Complainant Arvind Gupta through the present complaint U/S 12 of the Consumer Protection Act 1986 (hereinafter for short the Act) has prayed for the issuance of the necessary directions to the opposite parties to pay Rs.2,78,302/- the remaining claim amount alongwith up to date interest thereon @ 18% PA till entire realization of the amount in addition to Rs.50,000/- on account of harassment and mental agony caused by the opposite parties to him, in the interest of justice.

2.       The case of the complainant in brief is that he is father of Arnav Gupta. He got his son Arnav Gupta insured under a Health Insurance Policy Nos. 4034i/EPP/75338232/00/000 for the period of 19.11.2012 to 18.11.2013 and policy no.4113i/XOL/75338141/00/000 for the period of 22.11.2012 to 21.11.2013.  At the time of taking the policies, the insured Arnav Gupta was minor and the amount of premium in respect of the policies was paid by him to the opposite parties and as such he is consumer of the opposite parties. Arnav Gupta has now attained the age of majority, but he is unemployed and is not earning anything. He has further pleaded that unfortunately his son namely Arnav Gupta fell ill and got treatment from PGIMER, Chandigarh for three times i.e. 22.10.2012 to 2.11.2012, 17.11.2012 to 4.12.2012 and 18.3.2013 to 31.3.2013. He spent Rs.3,18,655/- on the treatment of his son in total and his son is still under treatment and is lying on bed at home. After the discharge of Arnav Gupta from the hospital he claimed the above referred amount from the opposite parties vide claim No.229199228101 vide claim form in the sum of Rs.73,152/- claim form in the sum of Rs.2,19,735/- and claim form in the sum of Rs.25,768/- alongwith all the requisite formalities as he had purchased the Health policy from the opposite parties but the opposite parties unilaterally sanctioned the amount of Rs.25,768/- and quoted an amount of Rs.17,000/- itself as requested amount and thus paid only Rs.40,353/- through cheque No.060645 dated 21.6.2013 which was got encashed by him. No such request for sanctioning amount of Rs.17,000/- was made by him and even the claim settled by the opposite parties in sum of Rs.40,353/- is also highly inadequate and unreasonable whereas he in all spent Rs.3,18,665/- and even submitted all the bills for the same. He requested the opposite parties a number of times to settle the remaining claim amount which comes to Rs.2,78,302/- but the opposite parties have been lingering on the matter on one or the other pretext without any cogent or reasonable cause.  A legal notice dated 24.11.2014 through his counsel was sent to the opposite parties calling upon them to settle the claim but of no use. Hence this complaint.

3.       Upon notice, the opposite parties appeared and filed their joint reply through their counsel taking the preliminary objections that the complainant has no cause of action and locus standi to file the present complaint; the complaint of the complainant is vague. The complainant has not disclosed all the relevant facts. The complainant himself alleging that his son remained in Hospital many times, but the Claim no. of the claims file has not been given in the petition and the petition is very confusing one and it is not possible to reply all the facts properly and as such the complaint is liable to be dismissed; the insurance company checked their record and as per their record two claims remained unpaid and has been closed by the Insurance Company due to the fault of the complainant as the complainant failed to fulfill the requisite formalities. The complaint regarding those claims is premature. The claim no.220100228170 has been registered regarding admission in Hospital, in which date of Admission is 22 October, 2012 and date of discharge is 2 November 2012 and the amount of Rs.73,152/- has been claimed and the diagnosis is regarding chronic renal failure, but the relevant documents i.e. duly filled ICICI Lombard claim Form, original discharge summary alongwith detailed course of hospitalization during the admission with regard to present complaints, investigation reports in original for the tests and other reports has not been submitted. The letters have been sent to the complainant in which the demand has been made regarding the said documents. The letter dated 15 May, 2013 has been sent in which the request has been made to provide the abovesaid documents, but no such documents has been provided After that again the letter dated 20 June, 2013 as final reminder has been sent and claim has been closed as no documents have been received. In the same way one another claim having no.220100228174 in which the date of admission is 17 November, 2012 to 4 December, 2012 has been registered in which amount of Rs.1,91,075/- has been claimed, but in this claim also the duly filled ICICI Lombard Claim Form, discharge summary and investigation in original has not been provided to the Insurance Company. The letters dated 15 May, 2013 and 20 June, 2013 has been sent in this regard and the claim has been closed as the complainant failed to provide the said documents, so the complaint is premature and is liable to be dismissed on this ground and the complaint of the complainant is not within limitation and even otherwise if the Ld.Forum comes to the conclusion that there is any liability of the insurance company then in that case, it is only when the complainant will complete the requisite formalities and that too after going through the documents and as per terms and conditions of the policy. On merits, it was submitted that the liability if any of the insurance company as per survey report. The claims have been duly paid as per terms and conditions of the policy and the detail of every amount has already been sent to the complainant. All other pleadings made in the complaint have been denied and lastly the complaint has been prayed to be dismissed.

4.      Complainant tendered into evidence his own affidavit Ex.C1, alongwith other documents Ex.C2 to Ex.C105 and closed the evidence.

5.       Counsel for the opposite parties tendered into evidence affidavit of Meena Sharma authorized signatory Ex.OP1, alongwith other documents Ex.OP2 to Ex.OP6 and closed the evidence.

6.       We observe with the judicial precision  that the OP insurers have in fact settled (vide Ex.C8) only one claim (Ex.C6) out of the 3 nos. of ‘claims’ whereas the other two claims Ex.C4 & Ex.C5 as filed by the complainant pertaining to the member’s (Master Arnav) hospitalization at PGIMR, Chandigarh; (for the different periods as duly mentioned in the complaint)] could not be settled for want of the supporting documents as detailed out in the requisition letters ExOP5 & ExOP6 alleged to have been dispatched (to the complainant) with however ‘no-proof’ of ‘Receipt’ (not even of ‘dispatch’) produced on the records of the complaint proceedings. Further, the OP insurers have addressed the present complaint as ‘premature’ in the absence of final ‘repudiation’ at their end and have also expressed their inclination to ‘settle’ the pending two claims ‘on merits’ in terms of the related ‘Policy’ provided the ‘requisitioned’ supporting documents are made available to them (by the complainant). We find this ‘gesture’ of the OP insurers as ‘consumer-friendly’ & their ‘requisition’ of documents as ‘just & genuine’ and are thus inclined to ‘order’ accordingly without digging deep into the technical merits/ demerits of the dispute.

7.       In the light of the all above, we are of the considered opinion that the present complaint shall be best disposed of by directing the OP insurers to finally requisition a bare minimum number of documents (just requisite to settle the two pending claims) from the complainant and settle the claim on merits  strictly in terms of the related policies in accordance with the IRDA guidelines on ‘settlement of claims’ within 30 days of receipt of the so-requisitioned documents from the complainant who shall also provide an active and expeditious cooperation, in his own interest.       

8.       Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

   (Naveen Puri)

                                                                       President     

ANNOUNCED:                                     (Jagdeep Kaur)

April 21, 2016.                                                  Member.

*MK*