BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 573 of 2014

Date of Institution: 05.11.2014

Date of Decision: 07.01.2016 

Kuldeep Singh son of S.Harjit Singh, resident of L-1/184, Gali No.5,New Kapoor Nagar, S.W.Road, Amritsar. 

Complainant

Versus

The Oriental Insurance Company through its Senior Branch Manager/ over all Incharge/ Branch Manager/ Divisional Manager having its Branch Office at M.M.Malviya Road, D.O. II, Amritsar.  

Opposite Party

Complaint under section 12 and 13 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Ms.Neena Kapoor, Advocate

              For the Opposite Party: Ms.Sneh Lata Kapoor, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member     

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Kuldeep Singh under the provisions of the Consumer Protection Act alleging therein that he took a Individual Medi claim policy bearing No.235300/48/2014/202 w.e.f. 17.05.2013 to 16.05.2014 for a sum  insured Rs.1 lac and used to make regular premium for renewal each and every year. Complainant alleges that on 10.5.2014, he met with an accident and suffered serious injuries. He was  admitted in Shri Guru Nanak Dev Hospital, Amritsar on account of accidental injuries on 10.5.2014. Complainant suffered right leg fracture and was advised surgery. He was admitted on 10.5.2014 in Shri Guru Nanak Dev Hospital, Amritsar and then shifted to Hargun Hospital, Amritsar on 14.5.2014 and was discharged on 22.5.2014. The complainant spent more than Rs.1 lac on his treatment on account of hospitalization and medicines. The complainant lodged claim with Opposite Party, but the Opposite Party refused to make the genuine claim of the complainant on the ground that the complainant should provide detail narration of the incidence and influence of alcohol at the time of incident, vide e-mail dated 1.8.2014 which is  unjustifiable, cryptic and unwarranted in the eyes of law.  Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to reimburse the cost of expenses to the tune of Rs.1 lac incurred by the complainant on account of illness suffered by him. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party appeared and filed written version in which it was submitted that the complainant is guilty of his own act and conduct and is estopped from filing the present complaint which renders his claim to be rejected as the complainant had been called a number of times to produce the documents and to clarify certain particulars, but he intentionally avoided to attend the office of Opposite Party. Hence the complaint of the complainant is not legally maintainable and merits dismissal. Even otherwise, due to contravention of the terms and conditions of the policy and exclusions contained therein, the complainant is not entitled to any compensation much less the amount claimed by him. As soon as the complainant lodged the claim regarding the accident in question, his claim was duly processed and he was called   some clarifications and submit certain documents as detailed narration of the incidence and influence of alcohol at the time of incidence certificate by the treating doctor, was called and he was also asked to explain the delay as the admission in the hospital was shown as 10.5.2014, date of discharge is 22.5.2014 itself and date of submission of claim papers is 13.6.2014, whereas as per the terms and conditions of the policy, the claim has to be lodged by giving notice/ intimation to the company within 48 hours of admission or before discharge from the hospital/ nursing home, unless waived in writing, but the complainant has failed to submit the claim within the statutory period as per terms of policy and failed to explain the delay occurred in the late submission of claim papers  and also failed to submit the detailed narration of the incidence and certificate from the doctor regarding influence of alcohol at the time of incident, which are very much necessary and essential for processing the claim, but despite this, the complainant failed to supply any information and documents, etc, to the Opposite Party nor even visited the office of Opposite Party with said clarifications and on the other hand, has filed the present complaint. As such, the claim of the complainant was repudiated and treated as ‘No Claim’ and in this regard, the complainant was duly informed vide letter dated 3.11.2014.   While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C58 and closed the evidence on behalf of the complainant.
4. Opposite Party tendered into evidence affidavit of Sh.R.K.Sharma, Divisional Manager Ex.OP1 alongwith documents Ex.OP2 to Ex.OP7 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that  the complainant got Individual Medi claim policy bearing No.235300/48/2014/202 (Ex.C53)  from the Opposite Party for the period w.e.f. 17.05.2013 to 16.05.2014 with a sum  insured Rs.1 lac.  On 10.5.2014, the complainant met with an accident and suffered serious injuries.  In this regard, FIR was registered with P.S.A-Division, Amritsar, copy of which is Ex.C56. The complainant was  admitted in Shri Guru Nanak Dev Hospital, Amritsar on 10.5.2014 and was discharged on 14.5.2014 as per discharged summary Ex.C11. The complainant was then shifted to Hargun Hospital, Amritsar on 14.5.2014 and was discharged on 22.5.2014 as per discharge card of Hargun Hospital, Amritsar Ex.C51. The  complainant spent about Rs.1 lac on his treatment. The  claim was lodged with Opposite Party, but the Opposite Party refused to make the claim of the complainant on the ground that the complainant has not provided detail narration of the incidence and influence of alcohol at the time of incident and that there was delay in submitting of claim. The complainant was discharged on 22.5.2014 from the hospital and claim papers were submitted with Opposite Party on 13.6.2014 which is clear violation of the terms and conditions of the policy  because as per clause 5.5 of the policy Ex.OP2, the claim documents i.e. final claim alongwith hospital receipts, original bills, cash memos/reports, etc. should be submitted to the complainant/ TPA within 7 days of the discharge from the hospital/ nursing home. The complainant filed the claim alongwith documents to the Opposite Party/ TPA of the Opposite Party on 13.6.2014 i.e. after a lapse of period of 21 days.  Ld.counsel for the complainant  submitted that all this amounts to deficiency of service on the part of the opposite party.
7. Whereas the case of the Opposite Party is that the complainant has not come to this Forum with clean hands and has suppressed the true and material facts. The complainant lodged the claim regarding accident in question with the Opposite Party which was duly processed and he was called upon some clarification and to submit certain documents regarding narration of the incidence and influence of alcohol at the time of incidence as well as reasons for delay in submission of the claim, with the Opposite Party. In this regard letter dated 23.6.2014 Ex.OP6, e-mail letter dated 1.8.2014 Ex.OP5 and then  letter dated 16.8.2014 Ex.OP4 were written to the complainant to submit the documents required by the Opposite Party and to explain the delay in lodging the claim with the Opposite Party/ TPA of the Opposite Party as the complainant was discharged from the hospital on 22.5.2014 whereas he submitted the claim papers with the Opposite Party on 13.6.2014. Whereas as per the terms and conditions of the policy, the claim has to be lodged with the Opposite Party within a period of 7 days from the date of discharge from the hospital. The complainant was also directed to submit the detailed narration of the incidence and certificate from the doctor regarding influence of alcohol at the time of incident, which is very much necessary and essential for processing the claim, but the complainant did not submit any reply. As such, the claim of the complainant was treated as ‘No Claim’ and he was informed in this regard vide letter dated 3.11.2014 Ex.OP3. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Party.
8. From the entire above discussion, we have come to the conclusion that  the complainant obtained  Individual Medi claim policy bearing No.235300/48/2014/202 (Ex.C53)  from the Opposite Party for the period w.e.f 17.05.2013 to 16.05.2014 with sum  insured Rs.1 lac.  The complainant met with an accident on 10.5.2014 and suffered serious injuries and was admitted in Shri Guru Nanak Dev Hospital, Amritsar. FIR No. 145 dated 11.5.2014  in this regard was registered at P.S.A-Division, Amritsar, copy of which is Ex.C56. The complainant remained admitted in Shri Guru Nanak Dev Hospital, Amritsar  from 10.5.2014 to  14.5.2014  as per discharge certificate Ex.C11. Thereafter, the complainant remained admitted  in  Hargun Hospital, Amritsar  from 14.5.3014 to 22.5.2014 as per discharge certificate of Hargun Hospital, Amritsar Ex.C2. The  complainant spent about Rs.1 lacs on his treatment, the bills of which in this regard are Ex.C2 to C49. The claim was lodged by the complainant with Opposite Party. TPA of the Opposite Party issued letters dated 23.6.2014 Ex.OP6, e-mail letter dated 1.8.2014 Ex.OP5 and then  letter dated 16.8.2014 Ex.OP4 to the complainant to provide certificate regarding the incidence and influence of alcohol at the time of incident and to explain the delay in submission of the claim papers because the complainant was discharged lastly from Hargun Hospital, Amritsar on 22.5.2014. The claim papers were submitted with the Opposite Party on 13.6.2014 whereas as per clause 5.5 of the terms and conditions of the policy Ex.OP2, final claim alongwith hospital receipt, original bills/ cash memos/ reports, claim form, etc. should be submitted to the company/ TPA within 7 days of discharge from the hospital/ nursing home. Whereas the complainant submitted the claim papers with the Opposite Party/ TPA of the Opposite Party  after a lapse of period of 21 days, but the complainant did not submit any reply. The TPA of Opposite Party again issued reminder letter dated 23.6.2014 Ex.OP6, e-mail letter dated 1.8.2014 Ex.OP5 and then  letter dated 16.8.2014 Ex.OP4, but the complainant did not submit the reply nor explained the delay in submission of the claim papers with the Opposite Party. Ultimately, the Opposite Party treated the claim of the complainant as ‘no claim’ vide letter dated 3.11.2014 Ex.OP3 which was duly served upon the complainant. No doubt, Opposite Party could not produce any evidence that the complainant was under the influence of liquor at the time of accident, but the complainant in the present case could not explain the delay in submission of the claim papers with the Opposite Party as the complainant was required to submit the claim papers within 7 days from the date of discharge from the hospital as per clause 5.5 of the terms and conditions of the policy Ex.OP2. Whereas the complainant has submitted the claim papers with the Opposite Party after a lapse of period of 21 days. Ld.counsel for the complainant submitted that the complainant never received the terms and conditions of the policy, so these terms and conditions of the policy Ex.OP3 are not binding upon the complainant  Here we do not agree with this contention of the ld.counsel for the complainant because the Opposite Party i.e. TPA of the Opposite Party wrote so many letters i.e. letter dated 23.6.2014 Ex.OP6, e-mail letter dated 1.8.2014 Ex.OP5 and then  letter dated 16.8.2014 Ex.OP4  in which the TPA of the Opposite Party has categorically stated that the complainant has violated the terms and conditions of the policy as the claim papers are to be submitted to the Opposite Party or its TPA, within 7 days from the date of discharge from the hospital as per clause 5.5 of the terms and conditions of the policy Ex.OP2, whereas in the present case, the complainant has submitted the claim papers with the Opposite Party/TPA after a lapse of period of 21 days and the complainant was required to explain this delay, but the complainant neither explained the delay in submission of the claim papers with the Opposite Party, nor even submitted any reply to these letters to the Opposite Party/ TPA. Not only this, the Opposite Party has taken specific plea in the written version that the complainant has not explained the delay in submission of claim papers with the Opposite Party/ TPA of the Opposite Party nor submitted any reply to the letters written by Opposite Party/ TPA of the Opposite Party to the complainant to explain this delay in submission of the claim papers with the Opposite Party, thereby violated the terms and conditions of the policy. But the complainant did not take any plea in the complaint that he has not received the terms and conditions of the policy nor in the affidavit filed by the complainant Ex.C1 which was filed by the complainant after the filing of the written statement of the Opposite Party,  the complainant has not taken any plea that he did not receive the terms and conditions of the policy, whereas the terms and conditions are the part and parcel of the policy. The complainant should have raised this objection at the very first moment, but the complainant has not taken any such plea in his pleadings as well as  in the evidence. So, the Opposite Party was justified in repudiating the claim of the complainant i.e. treating the same as ‘no claim’, vide letter dated 3.11.2014 Ex.OP2.
9. Resultantly, we are of the opinion that the complaint is without merit and the same is hereby dismissed with no order as to cost. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 07.01.2016                                                     (Bhupinder Singh)                                                                                                  President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member