DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, LUCKNOW
CASE No.326 of 2005
Sri Piyush Gupta, aged about 39 yrs.,
S/o Sri Mithlesh Kumar Gupta,
Principal Executive Officer,
Cancer Aid Society, Chowk,
Lucknow.
……Complainant
Versus
The Branch Manager,
The New India Assurance,
Jeevan Bhavan, Phase II, 6th Floor,
Newal Kishore Road, Lucknow.
.......Opp. Party
Present:-
Sri Vijai Varma, President.
Smt. Anju Awasthy, Member.
JUDGMENT
This complaint is filed by the Complainant against the OP for claims of treatment of the insured employees amounting to Rs.15,492.00 and damages of Rs.10,000.00.
The case in brief of the Complainant is that he is presently working as Principal Executive Officer at Cancer Aid Society and the society has taken insurance cover known as Rasta Aapatti Kavach of OP for the social workers who are in field. The then employees of the Cancer Aid Society Ms. Garima Singhal and Mr. Neeraj Sahu were covered under policy No.745 & 420500/48/01/06717 respectively, the premium of the same was paid by the Cancer Aid Society in the capacity of proposer. During the period of above insurance they met with an accident while working on duty. The claim was submitted to the Insurance agency and the surveyor deputed by them had inspected them at the hospital and the office of the society. The completed forms of claims with respective enclosures, prescription, bills etc. were submitted with the Insurance Co. for payment. All the expenditures were paid by the society due to inadvertent delay in passing the
-2-
same by the insurance agency which is a grave offence at their end since it involved medical expenditures, thereby threatening the life of the victims. In spite of several reminders and notices these claims are still pending and have not been paid. All the documents were submitted in time. The Complainant is a charitable organisation and has suffered tremendous loss due to the negligence of the OP, hence this complaint.
The OP has filed the WS wherein it is mainly submitted that the complaint is time barred. Incomplete/blank particulars were given. The OP has sent several reminders to the Complainant as well as to the insured to submit all the necessary documents with the OP as per the terms and conditions of the policy. The OP has hired the services of the Kanpur Claims Corporation who sent his representative to the Complainant and met personally and requested the Complainant to comply with the formalities of the claim. The Complainant has not paid any attention and not complied with the policy terms and conditions as mentioned. The surveyor also sent a number of letters and reminders to the Complainant through registered post dated 03.01.2002, 01.03.2002 and 05.04.2002 and requested the Complainant to send the claim form and necessary documents but the Complainant did not respond. Then ultimately the Complainant was told that if the said formalities are not complied within 15 days from the date of the last notice dated 05.04.2002 then there will be no other option than to close the claim file. The OP again sent a registered letter to the Complainant on 02.09.2002 and asked the Complainant to provide the necessary documents but nothing was done by the Complainant then the OP again sent a letter to the Complainant on 19.02.2003 and warned that if the required formalities as asked from the Complainant are not complied within 15 days from the date of letter, failing above the claim file of the Complainant will be closed. According to the Complainant the accident occurred on 06.10.2001 but in spite of repeated requests and reminder no attention and heed
-3-
was paid by the Complainant. According to the policy terms and conditions the Complainant has to submit his claim if any within specific time limit and complete the formalities as required otherwise the claim of the Complainant is to be treated as no claim as per norms of policy conditions. There is no negligence and deficiency in rendering service by the OP. In fact the negligence is on the part of the Complainant who knowingly did not comply with the policy terms and conditions in spite of repeated requests and reminders. The Complainant is not entitled to any relief. The claim of the Complainant is liable to be rejected with cost.
The Complainant has filed his affidavit with evidence with 22 papers and an affidavit in support of complaint with 54 papers. The OP has filed the affidavit of Sri A.K. Dewedi, Divisional Manager, New India Assurance Co. Ltd. with 9 annexures. The Complainant has filed written arguments.
Heard Counsel for the parties and perused the entire record.
In this case, it is not disputed that the Complainant is the Principal Executive Officer of Cancer Aid Society and that the employees of the Cancer Aid Society Garima Singhal and Neeraj Sahu were covered under policy No.745 & 420500/48/01/06717 respectively and New India Insurance Co. The disputed point according to the Complainant is that during the validity of the insurance policy of the employees they met with an accident and for the reimbursement of the expenses incurred on their treatment when the claim was pressed with the OP then the OP did not allow the claim and therefore they committed deficiency in service. On the contrary, the stand of the OP is that the Complainant was called upon to fulfil the formalities and submit documents within prescribed period but none responded and therefore the claim had to be closed, therefore there is no deficiency on the part of the OP. Another dispute is that the complaint is time barred and hence it is liable to be rejected.
-4-
Now, we first take up the point as to whether the complaint is time barred or not. In this regard, we find that the OP themselves in para 16 of the WS have stated that a letter was sent by the OP on 19.02.2003 warning the Complainant that if they do not submit the documents in 10 days then the OP shall be compelled to close the file. The OP thereafter has contended that as none responded, therefore they closed the claim file but no date about the closure of the file is mentioned by the OP and from their own statements it is clear that the matter was taken up by the OP in the year 2003 itself and the case has been filed on 06.05.2005. Therefore, it cannot be said that the case is time barred because no date of closure has been shown by the OP and that the matter has been pending till 19.02.2003 and obviously thereafter also as the closure date has not been disclosed by the OP. Besides there are letters issued by the Complainant for settlement of the claim which are dated 27.09.2003 and therefore the complaint which is filed on 06.05.2005 is well within 2 years of the matter being raked up, therefore it is not correct to say that the complaint is filed beyond time and it is concluded that the complaint is filed well in time.
Now, we take up next point i.e. whether the OP committed deficiency in service or not in not allowing the claim of the Complainant. In this regard, it is contended by the OP that the formalities were not fulfilled by the Complainant, therefore the claim could not be allowed but the letter issued by the OP on 19.02.2003 shows that the medical bills were submitted by the Complainant and that medical prescriptions were called for by the OP. According to the Complainant all the relevant documents were submitted and the Complainant has filed photocopies of the discharge tickets of Neeraj Sahu issued by Gandhi Memorial and Associated Hospital, Lucknow and also the medical prescriptions of Garima Singhal issued by the Gandhi Memorial and Associated Hospital. There does not appear to be any plausible reason as to why
-5-
these documents which have been submitted before the Forum were not submitted by the Complainant with the OP. The Complainant has submitted the medical papers and the receipts etc. pertaining to the employees who got injured in the accident. Therefore, it is clear that the OP were duly supplied with the medical papers of the insured employees of the Complainant, the receipts and amount spent on the treatment and there does not appear to be any justification for not allowing the claim of the Complainant once the employees were duly insured with the OP and the formalities were duly completed by the Complainant. The Complainant is therefore entitled to be reimbursed the amount spent on the treatment of the employees and the OP is bound to reimburse the Complainant of the amount of Rs.15,492.00 with interest. The Complainant has also been harassed in this regard and as the litigation is going on about for a decade, therefore the Complainant is not only entitled to compensation but also adequate cost of litigation.
ORDER
The complaint is partly allowed. The OP is directed to pay the amount of Rs.15,492.00 (Rupees Fifteen Thousand Four Hundred Ninety Two Only) with 9% interest from the date of filing of the case till the final payment is made to the complainant.
The OP is also directed to pay Rs.5,000.00 (Rupees Five Thousand only) as compensation and Rs.5,000.00 (Rupees Five Thousand only) as cost of the litigation. The compliance of the order is to be made within a month. If the compliance of the order is not made within a month then the OP shall pay 12% interest on the entire amount due.
(Anju Awasthy) (Vijai Varma)
Member President Dated: 27 May, 2015
