Order dictated by:
(Sh.Anoop Sharma, Presiding Member)
The complainant has filed the present complaint under section 11 & 12 of the Consumer Protection Act on the allegations that the complainant obtained mediclaim policy from the Opposite Party vide policy No. 36050034162800000006 for himself and his wife Sonia and daughter Bhumi valid from 7.4.2016 to 6.4.2017 for total sum insured Rs.3 lacs and paid the valid premium of Rs.4283/-. Under the said policy, the complainant, his wife Sonia and his daughter Bhumi are duly insured and covered. However, during the currency period of the said insurance, daughter of the complainant namely Bhumi fell ill and she was admitted in Simran Hospital and Child Care Centre, Opposite Old Octroi Post, Chheharta, Near Guru Nanak Dev University, G.T.Road, Amritsar on 14.7.2016 where she was hospitalized and she was discharged from the hospital on 20.7.2016. The complainant for this had to incur Rs.2680/- for blood tests etc. and Rs.3439/- for medical bills and Rs.20,600/- as hospital bill total Rs.26,719/-. The complainant immediately lodged the claim with the Opposite Party for reimbursement of the said claim amount as the daughter of the complainant was duly insured with Opposite Party under the aforesaid insurance policy and the said illness/ disease occurred to her during the currency period of insurance policy and she was hospitalized. The complainant submitted the claim form alongwith hospital bill, medicine and blood test bills as well as admission and discharge card of his daughter with the Opposite Party and the officials of the Opposite Party assured that the claim amount will be released to the complainant within few days. Since then the complainant has been visiting the Opposite Party’ office time and again, but no satisfactory reply is given to the complainant nor the claim of the complainant has been settled so far and now the Opposite Party assured that the claim amount will be released to the complainant within few days. Since then the complainant has been visiting the Opposite Party’ office time and again, but no satisfactory reply is given to the complainant nor the claim of the complainant has been settled so far and now the Opposite Party has refused to settled his genuine claim without explaining any reasonable excuse. Vide instant complaint, the complainant has sought the following reliefs.
- Opposite Party may be directed to immediately pay a sum of Rs.26,719/- being claim amount alongwith interest @ 24% per annum from the date of lodging claim till date of payment.
- To pay Rs.50,000/- as compensation to the complainant for the mental pain, agony, harassment and inconvenience suffered by him.
- To pay Rs.11,000/- as litigation expenses for the present litigation against the Opposite Party.
- Hence, this complaint.
2. Upon notice, Opposite Party appeared and contested the complaint by filing written statement taking preliminary objections inter alia therein that no cause of action has arisen to the complainant to file the present complaint as the averments of the present complaint does not depict any consumer dispute between the parties and the present complaint is a premature complaint. The present complaint is a bad for non-joinder for necessary parties. The complainant contains the averments with regard to treatment taken from Simran Hospital and Child Care Centre, Amritsar by the complainant. However, the said hospital has not impleaded as party in the present complaint. On merits, it was averred that all the relevant documents which are required to process the claim of the complainant have been submitted to the replying Opposite Party or its TPA. It is worthy to mentio over here that TPA, who is authorised to process the medical claims of the medical policies issued by replying Opposite Party has asked the complainant time to time to submit the documents which are required for the processing of the claim of the complainant, the said TPA has written letters dated 8.12.2016, 26.12.2016 and 11.2.2017 to the complainant asking him to provide the relevant documents with regard to the medical treatment taken by the daughter of the complainant in the hospital, but said documents has not been provided by the complainant uptill now, despite of the fact that TPA of the replying Opposite Party has asked for same from the complainant time to time, which clearly manifests that the claim of the complainant has not been process until now due to his own lapse. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
3. Today the case was fixed for evidence on behalf of the complainant, but at this stage, ld.counsel for the Opposite Party has stated that the Opposite Party has not received the required documents from the complainant for the settlement of his claim and the Opposite Party is still ready to process the claim of the complainant, if the complainant submits all the requisite documents with the Opposite Party. So, we are of the view that although, as alleged by the complainant that he has already submitted the required documents with the Opposite Party, but to settle the claim case of the complainant, it is no hitch to the complainant, if the required documents are again submitted with the Opposite Party. We are also supported with a case law Oriental Insurance Company Ltd. Vs. Rajbir Kaur, in First Appeal No. 711 of 2013 decided on 27.2.2015 of Hon’ble State Commission, Punjab, Chandigarh, wherein in similar case, the Hon’ble State Commission, directed the Insurance Company and stated that as per the regulations/ instructions issued by the IRDA, the claims made under the insurance policies are ordinarily to be settled within one month of the submission of the claim.
4. In such circumstances, we direct the complainant to submit the documents required by the Opposite Party and to complete all other formalities with the Opposite Party within 7 days from the date of receipt of copy of this order and consequently, Opposite Party shall process and settle the claim of the complainant either way, positively within further 30 days as per IRDA guidelines from the date of receipt of required documents from the complainant. The complaint is disposed of accordingly. However, the complainant is at liberty to file the fresh complaint after the final settlement of his claim, if he still not satisfy with the decision of the Opposite Party No order as to costs. Copies of this order be supplied to the parties free of cost and the file be consigned to record room after compliance.
Announced in Open Forum
Dated: 11.05.2017.
