ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Ms. Nipur Chandna, Member
The complainants is a mediclaim policy (Happy Family Floater) holder of the OP No. 1 vide policy No. 214400/48/2012/634 and the same is valid from 13.5.2011 – 12.5.2012. The OP no. 2 is the TPA of OP no. 1.
It is alleged by the complainant that she had lodged a claim with the OP for the reimbursement of the expenses incurred by her for the treatment of her son at R.G. Stone Urology & Laproscopy Hospital, New Delhi, wherein he was admitted for the period 2.10.2011 to 4.10.2011. But, the OP company did not settle the genuine claim of the complainant and repudiate it under the guise of clause no. 5.4 and 5.5. of the policy terms and conditions, whereas the complainant intimated the OPs in time. The complainant had therefore approached this Forum for redressal of her grievance.
The Insurance Company has contested the complainant and has filed its reply. It has denied any deficiency on its part and prayed for the dismissal of the complaint.
Para 3 of the reply of the written statement is relevant for the purpose of the disposal of this complaint and is being reproduced as under:-
- The complainant lodged a claim with the respondent for reimbursement of the expenses incurred by her for treatment of her son at R.G. Stone Urology & Laproscopy Hospital, New Delhi wherein he was admitted for the period 2.10.2011 to 4.10.2011. The complainant did not sent any notice to T.P.A. (Respondent No. 2) within 48 hours of admission in the aforesaid hospital nor she submitted all the relevant documents, bills, Reports etc within 7 days from the date of discharge from the hospital. It is submitted that the complainant has submitted the documents only on 22.10.2011 i.e. after the expiry of 18 days from the date of discharge from the hospital. A copy of the claim form is annexed as Annexure R-1 to this reply, which clearly establishes that these papers were given only on 22.10.2011.
Both the parties have filed their evidence by way of affidavit and corroborated the contents of complaint and written statement respectively.
We have heard argument advanced at bar and have perused the record.
The counsel for the complainant contended that the OP had repudiated the genuine claim of complainant on false and flimsy ground. The counsel for the complainant alleged that both the clause no. 5.4 and clause No. 5.5 are the waiver clause and IRDA has also passed an instruction through its circular dated 20.9.2011 “ Not to reject he claim of the insured on the grounds of delay intimation/delay submissions.”
The complainant has placed on record the copy of the e-mail dated 3.10.2011 which shows that the complainant had informed the OP company well within time. We are convinced with the contentions of the counsel for the complainant that the OP co. had repudiate the genuine claim of complainant on false and filmsy ground. In the light of the IRDA Circular dated 20.9.2011, we hold OP guilty of deficiency in services and direct it as under:-
- To pay to the complainant a sum of Rs.56,737/- alongwith interest @ 9% p.a. from the date of institution of complaint i.e. 10.4.2013 till payment.
- To pay to the complainant a sum f Rs.10,000/- for causing harassment, mental agony, and pain.
- To pay to the complainant a sum of Rs.5,000/- as a cost of litigation.
The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. If the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule. File be consigned to record room.
Announced in open sitting of the Forum on.....................