Date of Filing: 08.08.2014 Date of Final Order: 14.08.2015
The brief facts of the present case, as culled out from the record is that the Complainant, Miss. Putul Sen, D/o. Late Gouranga Sen purchased a Policy on 31/03/2013 from the O.P. No.1, Birla Sun Life Insurance Co. Ltd., Cooch Behar Branch through their Agent, Surajit Saha with this assurance that they will render proper service towards the Complainant and she has paid 1st premium Rs.15,343/- of the said policy which is covered 10th pay/20 years term. The details of the said policy is mentioned here below :
Policy Number | 006070427 |
Date of Commencement | 31/03/2013 |
Plan Name | Saral Health Policy |
Mode of payment | Annually |
Installment Payable | Rs.15,343/- |
Nominee | Swarup Sen |
During the subsistence of such policy the Complainant met with an accident and she felled down from the motor cycle of her elder brother namely Swarup Sen on 16/07/2013 and sustained injury on her left knee. After that, the Complainant and her elder brother had to go to Kolkata on the very day of accident, so after preliminary treatment they went to Kolkata. After reaching at Kolkata the Complainant fell sever pain on her left knee and that’s why she was admitted at Ramkrishna Mission Seva Pratisthan, Kolkata on 20/07/2013 with the problem of Left knee Acl Tear and she was treated by Dr. D.K. Jha and due to the acute problem of the Complainant operation was done on her left knee on 23/07/2013 in that Hospital and after the operation she was discharged on 05/08/2013. Due to such treatment of the Complainant at Kolkata she spent Rs.6,400/- for Bed charge, Rs.7,250/- for Operation charge, Rs.200/- for Service Charge, Rs.4,950/- for Laboratory Charge, Rs.150/- for X-Ray Charge, Rs.125/- for ECG Charge and Rs.28,242/- for Medicine, so total Rs.47,317/-. There after returning at Cooch Behar being the elder brother of the Complainant and as well as nominee of the said policy Sri Swarup Sen, made correspondence with the Insurance Company and the Complainant preferred claim towards the company. The O.P. No.1, Branch Manager of the Birla Sun Life Insurance Co. Ltd., Cooch Behar Branch advised him to deposited Hospital treatment certificate for Reimbursement claim form filled up by the Doctor/concerned who treated the patient, discharge card, treatment bill etc. and accordingly Mr. Swarup Sen submitted all the relevant papers to the O.P. No.1, Branch Manager of the Insurance Company, Cooch Behar.
After few days when Mr. Swarup Sen enquired about the Medi-claim of her sister then the O.P. No.1 informed him that the claim papers sent to their higher authority i.e. the O.P. No.2, The Zonal Office, Birla Sun Life Insurance Co. Ltd., Kolkata and the O.P. No.3, The Head Office, Birla Sun Life Insurance Co. Ltd., Thane, Mumbai. On 21/10/2013 the O.P. No.3 sent a letter dated 21/10/2013 to the Complainant asking her to provide some medical papers, accordingly the elder brother of Complainant went to Kolkata and after obtaining the same submitted to the O.P, insurance company. On 14/01/2014 by sending one letter to the Complainant, the O.P, Insurance Company demanded again some other medical papers and accordingly Mr. Swarup Sen again went to Kolkata obtaining the same as per their demand the Complainant provide the same to the O.P, Insurance Company. On 24.03.2014 the Complainant became astonished when the O.P. No.3 again sent a letter asking for some another medical papers. The Complainant spent huge amount of money to fulfill the extra demand of medical papers, in different times from the part of the O.Ps. The O.Ps instead of settling the claim of the Complainant, they harass the Complainant in various ways and thereby causes gross deficiency in service on their part. For such deficiency in service and negligence adopting by the O.Ps, the complainant suffered a great financial loss, unnecessary harassment mental agony and pain as the complainant is a nominee of the said policy.
Hence, finding no other alternative the complainant filed the present case praying for issuing a direction upon the O.Ps to pay (i) Rs.47,317/- for reimbursement against her Health Insurance policy, (ii) Rs.15,000/- as cost for went to Kolkata for collecting and submitting extra medical papers from the said hospital at Kolkata and submitting those to the O.P, insurance company, (iii) Rs.25,000/- as compensation for mental pain, agony and unnecessary harassment, (iv) Rs.25,000/- for unfair trade practice and deficiency in service & (v) Rs.20,000/- towards litigation costs, besides other relief(s) as the Forum deem fit, as per law & equity.
The O.P. Nos.1, 2 & 3, Birla Sun Life Insurance Co. Ltd. have contested the case denying all material allegation of the complaint contending inter-alia the case is not maintainable and the complainant has no cause of action to bring the case. The main contention of the O.Ps is that the policy is a contract between the policyholder and the Insurance Company and the parties to the said contract are bound by its terms and conditions. The O.Ps further contended that they appointed Third Party Administrator (TPA) as per IRD guideline to settle the medi claim procedure. The TPA must receive written notice of any claim against Health Insurance Benefits within 30 days of Hospitalization.
It is the case of the O.Ps that in the present case, the O.Ps vide letter dated 19/03/2014 informed the complainant to submit certain additional documents to process the claim. However, the Complainant failed to submit the said documents therefore the claim of the complainant could not be processed. Therefore, the present complaint is pre-mature and the same is liable to be dismissed. The allegation of the Complainant that the Complainant’s brother submitted the required documents is false and concocted and no documents as required by the O.Ps were received by the O.Ps. Therefore, the question of payment of claim does not arise.
It is the further case of the O.Ps that the replying O.P, Insurance Company in accordance with Clause 6(2) of the Insurance Regulatory and Development Authority (Protection of Policyholder’s Interest) Regulations, 2002 every policy documents sent by the Insurance Company to the policy holders is accompanied by a welcome letter which clearly mentions that in case policy holder is not satisfied with the terms and conditions of the policy, he/she can withdraw/return the policy within 15 days i.e. under the “Freelook period”. Furthermore, as per Clause 4(1) of the Insurance Regulatory and Development Authority, (Protection of Policy Holder’s interests) Regulation Act, 2002 copy of proposal form duly signed by the policyholder was also sent along with the policy document to the policyholder. In the present case, this answering O.Ps sent the policy and policy document along with copy of the proposal form of the policy to the complainant, which was received at the address of the complainant. Despite receipt of the policy and policy documents the complainant did not approach the replying O.Ps for any discrepancy made in the proposal form or any grievance relating to the policy or their terms and conditions during free look period, implying that the Complainant had agreed to subject policy and their terms and conditions were in order.
It is the specific case of the O.Ps that the replying O.Ps received a claim form on 16/09/2013 from the complainant that she was admitted on 23/07/2013 and underwent surgery in her left knee and was discharged on 05/08/2013 and further requested for re-imbursement of the expenses incurred by her in the said hospital. Thereafter the O.Ps vide letter dated 14/01/2014 & 19/03/2014 requested the Complainant to submit certain documents to process the claim. However, the complainant failed to provide the documents as required by the O.Ps therefore the claim could not be processed and is still pending. The O.Ps also stated in their written version that no correspondence made by the Complainant. Due to own omission, commission and negligence of the Complainant, the claim of the Complainant could not be processed. Therefore, there is no deficiency in service and negligence on the part of the O.Ps.
Ultimately, this answering O.Ps prayed for dismissal of the case with exemplary costs.
In the light of the contention of the complainant, the following points necessarily came up for consideration.
POINTS FOR CONSIDERATION
- Is the Complainant a Consumer as per Section 2(1)(d)(ii) of the C.P. Act, 1986?
- Has this Forum jurisdiction to entertain the instant complaint?
- Have the O.Ps any deficiency in service as alleged by the Complainant and are they liable in any way?
- Whether the Complainant is entitled to get relief/reliefs as prayed for?
DECISION WITH REASONS
We have gone through the record very carefully, perused the entire documents in the record. Perused the evidence on affidavit of both parties and W/Ar. also heard the argument by the parties.
Point No.1.
In the case in hand, Complainant obtained a policy from the Opposite Parties No. 1.The Complainant paid premium for the said policy and the Opposite Parties issued a policy certificate in favour of the Complainant. Thus, the relation between the O.Ps and the Complainant so established from the record we are in view that the Complainant is the Consumer of the O.Ps.
Point No.2.
The branch office of the O.Ps is situated within this district and the complaint value is far less than the prescribed limit for which this Forum has pecuniary as well as territorial jurisdiction to try the case.
Point No.3 & 4.
Undisputedly, the Complainant obtained a Mediclaim Policy from the Opposite Parties on 31.03.2013 and the Opposite Parties issued a policy certificate bearing No. 006070427 in favour of the Complainant. It is the case of the Complainant that she met an accident on 16.07.2013 by fell down from the motor cycle and sustained injury on her left knee as and resultantly the Complainant underwent surgery of the said knee. As per terms and condition of the Policy the Complainant’s brother as a nominee has preferred a claim to the Insurance Company with all relevant documents but the Insurance Company did not settle the claim on a flimsy ground.
It is the case of the Opposite Parties that the Complainant failed to submit certain additional documents as required by the Opposite Parties to process the claim. However, in absence of said documents the Opposite Parties did not settle the claim. The answering Opposite Parties received a claim form on 16.09.2013 with information that she was admitted on 23.07.2013 and underwent surgery in her left knee and was discharged on 05.08.2013 and requested for re-imbursement of the medical expenditure. The Complainant has failed to file the required documents even after two reminders, thus, the claim cannot be settled.
Evidently and admittedly, the Complainant took a medi-claim Policy from the Opposite Parties (Annexure “A”).
Annexure “B”,”C”, “D”, “E” series reveal that the Complainant admitted in the Ramakrishna Mission Seva Pratisthan, Kolkata for the purpose of surgery in her knee during the policy period and spent Rs. 28,242/- for medicine and total Rs. 47,317/- for her entire treatment there.
Annexure “I” Discharge Certificate reveals that the Complainant admitted in the Ramakrishna Mission Seva Pratisthan, Kolkata for the period 20.07.2013 to 05.08.2013 and underwent operation on 23.07.2013.
Admittedly, the Complainant filed the claim application to the Opposite Parties No.1 along with documents as to her treatment in Ramakrishna Mission Seva Pratisthan but the Opposite Parties demanded some additional documents by letter dated 14.01.2014 and 19.03.2014 Annexures “R3” & “R4” filed by the Opposite Parties. The Complainant in the Complaint as well as in Evidence on affidavit stated that the complainant submitted all the required documents with the claim application but the Opposite Parties asked more additional documents. The nominee of the Complainant went several times to Kolkata for collecting the documents and submitted to the Opposite Parties but that was too hard to him. The Opposite Parties did not settle the claim despite receiving the documents and further asked some documents by letter dated 19.03.2014, the Complainant being frustrated did not submit the further documents.
The Opposite Parties have taken plea that due to non-available of documents the claim cannot be settled till now. We are not convinced with the plea taken by the insurance Company as the Complainant submitted the documents of her hospitalization, discharge certificate and the bills of treatment etc. In our considered view, those are enough to settle the medi claim when the facts are not disputed. Moreover, the Opposite Parties received the claim of the Complainant on 16.09.2013. The Opposite Parties kept mum and withheld the matter till middle of January 2014, the reason best known to them and thereafter sent a letter on 14.01.2014 demanding further documents i. e. a gross negligence on the part of the Insurance Company.
In this juncture reliance has been placed upon the decision in the case L.I.C. of India Vs. Mr. Ranjan Ramchand Alimechandani of Mararashtra State Commission decided on 27.08.2008 where it is observed that appellant did not settle the claim within the stipulated period as per IRDA Regulations and thus appeal dismissed.
The documents filed by the Complainant transpire that the fact of the accident and Hospitalization are not in dispute. The Complainant for getting the mediclaim deposited the available documents to the Insurance Company. The Opposite Parties have taken plea that due to non-availability of the documents the claim of the Complainant cannot be settled.
The Ld. Agent of the Complainant has filed two decisions of Maharastra State Commission. Reliance has been placed upon the decision in Complaint Case No. CC/00/404 where the State Commission of Maharastra pleased to hold that Insurance Company acted contrary to the instructions of IRDA Rules and on flimsy ground kept the insurance claim pending and did not settle the same and, thus, the deficiency in service on the part of the Insurance Company on this count is well established.
In the case in hand the statement of facts emerging from the affidavits, it could be seen that the accident and hospitalization are not in dispute and the Complainant submitted the relevant documents to the O.Ps for getting insurance claim. But the Opposite Parties even after receipt of the documents as to the treatment of the Complainant at Ramakrishna Seva Pratisthan did not settle the claim for pretty long time for which deficiency in service cannot be ruled out.
In his argument the Ld. Advocate/ Agent of the O.P. submitted that in the present case entire onus upon the Complainant to prove his case but she failed to do and he submitted a ruling reported in 2000 (1) SCC66 where Hon’ble Apex court pleased to hold that “ The deficiency in service cannot be alleged without attributing fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be performed by a person in pursuance of a contract or otherwise in relation to any service. The burden of proving the deficiency in service is upon the person who alleges it”.
But in the present case we find that the Complainant has been able to prove his case of deficiency in service by cogent evidences and also able discharge onus casted upon her. Therefore, this ruling is not applicable in this case.
Ultimately, we constrained to hold that the Complainant suffered huge mental agony due to non-settlement of her genuine claim by the Insurance Company.
From the discussion made here in above and the documents made available in the record we have no hesitation to say that the deficiency in service of the Opposite Parties has been already proved and the Complainant is entitled to get relief and compensation.
Accordingly, all points are decided in favour of the complainant.
Thus, the case succeeds but in part.
ORDER
Hence, it is ordered,
That the case No. DF 52/2014 be and the same is allowed on contest but in part with costs of Rs.5,000/- against the Opposite Parties. The O.Ps. are hereby directed to settle the claim within 45 days by payment of Rs. 47,317/- as reimbursement against Health Insurance Policy also to pay Rs.10,000/-as compensation to the complainant for harassment, mental agonies and sufferings.
The ordered amount shall pay to the Complainant directly by the O.Ps. jointly/or severally within 45 days failure of which the said O.Ps shall have to pay Rs.100/- for each day’s delay and the amount to be accumulated shall be deposited in the “State Consumer Welfare Fund”, West Bengal.
Let plain copy of this Final Order be supplied, free of cost, to the concerned parties/Ld. Advocate by hand/be sent under Registered Post with A/D forthwith for information and necessary action, as per Rules.
Dictated and corrected by me.
Member President
District Consumer Disputes District Consumer Disputes
Redressal Forum, Cooch Behar Redressal Forum, Cooch Behar
Member Member
District Consumer Disputes District Consumer Disputes
Redressal Forum, Cooch Behar Redressal Forum, Cooch Behar
