BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE URBAN

 02^nd DAY OF FEBRUARY 2016

O R D E R

SRI. P.V SINGRI, PRESIDENT

The complainant has filed this complaint U/s.12 of the Consumer Protection Act, 1986 against the Opposite Party (herein after referred as OP) with a prayer to direct the OP to reimburse him claim of Rs.4,000/-, damages of Rs.50,000/- and litigation cost of Rs.5,000/-.

2. The brief averments made in the complaint are as under:

The complainant had taken a Insurance policy for CanCard holders issued by OP since 1^st February 2007 and was regularly renewing it continuously without a break since then.  Earlier, the OP had reimbursed the complainant the cost of health check up for the period ended 31^st January 2011.  As per clause 1.3.c of the policy document, the complainant was eligible for reimbursement of cost of health check up at the end of 31^st January 2015, since he did not preferred any mediclaim during the block of four underwriting years between 1^st February 2011 and 31^st January 2015.  Accordingly, the complainant submitted a claim with all supporting documents to OP’s ‘Third Party Administrator’ E-Meditek (TPA Services Ltd.,) Regional Office at Bangalore on 01^st February 2015 and the receipt of the same was acknowledged by the said Third Party Administrator.  Since the complainant did not receive any communication either from TPA or the OP, he wrote to OP on 13.03.2015 requesting to pursue the issue and settle the claim.  There was no response from the OP or the TPA.  The complainant approached the TPA on 02.04.2015 and was informed about the repudiation of his claim.  The TPA also handed over to him the copy of repudiation letter.  The reason for repudiation was on the ground that the policy has a break between 31^st December 2011 and 31^st January 2012.  The complainant showed the earlier insurance policies to the representative of TPA for verification.  That despite the same either the TPA or OP did not reimburse the medical expenses incurred by the complainant.  The complainant is very much annoyed aggrieved and suffered mental agony and sense of harassment due to the indifference of OP.  It is a clear case of deficiency in service by the OP.  The OP is not at all justified in repudiating the claim of the complainant.

For the aforesaid reasons, the complainant prays for an order directing the OP to reimburse the cost of health check up incurred by him to an extent of Rs.4,000/- and further direct the OP to pay him damages of Rs.50,000/- for harassment and anguish caused together with litigation cost of Rs.5,000/-.

3. In response to the notice issued the OP appeared through their advocate and filed an interim application Under Order 6 Rule 5 Read with Section.151 of CPC seeking better particulars from the complainant.  The complainant promptly furnished the better particulars, in response to the said interim application filed by the OP.  Thereafter, the case was posted for version to be filed by OP.  However, despite sufficient time and opportunity given the OP failed to file their version and contest the complaint.  Thereafter, the complainant was called upon to adduce evidence by way of affidavit.  Accordingly, the complainant filed his affidavit evidence in lieu of oral evidence.

4. Perused the allegations made in the complaint, sworn testimony of the complainant and the documents relied upon by the complainant.  The allegations made in the complaint coupled with the copies of insurance policy issued for the period 01.02.2011 to 31.01.2012, 01.02.2012 to 31.01.2013, 01.02.2013 to 31.01.2014 & 01.02.2014 to 31.01.2015 goes to establish that the complainant was holding valid insurance policy issued by the OP from 01.02.2011 to 31.01.2015 without any break.  The only cause for OP to repudiate the claim of the complainant, as could be seen from their letter of repudiation dated 26.03.2015, that the policy has a break between 2011-2012 & 2012-2013.  On the basis of the alleged break in policy, the OP has repudiated the claim as per clause.1.3(c) of the terms and conditions of policy.  From the copies of the policy placed on record goes to establish that absolutely there was no break in the policies held by the complainant between 01.02.2011 to 31.01.2015.  Therefore, we are of the opinion that the OP was absolutely not justified in repudiating the claim of the complainant on false and frivolous grounds.

5. Though the complainant furnished all the details of four policies held by him between 01.02.2011 to 31.01.2015 as requested by the OP in their interim application, the OP did not come forward either to admit or deny the same.  The OP for the reasons best known to them failed to file their version either admitting or denying the claim of the complainant, specially in view of the valid policies produced by the complainant for the above mentioned period of four years.  The conduct of the OP in repudiating the claim of the complainant on false and baseless grounds amounts to grave deficiency in service on their part.  The said conduct of the OP must have put the complainant to inconvenience, hardship and mental agony.  The OP is certainly liable to honour the claim of the complainant.  Apart from directing the OP to honour the claim of the complainant he shall have to be directed to pay a compensation of Rs.10,000/- for harassment and mental agony caused to the complainant as a result of deficiency in service together with litigation cost of Rs.3,000/-. 

6. The order could not be passed within the stipulated time due to heavy pendency.

7. In the result, we proceed to pass the following:

O R D E R

The complaint filed by the complainant U/s.12 of the Consumer Protection Act, 1986 is allowed in part.  The OP is directed to pay a sum of Rs.4,000/- to the complainant towards expenses incurred by him for health checkup within 30 days from the date of communication of this order.  In default OP shall pay the said amount together with interest @ 12% p.a from the date of claim till the date of realization.  Further the OP is directed to pay compensation of Rs.10,000/- to the complainant towards deficiency in service resulting in unnecessary harassment, mental agony to the complainant together with litigation cost of Rs.3,000/-.

Furnish free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Forum on this 02^nd day of February 2016)

MEMBER                           MEMBER                     PRESIDENT

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Witnesses examined on behalf of the complainant dated 31.10.2015.

1. Sri.S Sreedhar.

Documents produced by the complainant:

Witnesses examined on behalf of the Opposite party – Nil

MEMBER                            MEMBER                    PRESIDENT

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