PER SHRI. S. G. CHABUKSWAR – HON’BLE MEMBER
1) By this complaint the Complainant has claimed the reliefs of recovery of Rs.39,439/- medical expenditure with interest @ 18% p.a., Rs.25,000/- compensation for mental torture and Rs.40,000/- cost of litigation.
2) The case of the Complainant is that, Opposite Party issued to the Complainant Medical Policy bearing No.250800/48/8500009828. The Opposite Party collected from her the premium but did not give any information and education about various terms, conditions and procedure of the Insurance Policy. According to the Complainant, she had an accidental fall and her left wrist was fractured. She was admitted in the Hospital of Dr. Bhende on 09/02/2010. She was discharged on 10/02/2010. The Complainant informed to the Opposite Party about the accidental fall, need for hospitalization and requested for a claim form by the letter on 10/02/2010. The Complainant again informed to the Opposite Party that her treatment is still going on and hence, claim will be filed after treatment is finished by the letters dtd.09/03/2010, 07/03/2011. The Complainant informed to the Opposite Party by the letter dtd.25/04/2011 that she was under the treatment of the Doctor till the end of March, 2011. She had given the details of medical expenses incurred by her till 31/03/2011 in the said letter. She had claimed Rs.39,439.47. The Complainant informed to Opposite Party by the letter dtd.07/07/2011 that no communication has been received by her. On 14/07/2011 the Opposite Party repudiated the claim of the Complainant on the ground that the papers were not submitted within 30 days from the completion of Hospital treatment and there was delay of 416 days. The Complainant through her advocate issued letters to the Opposite Party and demanded the claim amount on 21/10/2011 and 06/02/2012 but in vain. The Opposite Party adopted the unfair trade practice and there is deficiency of service. Hence, this complaint for the reliefs as mentioned in above para no.1.
3) The Opposite Party has resisted the claim by filing written statement on 04/12/2012. The contention of Opposite Party is that Complainant was admitted in the Hospital on 09/02/010 and was discharged on 10/02/2010. The claim was submitted on 29/04/2011 after more than one year. There was inordinate delay of 416 days in submitting the claim. The certificate issued by Dr. Bhende/Laud’s Clinic is undated and it clearly shows that the Complainant was admitted for one day only. Then the Complainant was given a fitness certificate for joining duties from 04/09/2010 and she would be reviewed only SOS weeks/months. SOS clearly means “only if necessary” and that there was no continuous treatment till March, 2011 as claimed. The last receipt of Dr. Laud’s Clinic is also dated.04/09/2010. It clearly shows that treatment was completed on 04/09/2010. There is no medical proof or documentary evidence about continued treatment.
4) The further contention of Opposite Party is that the claim of the Complainant has already been repudiated by giving reasons and applying mind and following proper procedure. The cause of action first arose on 9th/10th Feb., 2010 and complaint is filed on 11/06/2012. The complaint is filed after the expiry of period of limitation as prescribed under the Consumer Protection Act. The Complainant has not filed application for condonation of delay. The complaint is barred by law of limitation. The Complainant is trying to gain a profit and make a windfall. The Insurance is only a compensation for genuine loss and is not a profit making instrument. The Opposite Party has denied that there is deficiency of service and unfair trade practice on its part. The Opposite Party has denied all rival contention of the Complainant and prayed for dismissal of complaint.
5) The Complainant alongwith complaint submitted documents at Exh.A, B, C & D. The Opposite Party has submitted documents alongwith written statement. The Complainant has submitted her affidavit of evidence on 03/08/2013. The Opposite Party has filed written argument on 05/04/2013 and Complainant has filed on 13/04/2014. We heard Shri. Sureshchandra N. Chataule, Ld.Advocate for the Complainant and Smt. Bhakti Barve, Ld. Advocate for the Opposite Party. Following points arise for our determination and our findings thereon are noted against each of them for the reasons given below -
Points Findings
1. Whether the complaint is within limitation ? Affirmative.
2. Does the Complainant prove that there is deficiency
of service and unfair trade practice on the part of
Opposite Party ? Affirmative.
3. Whether Complainant is entitled to the reliefs as Rs.39,439/-medical
Claimed ? expenditure, Rs.3,000/- mental
agony & cost Rs.2,000/-
4. What order ? As per final order.
Reasons :-
6) Point Nos.1: The contention of the Opposite Party is that, the cause of action first arose on 9th/10th Feb., 2010 and as the complaint is filed on 11/07/2012 beyond the period of two years the complaint is barred by limitation. This being legal objection we have taken this point for consideration first. It is an admitted that the Opposite Party has repudiated the claim of Complainant on 14/07/2011. The complaint is filed within two years from the date of repudiation letter i.e. on 11/07/2012. In view of recent decisions in various cases of the Hon’ble National Commission & State Commission, such as in the case of Laxmibai & Ors. V/s. ICICI Lombard General Insurance Co. Ltd. III (2011) CPJ 5017 (NC) wherein the Hon’ble National Commission by considering the decision of the Hon’ble Supreme Court of India in Kandimalla Raghavaiah and Co. V/s. National Insurance Co. Ltd., reported in III (2009) CPJ 175 (SC) and by considering the observations of the Hon’ble Supreme court in the case of State Bank of India V/s. B.S. Agricultural Industries, II (2009) CPJ 29 held that in a case where the claim is rejected by the Respondent/Insurance Company, the cause of action arises again from the date of such rejection. We therefore, find that considering the letter of repudiation of claim issued by the Opposite Party dtd.14/07/2011 the present complaint is filed within time the point no.1 is answered in the affirmative.
7) Point Nos.2 & 3: Admittedly the Complainant obtained Mediclaim Policy bearing No.250800/48/8500009828. The Complainant was admitted in the Hospital of Dr. Bhende due to the fracture of her left wrist on 09/02/2010. She was discharged from the hospital on 10/02/2010. On 14/07/211 Opposite Party has repudiated the claim of the Complainant on the ground that there was delay of 416 days in submission of the claim. According to the Opposite Party the claim was to be submitted by the Complainant within 30 days from the date of discharge i.e. 10/02/2010. The evidence and documents filed by the Complainant shows that she had approached to Shushrusha, Citizen Co-operative Hospital Ltd., Dadar Mumbai for various tests on 08/02/2010. She was admitted in Laud Clinic of Dr. Harish Bhende for treatment on 09/02/2010. She was discharged from the Hospital on 10/02/2010. Dr. Bhende issued medical certificate showing therein the dates of operation and discharge. He has not only mentioned the date on which he issued the certificate. However, the copy of discharge card is on record. The dates of admission and discharge are mentioned in the discharge card and medical certificate.
8) On 10/02/2010 the Complainant issued letter Exh.C to the Opposite Party and requested for sending the claim form. On 09/03/2010 the Complainant send letter to the Opposite Party and informed that she is still under the treatment and hence, claim cannot be filed within 30 days. The entire claim shall be filed after the total treatment is completed as per the opinion of Dr. Harish Bhende. The Opposite Party did not send claim form to the Complainant till 06/03/2011. On 07/03/2011 the Complainant issued letter to the Opposite Party and informed that as she did not receive the claim form she is presenting claim regarding the amount expended by her till 07/03/2011. The Complainant had further informed to the Opposite Party that Dr. Harish Bhende advised her for continues treatment till the end of March, 2011. On 25/04/2011 the Complainant again sent a letter to the Opposite Party and informed that she did not receive the claim form hence, she is presenting the claim of the amount of medical expenses made by her till 31/03/2011 and she was under treatment of Dr. Bhende till 31/03/2011. The Complainant has produced the bill issued by Dr. Bhende on 10/02/2010 vide Exh.D. The said bill is of Rs.28,310/-. The Complainant has given the statement of details of bills of medicines, x-ray and treatment. As per the said statement the Complainant has made expenditure on the medical treatment Rs.39,439.47 by the end of 10/02/2011. The Complainant has claimed the said amount towards the medical expenditure. The Complainant has submitted the receipts issued by Dr. Harish Bhende, Shushrusha Citizen’s Co-operative Hospital Ltd., Dadar, Mumbai and receipts of various medical stores of the medicine purchased by her till 10/02/2011 in support of the details mentioned in the statement.
9) Smt. Bhakti Barve, Ld.Advocate for the Opposite Party has argued that Dr. Harish Bhende had given to the Complainant fitness certificate for joining duties from 04/09/2010 and that she would be reviewed only SOS weeks. SOS means only if necessary. The treatment of Complainant and follow up was completed on 04/09/2010. However, on going through the medical certificate it is clear that Dr. Harish Bhende advised the Complainant for normal/light duty from 04/09/2010. As per statement of expenditure Dr, Bhende advised the Complainant for x-ray on 04/09/2010. Accordingly she made expenditure of Rs.408/- on x-ray and follow-up fees Rs.65/- on 04/09/2010. Thereafter, the Complainant purchased the medicine from Worli Medical Stores & Rakhangi’s Medical Stores total Rs.1,594/- on different five dates till 10/02/2011. The Complainant has purchased the above medicine as per the advice of Dr. Bhende. The above evidence shows that the Complainant was under treatment by the end of March, 2011 and she made expenditure on treatment Rs.39,439/-.
10) The Opposite Party did not provide the claim form to the Complainant though she had made demand of it in writing. Lastly she herself presented the claim by the letter to the Opposite Party on 25/04/2011. Hence, it cannot be said that there is delay in submitting the claim on the part of the Complainant. Not only this but the Complainant has conveyed to the Opposite Party by the letters from time to time that she is under the treatment of Dr. Harish Bhende and he advised her for continuous treatment by the end of March, 2011. In view of this it cannot be said that there is delay in submitting the claim on the part of the Complainant. It appears that the Opposite Party has repudiated the claim of the Complainant only on technical ground which cannot be held as just and proper ground. From the above evidence and discussion we hold that, the Opposite Party has adopted unfair trade practice and there is deficiency of service. The claim made by the Complainant is being genuine she is entitled to medical expenses of Rs.39,439/- from the Opposite Party with interest @ 6% p.a. from the date of repudiation of claim i.e. 14/07/2011 till it’s realization and Rs.3,000/- as compensation towards the mental harassment. Considering the nature of complaint it is just to grant her cost of complaint Rs.2,000/-. Hence, point no.2 & 3 are answered in the affirmative.
In the result complaint deserves to be allowed with cost. Hence, we proceed to pass following order -
O R D E R
i. Complaint No.137/2012 is allowed with cost against Opposite Party.
ii. Opposite Party is directed to pay to the Complainant Rs.39,439/- (Rs.Thirty Nine Thousand Four Hundred Thirty Nine Only)
towards the medical expenditure with interest @ 6% p.a. from 14/07/2011 till the realization of the said amount.
iii. Opposite Party is directed to pay to the Complainant Rs.3,000/-(Rs.Three Thousand Only) towards compensation for mental
harassment caused to her.
iv. Opposite Party is directed to pay to the Complainant Rs.2,000/- (Rs.Two Thousand Only) towards the cost of this complaint.
v. Opposite Party is directed to pay the amount mentioned in above para Nos. ii, iii & iv to the Complainant within 45 days from the
date of service of this order.
vi. Certified copies of this order be furnished to the parties.
