DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the 18^th day of March, 2024.

Present      :   Sri. Vinay Menon V., President

                    :   Smt. Vidya A., Member                      

                      :  Sri. Krishnankutty N.K., Member                                      Date of Filing: 15/07/2022    

              CC/130/2022

1. Lakshmi Kalyanaraman,

W/o. Late Kalyanaraman,

413, Kashyapa, Archana Colony,

Akathethara, Palakkad  

2. Vinod Venkiteswaran,

S/o. Late Kalyanaraman,

413, Kashyapa, Archana Colony,

Akathethara, Palakkad                                          -           Complainants

(By Adv.  K.K. Thankappan)

                                                                                                  Vs

1. The Divisional Manager,

New India Assurance Company Ltd.

P.B.No.513, Kollanur Building,

Palace Road, Thrissur – 680 020

2. Medi Asst. India TPA Pvt.Ltd.,

       4^th Floor, Chickagao Plaza,

      Rajai Road, Cochin – 682 035                                -           Opposite parties  

(O.P.s by Adv. T.P.George)             

O R D E R

By Sri. Vinay Menon V., President

1. Undisputed pleadings are that one late Kalyanaraman was the beneficiary of a Mediclaim Policy floated by OP1 during 1/8/2016 to 31/7/2017. He underwent treatment in many hospitals and died on 10/1/2017. Claim was filed belatedly during January, 2020 by the complainants, who are the legal heirs of the deceased. 

Here the pleadings fork and the complainants plead that the delay was condoned by OP1 and OP1 contend that there was undue delay on the part of the complainants, preventing the O.P.s from verifying the veracity of the claim.  In view of the undue delay the claim was repudiated based on the terms and conditions of the policy document.  It is aggrieved by this repudiation that this complaint is filed.

2.  The following issues arise for consideration 

1. Whether the claim was filed by complainant within the stipulated period ?
2. Whether the complainant had submitted original bills and other necessary documents for processing the claim?
3. Whether the lapses on the part of complainant, if any, are material and vital, so as to reject the claim?
4. Whether the rejection of claim by OP amounts to deficiency in service?
5.  Whether the complainant is entitled to the reliefs sought for?

6.         Any other reliefs?   

3.          (i)      Complainants’ evidence comprised of proof affidavit and Exhibits A1 to A8.    

(ii)      OP1 filed proof affidavit. Ext. B1 was marked.  

            Issue Nos.1 & 3

4.         Undisputed case of the parties is that the beneficiary under the insurance policy died on 10/1/2017. A claim was filed on 16/1/2020. As per complainants, they were advised to produced all documents on 17/2/2020. Thereafter after two years the complainants again approached the 2^nd OP on 16/5/2022. On 19/5/2022, the 1^st OP informed the complainants that the policy was in a lapsed condition and hence the claim could not be entertained. 

5.         The 1^st OP in their version contended that there was inordinate delay in informing the 1^st OP regarding the factum of death of the beneficiary under the policy and therefore there was violation in  clause 5.5 of the terms and conditions under which the policy was issued.   In order to substantiate their contentions, the 1^st OP had marked Ext.B1 in evidence. Ext.B1 is the terms and conditions along with the schedule of policy issued to the deceased Kalayanaraman. Clause 5.5 of Ext.B1 is as follows:

            “5.5:  NOTICE OF CLAIM:        

            If You intend to make any claim under this Policy You must :

1. Intimate TPA in writing on detection of any Disease/Injury being suffered immediately or forty  eight  hours before Hospitalization.
2. In case of hospitalization due to medical emergency, intimate TPA within twenty four hours from the time of hospitalization.
3. Submit following supporting documents TPA / Policy issuing office (as the case may be) relating to the claim within 7 days from the date of discharge from the Hospital:” 

[ Rest of the Clause are not reproduced herein].

  6.       death occurred on 10/1/2017. It is to be noted that any attempt to inform the 1^st OP with regard to the treatment or death was made only after nearly three years of the death.  Cause for delay is that the complainants were under acute mental stress and suffering for nearly three years. The said intimation was made as per Ext.A6. Any further attempts after 16/1/2020 is see made only on 23/5/2022, i.e. by issuance of Ext.A1.

7.         Complainants have failed to prove that such acute mental stress and suffering was acute enough to debilitate them from carrying out their obligations under the terms and conditions governing the relation with the O.P.s.  Thus, we find that there is inordinate delay violating the policy terms and conditions.

8.         We hold that a delay of three years and thereafter two years in following up the already delayed claim are vital and hits at the crux of a valid contract wherein time is of utmost importance and the essence of contract.

            Issue No.2

9.         In view of the findings in issue Nos.1 & 3 we hold that this issue need not be discussed.  

            Issue Nos. 4,5 & 6  

10.       As already stated, repudiation of the claim was made in view of the inordinate delay on the part of complainants and violation of terms and conditions stipulated under clause 5.5 of Ext.B1 policy. Therefore, we hold that there is no deficiency in service on the part of OPs.

11.       Complainants are not entitled to any of the reliefs sought for.

12.       In the facts and circumstances of the case, parties are directed to bear their respective costs.

13.       With the aforesaid directions, this complaint is dismissed.

                        Pronounced in open court on this the 18^th day of March,   2024.    

                             Sd/-                                                                                                                             

                                                                                                                                                  Vinay Menon V

                                                                                   President

                                                                                         Sd/-

                          Vidya.A

                                              Member         

                               Sd/-

                Krishnankutty N.K.

                                                                                                                                                   Member    

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1    -  Copy of lawyers notice dated 23/5/2022

Ext.A2   –  Original postal notices (2 notices)

Ext.A3   -   Original postal acknowledgment from OP1     

Ext.A4   -   Original postal acknowledgment from OP2     

Ext.A5   –  Original  of lawyers notice dated 10/6/2022

Ext. A6  –  Copy of representation dated 16/1/2020

Ext.A7  -    Copy of policy schedule  

Ext.A8 –    Copy of collection receipt cum adjustment voucher

Exhibits marked on the side of the opposite parties:

Ext.B1 –  Copy of Policy schedule and terms and conditions.  

Court Exhibit:  Nil

Third party documents:  Nil

 Witness examined on the side of the complainant : Nil

Witness examined on the side of the opposite parties:   Nil

Court Witness: Nil

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.