CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/502/10

          Date of Institution:-    21.09.2010

          Order Reserved on:- 15.05.2024

                   Date of Decision:-19.09.2024    

IN THE MATTER OF:

IshwerPersadGoel

RZ1-12B, Old Som Bazar WaliGali,

Pooja Digital Studio, PalamDabri Road,

Delhi - 110045

.….. Complainant

VERSUS

1. The Oriental Insurance Company Ltd.

613-620, AnsalChamers-II,

Bhikaji Kama Place

Also at

The Oriental Insurance Company Ltd.

Bombay Life Building,

N-36, Connaught Circus,

New Delhi – 110001

2. The Raksha T.P.A. Pvt. Ltd.

15/5 Mathura Road, Faridabad

Haryana – 121003…..Opposite Parties

Suresh Kumar Gupta, President

1. The complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations that he has taken a mediclaim policy by the name of Happy Family Floater Policy (Silver Plan)bearing no.215100/48/2010/3470 for a insured sum of Rs.3 lakh valid from 17.02.2010- 16.02.2011 from OP-1. OP-2 is TPA of OP-1. On 01.05.2010 he was admitted to Ekansh Nursing Home for the treatment of Meniscus Tear Right Knee Discoid Meniscus and discharged on 05.05.2010. On 03.05.2010, an intimation vide letter dated 02.05.2010 was sent to OP-2 regarding hospitalization through speed post. He has submitted the claim of Rs.61,712/- with the relevant documents to OP-2 by speed post-dated 17.05.2010 with covering letter dated 10.05.2010. On 06.07.2010, he made a call to OP-2 and it was informed that claim has been rejected. He has downloaded the letter from website of OP-2. The letter shows that hospital is not as per norms of the policy so claim is not payable. He has already submitted the registration certificate of the hospital valid till 31.03.2010. He has visited the hospital and told that his claim has been rejected as nursing home is not registered. The nursing home told that no hospital/nursing home gets renewal in advance and no claim can be rejected on this premise. The hospital provided new registration certificate valid till 31.03.2011. The claim has been rejected on invalid grounds. Hence, this complaint.

2. The OP-1 has the reply with the averments that complaint is not maintainable. The clause 5.5 of the terms and conditions of the policy says that final claim along with original of the hospital bills/cash memos/reports, claim form and list of documents as provided below should be submitted to company/TPS within 7 days from the discharge from the hospital. The complainant was remained hospitalized from 01.05.2010-05.05.2010 and submitted the papers on 21.05.2010 i.e. 16 days after the discharge from the hospital. The delay is not justified so claim falls under clause 5.5 of the insurance policy and accordingly the claim was recommended as non-admissible. The amount claimed by the complainant is excessive. The complainant has not taken the treatment from the hospital/nursing home as defined under clause 2.1 of the policy. The complicated question of fact and law is involved which cannot be decided in the summary proceedings. The complaint is bad for non-joinder and misjoinder of parties and moreover this Commission does not have territorial jurisdiction to decide the complaint as policy was issued from Karol Bagh.

3. The complainant has filed their rejoinder wherein he has reiterated the stand taken in the complaint and denied the averments made in the written statement.

4. The parties were directed to lead the evidence.

5. The complainant has filed his own affidavit in evidence and corroborated the version of complaint and placed reliance on the documents annexed with the complaint which are Annexure-A to F, Annexure-X.

6. The OP has filed the affidavit of Sh. Satish Kumar, Assistant Manager in evidence and corroborated the version of written statement.

7. The parties did not turn up to address the arguments but Ld. Counsel for the OP has appeared later on but did not address the arguments. The case was old so it was reserved for orders.

8. The Head Office of OP-1 is at BhikajiCama Place which comes under the Police Station, R. K. Puram. This Commission exercises jurisdiction over Police Station, R. K. Puram so this Commission have jurisdiction to entertain and decide the complaint.

9. The perusal of the record shows that issuance of policy in question is not in dispute. The OP has not disputed the admission of complaint in Ekansh Nursing Home 01.05.2010 -05.05.2010. The complainant has paid a bill of Rs.61,712/- to the Nursing Home. The complainant has submitted the treatment record along with other documents by speed post on 17.05.2010 with covering letter dated 10.05.2010. The documents were allegedly received by the OP on 21.05.2010. The claim was rejected under clause 5.5 of the terms and conditions of the insurance policy on the ground of delayed intimation.

10. The Act is meant to protect the interest of the consumers. There should be liberal construction of the provisions of the Act.

11. The insured has to lodge the claim with documents with the insurer within 7 days from the date of discharge from the hospital/nursing home. In the instant case, the complainant was discharged on 05.05.2010. On 03.05.2010, the complainant has intimated to OP-2 about his hospitalization by letter sent through speed post which is Annexure-B. On 17.05.2010, the complainant has submitted the treatment documents along with covering letter dated 10.05.2010 to OP-2 by speed post which were allegedly received by the OP on 21.05.2010.

12. The complainant has intimated to the OP-2 about his hospitalization and this fact is nowhere controverted by OP-1 and moreover OP-2 has been proceeded ex-parte.

13. The documents about the claim were received on 21.05.2010 by the OP. The intimation is dated 17.05.2010 with covering letter dated 10.05.2010 (Annexure-C) whereas it should have been sent within 7 days from the date of discharge from the nursing home.

14. The OP-1 has not come forward with the plea that claim is not genuine. No malafide has been attributed to the complainant by the OP-1. There can be a delay of few days due to the reason that patient/complainant was in the recovery phase after the discharge from the nursing home. One should not expect that patient/complainant should start filing the papers for the medi-claim soon after his discharge from the hospital/nursing home. The rejection of claim on technical ground in a pure mechanical manner will result in the loss of confidence of the insured in the insurance company. The insurance company should opt for practical approach. The condition to lodge the claim within 7 days from the date of discharge from the nursing home should not be a shelter to the insurance company to reject the genuine claim.

15. The delay is one of the grounds of rejection. This is a rejection in a mechanical manner as there is no finding from the OP-1 that claim is not genuine. The OP-1 should have gone for practical approach rather than mechanical approach by keeping in view the fact that practical approach will still confidence in the mind of the public that genuine claims will not be rejected even if there is slight delay.

16. The rejection of claim in a pure mechanical manner is nothing but deficiency of service on the part of OPs.

17. The Annexure-D filed by the complainant shows that the claim of Rs.61,712/- has been rejected on the ground that hospital does not fulfil the norms laid down in clause 2.1 of the policy i.e. nursing home is not registered with the appropriate authority. This ground does not find support from the evidence. The complainant has placed Annexure-F on record which shows that Ekansh nursing home is registered with Directorate, Health Services, GNCT of Delhi till 31.03.2011. The OP-1 has not checked the record before rejecting the claim on this premise. It shows that OP-1 has adopted a very casual approach in rejecting the claim. Such kind of rejection compels the claimant to approach the Commission which not only puts a hole in his pocket but also causes mental harassment and agony. The rejection of claim on such ground is clearly a deficiency of service

18. In view of our aforesaid discussion, the complaint of the complainant is allowed to the effect that OP shall pay a sum of Rs.61,712/- along with an interest @9%from the date of filing the complaint i.e. 06.07.2010 to thecomplainant till its realization. The complainant is entitled for compensation of Rs.1,00,000/- for mental harassment and agony and Rs.40,000/- for litigation expenses. The OP is directed to comply with the order within 45 days from the receipt of the order failing which complainant will be entitled for interest @9% p.a. on the amount of mental harassment, agony and litigation charges i.e. from the date of order till its realization.

• A copy of this order is to be sent to all the parties as per rule.
• File be consigned to record room.
• Announced in the open court on 18.09.2024.