Complainant Smt.Harbhajan Kaur and Darshan Singh vide the present complaint filed U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short The Act) for issuance of the necessary directions to the titled opposite parties to refund the amount of Rs.81,373/- alongwith interest @ 18% per annum from the date of its accrual till realization. Opposite parties be further directed to pay Rs.10,000/- as costs on account of mental and physical agony suffered by them due to their illegal, unfair trade practice, in the interest of justice.
2. The case of the complainants in brief is that complainant no.1 duly relying upon the assertions of opposite party no.3 purchased the health policy alongwith her husband i.e. complainant no.2 with a sum insured of Rs.2,00,000/- each and hence they are consumers of opposite parties. They paid the premium amount through cheque to opposite party no.3.They had been regularly renewing the health insurance policy every year and opposite party no.3 had been collecting the renewal premiums from them at their residence near Milk Plant, G.T.Road, Gurdaspur. They had given an amount of Rs.17,756.27 and Rs.12,868.47 for the renewal of the policy for the period from 23.3.2015 to 22.3.2016 to opposite party no.3 on account of insurance of complainant no.1. They have further pleaded that on 1.7.2015 the complainant no.1 was diagnosed with Dysfunctional Uterine bleeding and in order to get proper medical treatment she was admitted in Bahri Hospital, Dinanager on 9.7.2015. Her uterus was removed through operation by the Doctor and she was discharged from the hospital on 13.7.2015. She had paid an amount of Rs.29,042/- for the abovesaid treatment and this fact was duly intimated to the opposite parties. The claim was duly received by the opposite parties on 3.8.2015 and the claim qua the post treatment expenses amounting to Rs.52,331/- incurred by her was received by the opposite party on 27.10.2015. Till now the opposite parties have not appraised the complainants regarding the fate of the abovesaid claims. They made several efforts to enquire into the matter from the opposite parties but the same with malafide intention are putting of the matter with one pretext or the other. The opposite parties being in dominant position are harassing and illegal behaviour the opposite parties are causing great mental and physical agony to the complainants. Complainant no.1 had also sent a legal notice through her counsel on 28.4.2016 but the same had not given any reply. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.
3. Upon notice, the opposite parties no.1 and 2 insurer appeared through its counsel and filed its written version taking the preliminary objections that the present complaint is not maintainable and no cause of action ever arose in favour of the complainant. It was submitted that the complainant was admitted for the management of Dysfunctional Uterine bleeding and underwent Hysterectomy. Later on patient was discharged with advice. As per documents provided documents are not up to the line to process the claim so as to get more clarify a query was raised vide letter dated 14.08.2015 demanding documents i.e. 1) Biopsy report of the excised part (uterus), 2) Treating doctor’s certificate regarding duration and history of the present illness alongwith the copy of all investigation, treatment and follow up records prior to current hospitalization and 3) Treatment record post current hospitalization. The opposite party when had not received any reply then on 31.8.2015 again the same queries were raised vide letter dated 31.8.2015. Opposite parties have further submitted that since no reply was received from the complainant the opposite party was left with no other alternative but to sent the claim for investigation and verification. The opposite party duly got investigated the claim from Authentic Health Care Service Pvt.Ltd and as per investigation report the complainant herself has admitted that she is suffering from HTN since 4 years and thyroid problem since 12 years on regular medication. Therefore, based on the information received from the investigator, additional query was sent to the complainant vide letter dated 21.9.2015 stating that “We are currently processing your claim and require additional document(s) to arrive at a decision on the same. We request you to submit the following document(s):
1. All consultation, investigation, treatment and follow up records pertaining to Hypertension since first diagnosis.
2. All consultation, investigation, treatment and follow up records pertaining to Thyroid problem since first diagnosis.
3. Biopsy report of the excised part (uterus).
4. Latest Thyroid Function Test report.
5. Treating doctor’s certificate regarding duration and history of the present illness alongwith the copy of all investigation, treatment and follow up records prior to current hospitalization
6. Treatment record post current hospitalization.
Since no reply was received therefore the opposite party sent reminders to the complainant raising the same queries on 6.10.2015 and 14.10.2015. The copy of investigation report, letters dated 21.9.2015, 6.10.2015 and 14.10.2015 were attached with the file as annexure OP-6. It was next submitted that the opposite party again on 30.10.2015 received a claim for reimbursement for patient Harbhajan Kaur who got admitted in Bahri Hospital for management of Dysfunctional Uterine bleeding and underwent Hysterectomy with date of admission 9.07.2015 and date of discharge 13.07.2015 ad final claimed amount of Rs.52,331/-. The same is for Pre-Post Category. The copy of claim form dated 30.10.2015, bills, Medical lab reports and letter received from the Hospital were annexed as annexure OP-8. Since the complainant failed to provide the abovesaid documents, therefore the opposite party raised a query vide query letter 14.11.2015 stating therein that “we are currently processing your claim and require additional document(s) to arrive at a decision on the same. We request you to submit the following document(s):
1. All consultation, investigation, treatment and follow up records pertaining to Hypertension since first diagnosis.
2. All consultation investigation, treatment and follow up records pertaining to Thyroid problem since first diagnosis.
3. Biopsy report of the excised part (uterus)
4. Latest Thyroid Function Test report.
All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
4. Notice issued to the opposite party no.3 had not been received back. Case called several times but none had come present on behalf of opposite party no.3, therefore, it was proceeded against exparte vide order dated 8.9.2016.
5. Counsel for the complainant tendered into evidence affidavit of complainant Ex.C1 along with the other documents exhibited as Ex. C2 to Ex.C21 and closed the evidence.
6. Counsel for the opposite parties no.1 and 2 tendered into evidence affidavit of Deepti Rustagi working as Assistant Vice President Legal Ex.OP-1,2/1/A alongwith other documents Ex.OP-1,2/1 to Ex.OP-1,2/10 including Ex.OP-1,2/1A and closed the evidence.
7. We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for of some of the documents that have been somehow ignored to be produced by the contesting litigants. We observe that the prime dispute has prompted from the OP’s claim repudiation in response to the complainant’s two nos. of insurance claim(s) of Rs.29,042/- & Rs.52,331/- (Ex.C4 & C8) for reimbursement of the hospitalization expenses incurred by her upon her medical treatment/hospitalization first for ‘hysterectomy’ at Bahri Hospital, Gurdaspur and again for ‘CA Cervix’ (Bailiginal) at SGRD Hospital, Amritsar. Further, the OP insurers have duly admitted in the written statement & also in its affidavit (Ex.OP1,2/1) that the impugned insurance claim(s) was repudiated in terms of the related Policy since the complainant had failed to supply/submit the requisite documents requisite for settlement of the impugned claims as demanded of her repeatedly through a number of reminders etc; whereas they have duly admitted therein itself, the receipt of all documents as submitted by the complainant along with her claims. We, further find that there were no hurdling impediments in settlement of the first hysterectomy surgery claim and the delay caused by the OP insurers with its subsequent repudiation lines them up for an adverse statutory award. Somehow, the complainant has not been able to establish the submission of biopsy report along with the treating doctor’s diagnosis, treatment chart and opinion as requisitioned by the OP insurers and she is presently directed to submit the same for an expeditious settlement of her second claim for Rs.52,331/- . We also find that the complainant has admittedly provided all the requisite information as desired in the claim formats and the information(s) sought by the OP insurers and the same were already available with them (vide the related proposal form(s) etc) and otherwise also vide the documents accompanying the impugned insurance claims and its enclosures etc.
8. The OP insurers have somehow not produced the proposal/subsequent renewal forms and these should also contain more information etc. To sum it up all, the OP insurers have failed to produce any cogent evidence to support the above grounds/basis of repudiation and in its absence these shall amount to ‘bald’ statements, only. It is also not proved on record that the complainant and/or the patient did conceal any pre-existing ailment at the time of purchase of the Health Policy. Thus, the OP insurers’ impugned repudiation of the insurance claim does not entail legality under the applicable law and need be set-aside.
9. In the light of the all above, we partly allow the present complaint and thus ORDER the OP insurers to settle and pay the impugned insurance med-claim(s) with full Hospitalization and Other Benefits etc as applicable under the related Policy to the complainant besides Rs.5,000/- as compensation (for the harassment inflicted) and another Rs.3,000/- as cost (of litigation) within 30 days of the receipt of the copy of these orders otherwise the aggregate awarded amount shall attract interest @ 9% PA from the date of the orders till actual payment.
10. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to records.
(Naveen Puri)
President
Announced: (Jagdeep Kaur)
May 08, 2017 Member
*MK*
