Complaints filed on: 06-08-2021
Disposed on: 25-01-2023
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, TUMAKURU
DATED THIS THE 25th DAY OF JANUARY 2023
PRESENT
SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT
SRI.KUMARA.N, B.Sc. (Agri), LL.B., MBA., MEMBER
SMT.NIVEDITA RAVISH, B.A., LLB.(Spl)., LADY MEMBER
CC.No.63/2021
Sathish P.S. S/o Late Siddananjappa
Aged about 41 years,
R/o Pinnenahalli Village,
Chelur Hobli, Gubbi Taluk,
Tumakuru District.
……….Complainant
(By Sri. A.S.Chandrashekaraiah, Advocate)
V/s
The Manager,
Cholamandalam MS General Insurance
Co., Ltd., Dare House, 2, NSC Bose Road,
Parrys, Chennai, Tamilnadu State-600 001.
……….Opposite Party
(OP Sri. N.V.Naveen Kumar, Advocate)
:ORDER:
BY SMT.G.T.VIJAYALAKSHMI, PRESIDENT
This complaint has been filed by the complainant against the OP U/s 35 of the Consumer Protection Act 2019 with a prayer to direct the OP/Insurance Company to settle the claim for Rs.76,810/- along with Rs.25,000/- towards cost.
2. The brief facts of the complaint are as under:-
The complainant has borrowed loan for construction of residential house situated at Pinnenahalli Village, Chelur Hobli, Gubbi Taluk, Tumkur District vide loan account No.HL05TMA000014640 from the OP on 31.07.2020 and while borrowing the said loan the OP has also collected premium of Rs.4,886/- towards the health insurance valid from 03.08.2020 upto 02.08.2021 undertaking to provide the expenditure with respect to the health of the complainant and issued the policy in favour of the complainant and also issued health card bearing membership No.A6115557A. It is further case of the complainant that on 30.08.2020 at about 10.30 AM the complainant while working in front of his house at Pinnenahalli Village, he fall and sustained left side segmental radius fracture and ulna mid shaft fracture”, immediately after the incident, he took NATI treatment and thereafter he got admitted to Hemavathi Hospital, Tumakuru for treatment, wherein the complainant admitted as an inpatient from 12.09.2020 to 15.09.2020, wherein the duty doctor has operated ORIF with 12 holed DCP for radius and 7 holed DCP for ulna done under BB on 13.09.2020, then he discharged from the said hospital with an advice for follow up treatment and even today he has been taking treatment from the above hospital as inpatient and also outpatient and thereby spent Rs.76,810/- towards medical and other circumstantial expenses.
It is further case of the complainant that as per the policy issued by the OP, the OP has bear the above said expenses and in that regard he has given requisition to the OP for claiming the above said medical expenses within time and the same has been registered in claim No.2876026489 and the complainant has furnished all the documents as requested by the OP. It is further submitted that as suggested by the OP, the complainant has produced all the documents, but on 01.02.2021, the OP has issued health claim repudiation letter stating that “deficiency of documents requested are not submitted by the complainant/insure and hence the claim is closed” and thereby declined to settle the claim. Hence, without any alternative, the complainant has filed this complaint.
3. On receipt of notice by this Commission, the OP appeared through their counsel and filed their version and admitted the health policy issued by them to the complainant subject to the terms and conditions, exceptions and limitations thereof and the confirmations of compliance of section 64VB of the Insurance Act, 1938. The OP contended that the complaint filed by the complainant is not maintainable either in law or on facts. It is further contended that after receipt of the claim from the complainant, the OP has registered the claim and immediately sought for the documents to process the claim, but the complainant was failed to provide the required documents and in this regard, the OP has issued health claim query letter on 05.12.2020, 21.12.2020 and on 06.01.2021 a health claim query reminder cum closure letter was sent to the complainant seeking the documents mentioned in the letter and the said letter were served personally on the complainant and the documents sought in the said letter is as under:
“Pre and post surgical x-ray film and report supporting the diagnosis, letter from treating doctor regarding the details of incident leading to injury including time, date, place condition (under influence of any substance) of patient at the time of incident along with a copy of MLC if any for further processing of the claim.
But the complainant did not come forward to produce the said documents.
The OP further contended that on scrutiny of the claim documents submitted, the claim is not admissible for the following reasons;
“Query response/deficiency documents requested are not submitted by the insured in spite of several reminders, hence the claim is closed.
It is further contended that the OP has rightly repudiated/close the claim for want of sufficient documents and there was no deficiency of service committed by the OP in rejecting the same. It is clear case of breach of policy terms and conditions by the complainant in not providing the sufficient documents to process the claim. Hence, on these among other grounds, it is prayed to dismiss the complaint.
4. The complainant has filed his affidavit evidence along with list of documents and marked the same as Ex.P1 to P11. Sri. Sagar .G.L., Assistant Manager – TP Claims, of OP has filed his affidavit evidence on behalf of OP and produced some copies of documents.
5. We have heard the arguments from both side counsels.
6. On perusal of pleadings and documents produced by both parties, the points that would arise for our consideration are:
1) Whether there is any deficiency in service on the part of OP?
2) Whether complainant is entitled for reliefs sought for?
7. Our findings to the aforesaid points are as under:
Point No.1: In the affirmative
Point No.2: As per the final order
:REASONS:
8. On perusal of pleadings, evidence and documents submitted by the parties, it is seen that the complainant has borrowed loan for construction of residential house vide loan A/c No.HL05TMA000014640 from the OP on 31.07.2020 and while borrowing the said loan, the OP has collected premium of Rs.4,886/- towards health insurance and it is valid from 30.08.2020 to 02.08.2021. It is an admitted fact that the OP issued policy and health card bearing membership No.A6115557A to provide the expenditure with respect to the health of the complainant.
9. It is also an admitted fact that on 30.08.2020 at 10.30 AM, the complainant in front of his house fell down and sustained factures. After the incident, he took NATI TREATMENT and thereafter he got admitted to Hemavathi Hospital, Tumakuru for treatment as an inpatient from 12.09.2020 to 15.09.2020 and discharged. Totally the complainant has spent Rs.76,810/- towards medial and circumstantial expenses and given requisition to the OP to claim the above medical expenses. The complainant also submitted all required documents with claim form to the OP.
10. Now, the main allegation of the complainant is that, in spite of submission of documents as requested by the OP, the OP has issued health claim repudiation letter on 01.02.2021 stating that “deficiency of documents requested are not submitted by the complainant/insure and hence the claim is closed” and thereby declined to settle the claim”.
11. The OP contended that, after receipt of the claim from the complainant, the OP has registered the claim and immediately sought for the documents to process the claim, but the complainant was failed to provide the required documents and in this regard, the OP has issued health claim query letter on 05.12.2020, 21.12.2020 and on 06.01.2021 a health claim query reminder cum closure letter was sent to the complainant seeking the documents mentioned in the letter and the said letter were served personally on the complainant and the documents sought in the said letter is as under:
“Pre and post surgical x-ray film and report supporting the diagnosis, letter from treating doctor regarding the details of incident leading to injury including time, date, place condition (under influence of any substance) of patient at the time of incident along with a copy of MLC if any for further processing of the claim.
But the complainant did not come forward to produce the said documents. Hence, repudiated the claim.
12. In view of the above admitted facts and contentions and on perusal of exhibits, it is seen that the complainant submitted the documents relating to his treatment, it includes discharge summary of the Hemavathi Hospital, x-ray reports and medical bills. When these exhibits clearly contains the information sought by the OP. Hence, there is no need to submit the documents as sought by the OP i.e. x-ray, treating doctor letter, incident time and date, etc. Therefore, in spite of submission of all necessary documents relating to treatment, the claim closed by the OP amounts to deficiency in service on the part of OP. Hence, OP is liable to settle the claim of the complainant. For the act of the OP, the complainant compelled to approach this Commission and thereby caused mental agony. For that, the OP is liable to pay Rs.15,000/- as compensation and Rs.10,000/- as litigation expenses. Accordingly, we pass the following:-
:ORDER:
The complaint is allowed.
The OP is directed to pay Rs.76,810/- to the complainant with interest @ 8% PA from the date of repudiation of the claim i.e. 01.02.2021 to till realization .
The OP is further directed to pay Rs.15,000/- as compensation and Rs.10,000/- as litigation expenses.
The OP is directed to comply the above order within 45 days from the date of receipt/knowledge of this order.
Supply free copy of this order to both parties
