad East, Mumbai- 400097.
2. Axis Bank Ltd. Main Branch, Near Sangwan Chowk, Sirsa through its Branch Manager.
..…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI S.B.LOHIA………………………………PRESIDENT
SHRI RANBIR SINGH PANGHAL…………MEMBER.
Present: Sh. Sandeep Chaudhary, Advocate for the complainant.
Sh.A.S.Kalra, Advocate for the opposite party No.1.
Opposite party no.2 exparte.
ORDER
Case of complainant, in brief, is that husband of the complainant Anil Kumar had purchased a mediclaim policy from opposite party no.1 through op no.2 vide policy No.0200204521 01 dated 12.7.2014. The type of policy was Family Floater Plan and the same was valid up to 11.7.2015. The complainant, her husband Anil Kumar and her son Manik Bathla were covered under the policy. The op no.1 through op no.2 had charged a sum of Rs.6885/- from the husband of complainant qua the premium of said policy and assured the complainant that all the mediclaims shall be covered under the policy. On 7.9.2014, the complainant fell seriously ill and her husband got her admitted in Janta Maternity and General Hospital, Sirsa where she remained admitted from 7.9.2014 to 9.9.2014. A total sum of Rs.14,000/- was spent by her husband on her treatment, tests and medicines etc. Thereafter, the complainant intimated op no.1 about the same and fulfilled the necessary formalities and claimed the treatment expenses but the claim of complainant was repudiated by ops No.1 & 2 orally and they declined to indemnify her claim. The complainant also got served a legal notice upon ops but to no effect. The opposite parties have caused deficiency in service and unfair trade practice towards the complainant. Hence, this complaint.
2. Upon notice, opposite party no.1 appeared and contested the complaint by filing written statement asserting therein that complaint is pre mature as the complainant herself is guilty with respect to non settlement of the claim. Despite repeated requests and reminders, the complainant failed to submit required documents with the answering op. There is no deficiency in service in any manner on the part of answering op. The claim was lodged by complainant with Family Health Plan Limited (TPA for answering op) on 27.9.2014 with a request for reimbursement of medical bills to the complainant. The complainant provided claim form alongwith copy of discharge summary and few medical bills. On scrutiny of the documents, it was noted that Samiti was admitted in Janta Maternity and General Hospital from 7.9.2014 to 9.9.2014 for alleged treatment of acute sinobronchitis. Following shortfalls were noted in the documents provided by the complainant:-
* The complainant was admitted in Janta Maternity and General Hospital from 7.9.2014 to 9.9.2014. However, the discharge summary was issued on 13.1.2015.
* In the entire hospitalization, only allergy test was done, no other investigations- complaints of cough, fever, chest x-ray or blood investigations was done.
The complainant was requested through various telephonic conversations and reminders letters dated 14.10.2014, 22.10.2014, 5.11.2014, 14.11.2014 and 9.2.2015 to provide all investigation reports, original final bill (with break-up) and payment receipt, original discharge summary, previous treatment records prior to hospitalization including 1st consultation letter and treating doctors certificate regarding indication for hospitalization. However, despite the same, the complainant failed to provide necessary documents to answering op and since the claim file could not be kept indefinitely, the claim was closed as no claim due to no response. The same was duly communicated to the complainant vide letter dated 2.3.2015. It is submitted that if the complainant provides above noted documents to the answering op, the claim can be processed with respect to policy terms and conditions.
3. None appeared on behalf of op no.2 despite service and as such op no.2 was proceeded against exparte.
4. By way of evidence, the complainant produced affidavit Ex.C1 and documents Ex.C2 to Ex.C34. On the other hand, ops produced affidavit Ex.R1 and documents Ex.R2 to Ex.R11.
5. We have heard learned counsels for the parties and have gone through the record of the case carefully.
6. It has been established on record that husband of the complainant namely Anil Kumar had purchased a medi claim policy from opposite party no.1 through op no.2 on 12.7.2014 vide which Anil Kumar himself, his wife Samiti i.e. complainant and their son Manik Bathla were covered under the policy as is evident from policy schedule Ex.C9. It has also been established on record that complainant remained admitted in Janta Maternity and General Hospital, Janta Bhawan Road, Sirsa from 7.9.2014 to 9.9.2014 and was diagnosed with acute sinobronchitis. The complainant claims to have spent an amount of Rs.14,000/- on her said treatment but claim amount has not been released to her by the opposite party no.1. Whereas the op no.1 has averred that despite several reminders the complainant has not provided the above said relevant documents and ultimately the claim has been closed. The learned counsel for the complainant has argued that the complainant has already submitted almost all the documents to the opposite party No.1 and so her claim should be accepted by this Forum. But we do not think it possible. The complainant may be in possession of original final bill, original discharge summary and can obtain treating doctors certificate etc. and therefore, she is directed to submit the said documents alongwith investigation reports, if same are in her possession and previous treatment records, if any to the opposite party no.1 within a period of one month upon which the opposite party will settle the claim of the complainant within a further period of one month. The present complaint stands disposed of accordingly. Copy of this order be supplied to the parties as per rules. File be consigned to record room after due compliance.
Announced in open Forum. President,
Dated:20.9.2016. Member. District Consumer Disputes
Redressal Forum, Sirsa.
