By. Smt. Renimol Mathew, Member:-
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get the benefit of his medi claim policy.
2. Brief of the complaint:- The complainant is the policy holder of opposite party's Family Medicare Policy. Policy Number is 101602/48/11/06/00001378. The period of insurance is from 20.09.2012 to 19.09.2013, complainant and his daughter admitted and treated during the policy period and the complainant submitted 3 claim form to opposite party No.1 then complainant received 3 deficiency letter from opposite party No.2. As per the deficiency letter dated 30.03.2012 and 29.10.2012 complainant submitted the required details before opposite party No.1's office at Sulthan Bathery. Thereafter several occasions complainant approached opposite party No.1 to get the benefit of his policy. But complainant could not avail the benefit of his medi claim policy till the date of this complaint. Hence filed this complaint.
3. Notice served to opposite party and they filed version. In the version they stated that there is no deficiency of service from the part of them. Opposite party admitted that they have received the claim of the treatment of complainant and his daughter Darsana during the period of 19.02.2012 to 22.02.2012 and 19.02.2012 to 24.02.2012 and 10.08.2012 to 13.08.2012, but the complainant not submitted the claim form and intimation in time, and not produced the relevant records required by TPA. As per policy condition the policy holders has to submit the intimation to TPA/Insurance company within 24 hours of hospitalization. In this case the complainant was not complied the condition. Since there was delay the TPA sought the reason from the insured which was not received even after the reminder on 16.04.2012 hence finally the claim was closed in the system on 16.05.2012. In claim No.1985954 of the complainant the TPA was asked to produce the X ray and Chest Report. Though the TPA sent reminder on 21.04.2012 the complainant did not produce the document to process the claim. Hence the claim of the complainant was closed on 16.05.2012. In claim No.2090471 with respect to the daughter of the complainant ie Darsana for the treatment from 10.08.2012 to 13.08.2012 for Acute Bronchitis the claim from the insured was received only on 07.09.2012. As per policy condition the insured has to submit the claim form and documents to TPA/Insurance company within 15 days of discharge from the hospital. Since the complainant failed to comply this requirement the reason was sought from the insured which was not received even after the reminder on 08.10.2012 hence finally the claim was closed in the system on 10.12.2012. Therefore there is no deficiency of service on the part of the opposite party. The complainant has failed to perform his part in time as per the policy condition.
4. On considering the complaint, version and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite party?
2. Relief and Cost.
5. Point No.1:- Complainant filed proof affidavit and examined as PW1, Ext.A1 to A3 and Ext.X1 series are marked. Opposite party also filed affidavit and examined as OPW1 and Ext.B1 to B4 documents are marked. On perusal of documents Forum find that while processing the claim TPA found certain defects and sent 3 deficiency letters to the complainant asking for the reasons for the delay in submitting the intimation of hospitalization and full set of original documents which are required to reach the conclusion regarding the admissibility amount as per the policy. But complainant at the time of cross-examination stated that he had submitted the required records before the opposite party's branch office at Sulthan Bathery. But in this case the only dispute is regarding the requirements mentioned in the deficiency letter(Ext.B1 to B4). But in the complaint, complainant submitted that he had submitted the required details to the opposite party's branch office at Sulthan Bathery much earlier than this complaint. Hence we opine that there is deficiency of service from the part of opposite party.
6. Point No.2:- Point No.1 is found in favour of the complainant,hence the complainant is entitled to get the claim amount with cost and compensation. The Point No.2 is decided accordingly.
In the result, the complaint is partly allowed and the opposite party is directed to pay the bill amount of Rs.8,497/- (Rupees Eight Thousand Four Hundred and Ninety Seven) only to the complainant and also directed to pay Rs.5,000/- (Rupees Five Thousand) only as cost and compensation to the complainant. This order must be complied by the opposite party within 30 days from the date of receipt of this Order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 31st day of March 2015.
Date of Filing: 11.03.2014. PRESIDENT :Sd/- MEMBER :Sd/- MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. P. K. Balan. Complainant.
Witness for the Opposite Party:-
OPW1. Sajeevan. Branch Manager, United India Insurance
Company, Sulthan Bathery Branch.
Exhibits for the complainant:
A1. Family Medicare Policy document.
A2. Reminder Deficiency Letter. dt:29.10.2012.
A3. Deficiency Letter. dt:30.03.2012.
Exhibits for the opposite party:-
B1. Copy of Deficiency Letter. dt:30.03.2012.
B2. Copy of Deficiency Letter. dt:26.03.2012.
B3. Deficiency Letter. dt:08.10.2012.
B4. Reminder Deficiency Letter. dt:29.10.2012.
X1(Series). Documents produced by opposite parties (79 Pages).
Sd/-
PRESIDENT, CDRF, WAYANAD.
a/-
