MR. KUNDAN KUMAR KUMAI

This is an appeal u/s 15 of the Consumer Protection Act, 1986, preferred against the judgement and order dated 02/12/2022, passed by the Ld. DCDRF, Raiganj, Uttar Dinajpur, in Consumer Complaint No.23/2020.

Brief fact of the Appellants’ case is that, the predecessor of the Appellant viz. Rabindra Nath Baskey, had obtained one Mediclaim Insurance Policy from the Respondent no.1/OP no.1, being Policy No. 313501/48/2016/2685 and the same was valid from 08/02/2016 to 07/02/2017. During the tenure of the Policy, Rabindra Nath Baskey had fallen seriously ill due to spinal injury and he had been admitted in the Proforma Respondent/ Proforma OP clinic, on 10/02/2016 and he had been discharged on 29/03/2016, subsequently he expired on 04/05/2016. A claim was lodged before the Respondent no.1/OP no.1, along with all the original medical documents of treatment, of the deceased. Inspite passage of several days, no response was received from the Respondent no.1/OP no.1., the Appellant no.2 met with the Respondent no.1/OP no.1. On going through the bills and papers of treatment of the Respondent no.1/OP no.1, issued a letter dated 02/01/2018 requesting the Proforma Respondent/Proforma OP to supply the money receipt as requirement of TPA, for clearing the payments, with a copy to the Appellant no.2/Complainant no.2. The Proforma Respondent/Proforma OP, supplied all the medical papers to the Respondent nos.1 & 2/OP nos. 1 & 2. Despite receiving all the medical documents, the Respondent nos.1 & 2/ OP nos. 1 & 2, did not clear the claimed amount. The Appellants visited the office of the Respondent no.1/OP no.1 but the Respondents/OPs, failed to give any positive reply. Hence, when long delay was caused, they issued a Legal Notice dated 19/08/2019 which was duly served upon the Respondents. Thereafter, the Respondent no.1, sent a reply through their Advocate by letter, dated 06/09/2019, requesting the medical documents of the deceased. The Appellant no.1/Complainant no.1, sent all the copies of the medical documents, through their Advocate’s letter dated 21/10/2019. In the earlier letter it had been claimed that the Appellants had submitted the claim after a delay of 1028 days, but that was not true as the same had been submitted on 29/11/2016 and on 02/01/2018, the Proforma Respondent/Proforma OP had been requested to supply the documents, which had been supplied by the Appellants, after collecting the same. It had also been mentioned that the Appellants had been refrained from storing xerox copies of the X-Ray plates which they had submitted. But when the Respondents failed to take any action, the Complainants lodged the instant case before the Ld. DCDRF below, with necessary prayers.

The Respondents appeared before the Ld. DCDRF, Raiganj, Uttar Dinajpur by filing written version wherein they admitted the Policy, but the claimed documents had been submitted on 05/02/2019 after a delay of 1028 days. In this regard, several letters had been issued to the Appellants for providing clarification of the delay, for submission of the claimed documents. Thereafter, the Respondents had repudiated the claim when the Appellants had failed to supply any clarification of the delay. Hence prayed for dismissal of the case.

After going through the averments and the documents and hearing the parties the Ld. DCDRF, Raiganj, Uttar Dinajpur had dismissed the case vide the impugned order.

Being aggrieved by the above order the Appellants filed the instant appeal on the ground that the Ld. Forum below had erred in law and facts while passing the impugned order.

                                                                              Decisions with Reasons

Ld. Advocate for the Appellant at the time of final hearing, had submitted that the Appellants had submitted their claim in proper time, but the Respondent no.1 must have either misplaced or lost the documents, for which reason by letter dated 02/01/2018, requested the Proforma Respondent/Proforma OP, to supply the money receipt as per requirement of T.P.A., for clearing the payments of the Appellants. This further vindicates that when the Respondent no.1 issued the letter dated 02/01/2018, their claim, that the Appellants had lodged their claim after a delay of 1028 days on 05/02/2019, appears to be false.

 That apart it was further argued that the Respondent no.2 had issued a letter dated 29/11/2016, to the deceased Rabindra Nath Baskey, seeking for paid money receipt of Rs.1,50,000/- for hospitalization from 10/02/2016 to 29/03/2016. Had the Appellants not submitted their claim prior to 29/11/2016, the question of issuance of the letter dated 29/11/2016, would not have arisen, following which the allegation, that the Appellants had submitted their claim on 05/02/2019, does not hold much water. That apart no supportive documents in favour of their claim, had been filed by the Respondent no.1. Moreover, paragraph 7 of the written version submitted by the Respondents mentions, issuance of several letters for providing clarifications for the delay in submission of documents, has not been supported by any sort of evidence. The Ld. Advocate had relied in the Circular being IRDA/HLTH/MISC/CIR/216/09/2011 dated 29/09/2011, issued by the IRDA. He had further relied in the judgment passed by the Hon’ble Supreme Court of India in Om Prakash Vs. Reliance General Insurance & Anr. on 04/10/2017 and Ankita Bhattacharjee & Ors. Vs. Bajaj Allianz General Insurance Co. Ltd., decided by this Commission on 29/08/2023. He therefore prayed for allowing the appeal.

Ld. Advocate for the Respondents, on the other hand, had argued that though the predecessor of the Appellant, Rabindra Nath Baskey, was the Policy holder of the Mediclaim, but the claim documents  had not been submitted, even though the deceased had been discharged on 29/06/2016 and the same had been submitted only on 05/02/2019 after a delay of 1028 days. He had also argued that several letters had been sent for providing clarification for delay in submission of the documents. But, on non-receipt of the clarification, had been repudiated. He had relied in the judgement passed by the Supreme Court in Export Credit Guarantee Corpn. Of India Ltd. Vs. Garg Sons International reported in II (2013) CPJ 1 (SC). He therefore prayed for dismissal of the appeal.

From the materials on record and submissions made, it becomes clear that the execution of the Mediclaim Policy or its validity, of the deceased, was never disputed. The only point of dispute which has been raised on behalf of the Respondent no.1 is that the claimed documents had been submitted after a delay of 1028 days on 05/02/2019.

In this regard, there is an existence of the document that the additional document requested, issued on 29/11/2016, in the name of the deceased, Rabindra Nath Baskey by the Respondent no.2, wherein it had been categorically mentioned that the claimed documents had been received and only the receipt of Rs.1,50,000/- (Rupees one lakh fifty thousand) only, had been requested. Moreover, the copy of the duplicate money receipt dated 03/01/2018 issued by the Proforma Respondent showing the payment of Rs.1,50,000/- (Rupees one lakh fifty thousand) only, on 6 dates starting from 10/02/2016 till 29/06/2016 clearly and categorically establishes the compliance of the letter dated 29/11/2016 and in the process also demolishes the claim of the Respondent no.1, that the claim had been submitted only 05/02/2019 after a delay of 1028 days, for which reason, the repudiation had been necessitated. No doubt, the delay had been caused but the address of the Proforma Respondent clearly shows that the treatment had been done in far away Kolkata whereas the Appellants are residents of a remote village at Uttar Dinajpur, which might have attributed to the delay in providing the money receipt. In this regard, when the facts are admitted, the question of repudiation of the claim, merely on the ground of delay, is well settled by the Hon’ble Superior Authorities, that such delay should not be viewed pedantically.

Under the circumstance, when the facts are admitted, the Appellants are entitled to the claim of Rs.1,50,000/- (Rupees one lakh fifty thousand) only, with an interest @ 9% from 03/01/2018 till the date of payment. That apart they are also entitled to Rs.50,000/- (Rupees fifty thousand) only, as compensation for mental pain and agony along with Rs.10,000/- (Rupees ten thousand) only, as litigation cost. As a result, the instant appeal succeeds.

           It is therefor,

                                                                                ORDERED

That the instant appeal be and the same is allowed on contest but without cost.

The impugned order is hereby set aside.

The Respondent no.1/OP no.1 is hereby directed to comply with the directions mentioned in the body of the judgement within 45 days, from the date of receipt of this order.

Copy of the order be sent to the parties free of cost.

Copy of the order be sent to the Ld. DCDRF, Raiganj, Uttar Dinajpur for necessary information.