ORDER

(Passed on 29 /09/2018)

PER SHRI.ATUL D.ALSI, PRESIDENT.

The complainant has filed this complaint U/s 12 of the Consumer Protection

Act,1986 against the repudiation of insurance claim by the OP on the ground of delay and praying for direction to the OP to pay insurance claim alongwith  interest and further claiming compensation and cost of proceeding.

2.       The facts in short giving rise to this petition are that the complainant is a doctor by profession residing at Chandrapur and he has insured himself under Medical Health Care Policy for the period between 31/3/2016 to 30/3/2017 vide policy No.182500/48/2016/1916. On 11/6/2016 the complainant suddenly fallen down on a public road and suffered injury to his right shoulder. The complainant was admitted to Hospital on 9/7/2016 and after X-ray and MRI, the complainant was operated there. He was discharged from the hospital on 11/7/2016. The complainant incurred expenses of Rs.1,50,000/- towards operation charges, Rs.1,573/- for medicines and other expenses amounting to Rs.12,200/-. After operation, the doctor advised him bed rest for two months. After the incidence of accident, the complainant has intimated to the insurance company about the accident. The complainant alongwith all relevant documents filed insurance claim with OP on 27/7/2017 but the claim was repudiated for the reason of delayed submission by 8 days from the date of discharge from the hospital. The complainant has supplied all relevant documents and certificates with the OP in respect of his treatment. Therefore rejection of insurance claim on technical ground amounts to deficiency in service. Therefore the petition is filed.

3.       The complaint is admitted and notices were served on the OP. The OP  filed its r reply and thereby denied allegations against them. The OP denied

that the complainant could not file the claim within prescribed time limit as he was  asked to take rest for two months from date of discharge. The claim of the complainant was received by the OP on 3/8/2016 and as such, there was delay of 8 days in submission of claim form by him.  It further submitted that The complainant has mentioned that he was treated by Dr.Sonar at Sports Med Hospital, Nagpur and he has also filed receipt of payment of Rs.1,50,000/- to the said hospital.  However, the documents submitted by the complainant with the claim form clearly reveals that he was treated at Om Surgical & Trauma Care Centre. The applicant himself is a qualified doctor and he has accepted bills, discharge card from Dr.Sonar showing Hospital’s name as Om Surgical & Trauma Care Centre. However, the complainant was never admitted in that hospital and Dr.Satish Sonar has not visited that hospital for last two years.  Hence it is clear that Dr. Sonar used old stationary of Om Surgical & Trauma Care Centre with which he was working erlier.  Hence the documents submitted by the complainant in support of his mediclaim were bogus, fabricated, tampered and as such, his claim was rightly repudiated by the OP.  Therefore the petition deserves to be dismissed with cost.

4.       Counsel for the complainant argued that after post operation treatment and rest, the complainant filed insurance claim and hence there was delay in filing the claim. The OP has repudiated the bonafide claim on flimsy and technical ground.  As per the circular issued by Insurance Regulatory Authority vide IRDA/HLTH/MISC/CIR/216/09/2011 dated 20/9/2011, the insurance claim cannot be repudiated  for delay in intimation and submission of claim. The complainant submitted the affidavit of Dr.Sonar that the certificates issued for the treatment are correct. Hence the rejection of claim on technical ground amounts to deficiency in service.  Therefore the petition may be allowed as prayed. 

5.         Counsel for the OPs argued that  Dr.Satish Sonare has willfully issued defective medical certificate by playing mischief and with a view to gain wrongful benefit for the complainant and to cause wrongful loss to the OP.  Dr.Sonar was not at all authorized to utilize the old stationary and letter head of Om Surgical & Trauma Care Centre where he was working two years prior to the date of alleged treatment of the complainant. The circular of IRDA dated 20/9/2011 is not binding to the case in hand as it relates only to the genuine claims, but here the case is of mischief and fabrication of record. Therefore rejection of claim does not amount to deficiency in service. Hence the complaint deserves to be dismissed with cost.

6. We have gone through the complaint, written versions filed by OP, affidavit, documents and WNA filed by the parties. We have also heard the oral arguments advanced by parties.

                    Points                                                                                     Finding

1. Whether the complainant is a Consumer ?                                      Yes

2.  Whether  there is deficiency in service on the part

     of OP ?                                                                                             Yes

3.  What order ?                                                                  As per final order..

As to issue No.1

7.      The complainant has filed on record the copy insurance policy on record. O.P. has not disputed the Mediclaim insurance policy obtained by the complainant. Hence the complainant is a consumer within the meaning of Section 2(1) D and the services as promised are the services within the meaning of section 2(1)(d)(ii) of CP act. and hence the issue is decided accordingly.

As to issue No.2

8.       Dr.Satish Sonar, M.S. Ortho (GMC Mumbai) and DNB Ortho (New Delhi) has certified that old discharge card was given from the hospital where he was attached. This contention has been proved by the complainant by filing affidavit of Dr.Sonar on record. Therefore the contention of OP that the certificate issued by Dr.Sonar are false and fabricated can not be accepted. It is a routine practice in the medical profession and is also need of the time that one doctor is attached to various hospitals as a consulting doctor and offer his services on call by the hospital. 

9.       The basic dispute between the parties is in respect of late submission of insurance claim by 8 days after the time limit prescribed for submission of claim from the date of discharge. It is admitted that the complainant was admitted in the hospital on 9/9/2016 and after surgery to his right shoulder, he was discharged on 11/7/2016. The insurance claim came to be received by the OP on 3/8/2016. As per the discharge card, the treating doctor had advised two months rest to the complainant. After discharge, post operation follow up treatment and after taking rest, the complainant submitted insurance claim with relevant documents. Therefore, the reason for late submission of insuance claim is bonafide. The clause No.2 of the policy agreement which is filed at Exh.4/1 provides as under..

         “Claim documents to be submitted within 15 days of discharge”.

10.    However, this clause is not mandatory in nature in terms of policy terms and conditions because there is no stipulation that if the claim has not been submitted within 15 days, it will not be entertained or would be repudiated. Therefore, the clause is directory in nature and not mandatory. Non submission of insurance claim within 15 days does not give right to repudiate a genuine claim. Non submission of insurance claim within 15 days is not an illegality but is an irregularity. As per the circular issued by Insurance Regulatory Authority vide IRDA/HLTH/MISC/CIR/216/09/2011 dated 20/9/2011, the insurance claim cannot be repudiated  for delay in intimation and submission of claim. When the clause is not mandatory, then  submission of documents for claim late by 8 days does not rise the right to cancel the whole policy. It is not fundamental breach of policy. Hence for the claim of complainant is allowed on “non standard basis of claim of policy” and therefore, complainant is entitled to 50% of the assured amount i.e. Rs.50,000/- against the sum assured amount of Rs.1,00,000/- of the policy without any interest, compensation and cost of litigation as per following order.     

As to issue No.3

11. In view of our findings to the issue Nos.1 & 2 as above, we partly allow the petition in the following terms..

Final order

     1. The Complaint is partly allowed.

2.  The OP is directed to pay 50% of the sum assured i.e. Rs.50,000/- to the complainant as on non standard claim of the policy bearing No.182500/48/2016/1916.

       3. Parties to bear their own cost.

       4. Copy of the order be furnished to both the parties free of cost.

(Smt.Kalpana Jangade (Kute)  (Smt.Kirti Vaidya (Gadgil)     (Shri.Atul D.Alsi)

               Member                                 Member                                    President