Order dictated by:

Sh.Anoop Sharma,Presiding Member

1. Present complaint has been filed by Yog Raj under the provisions of the Consumer Protection Act alleging therein that his wife Smt.Parveen  got a mediclaim policy  from the opposite party vide cover note No. 233300/48/2016/778 on 15.5.2015 for the period from 15.5.3015 to 14.5.2016 by paying premium of Rs. 1749/- for sum assured Rs. 1,00,000/- for herself as well as her family members including complainant . However, the cashless hospitalization card in the name of the complainant as well as his wife and children were issued about one month later  from the date of policy.  During the subsistence of the policy period on 25.5.2016, complainant suffered  paralysis attack and he was taken to EMC Hospital, Shakti Nagar I/s Lahori Gate, Amritsar where he incurred an amount of Rs. 32000/- on his treatment and discharged from the said hospital on 1.6.2015. At that time cashless cards were not issued  and the same were issued one month later from the date of policy.  So the complainant paid Rs. 32000/- in cash from his own pocket. Thereafter complainant lodged claim with the opposite party alongwith original documents  as required by the opposite party on 9.6.2015. But the opposite party dilly dallying the matter on one pretext or the other   and ultimately opposite party has repudiated the claim of the complainant  on false and flimsy grounds vide letter dated 1.3.2016. Infact the opposite party never sent any alleged four letters on the correct address of the complainant  as alleged in the repudiation letter . Thereafter another written reminder was sent to the opposite party on 18.3.2016 through speed post  stating that all the documents had already been submitted  to the opposite party , but to no effect. Vide instant complaint, complainant has sought for the following reliefs:-

1. Opposite party be directed to pay the claim amount of Rs 32000/- alongwith interest @ 18% p.a.
2. Compensation to the tune of Rs. 50000/- alongwith litigation expenses to the tune of Rs. 11000/- may also  be awarded to the complainant.

Hence, this complaint.

2.       Upon notice, opposite party appeared and filed written version in which it was submitted that as per terms and conditions of the policy in question, the complainant was required to intimate the opposite party immediately regarding the hospitalization . However, the complainant had failed to intimate the opposite party regarding his hospitalization. Hence, the complainant has violated the terms and conditions of the policy and is not entitled to the relief claimed for ; that complainant is estopped by his own act and  conduct from filing the complaint.  The opposite party had requested the complainant vide various letters to submit the requisite following documents and information:-

1. Original cancelled cheque ;
2. Reason for non intimation at the time of hospitalization ;
3. Reason for not availing cashless facility in Network hospital
4. History , duration and cause of ailment as verified by the treating doctor
5. All original investigation reports done during hospitalization alongwith MRI film against the enclosed report.
6. Past treatment records related to present ailment.
7. Original payment receipt of Rs.20,376/- against the Final Hospital bill . However, the complainant miserably failed to comply with the same and neither submitted the requisite documents nor furnished the clarifications sought for vide letters mentioned above. That as such, the opposite party vide its letter/e-mail dated 1.3.2016 closed the claim file of the complainant due to non submission of requisite papers and information.

That the complainant has not approached this Forum with clean hands and has concealed the material facts.  The complainant has violated the basic terms and conditions of the policy and is not entitled to the relief claimed for . As such the opposite party vide its letter dated 1.3.2016 closed the claim file of the complainant due to non submission of requisite papers and information.

3.       In his bid to prove the case Sh.U.K.Gaind,Advocate counsel for the complainant tendered into evidence duly sworn affidavit of the complainant Ex.C-1 alongwith documents Ex.C-2 to Ex.C-15 and closed the evidence on behalf of the complainant.

4.       To rebut the aforesaid evidence Sh.Sandeep Khanna,Adv.counsel for the opposite party tendered into evidence affidavit of sh.Gurdeep  Singh,Divisional Manager Ex.OP1, copy of policy schedule Ex.OP2, copy of terms and conditions Ex.OP3, letter dated 24.11.2015 Ex.OP4, letter dated 24.7.2015 Ex.OP5 and closed the evidence on behalf of the opposite party.

5.       We have heard the ld.counsel for the parties and have carefully gone through the record on the file.

6.       We have gone through the entire record produced by both the parties particularly the Insurance policy Ex.C-2 i.e. policy for the period from 15.5.2015 to 14.5.2016 in the name of complainant, his spouse  and children. As per this policy, the complainant alongwith his spouse and children was assured to the tune of Rs. 1 lac . The complainant was admitted in EMC Hospital on 25.5.2015 due to paralysis attach and was discharged on 1.6.2015. Complainant incurred an expenditure of Rs. 32,000/- on his treatment . It was the case of the complainant that as the cashless cards were not issued at the time of hospitalization of the complainant and the same were issued later on, so the complainant incurred the hospitalization charges from his own pocket. Thereafter complainant lodged claim with the opposite party alongwith requisite original documents as required by the opposite party on 9.6.2015. But the opposite party vide letter dated 1.3.2016 repudiated the genuine claim of the complainant on the ground that opposite party sent four letters to submit requisite documents for the settlement of the  claim. Infact the opposite party never sent any alleged four letters on the correct address of the complainant. Rather the opposite party sent two letters dated 24.7.2015 and letter dated 24.11.2015 at the address  Gali Shekhan Katra Bhai Sant Singh, Amritsar and not at the present address i.e. H.No. 787, Gali Bagichi Tek Chand, Near  Durgiana Abadi, Amritsar seeking certain documents i.e. original cancelled cheque of PNB Bank from which policy was issued with name of policy holder printed on it, Reason for non intimation at the time of hospitalization, reason for not availing cashless facility in network hospital, history, duration and cause of ailment as certified by the treating doctor, All original Investigation reports done during hospitalization alongwith MRI film against the enclosed report, past treatment records related to present ailment, if any, original payment receipt of Rs. 20,376/- against the final deposit bill.

7.       From the appreciation of the facts and circumstances of the case , it becomes evident that the complainant has placed on record copy of hospital bill  Ex.  C-14 i.e. EMC Superspeciality Hospitals  Pvt.Ltd to the tune of Rs. 20,376/- alongwith copies of  medicine bills Ex.C-6 to Ex.C-13 to the tune of Rs. 9372/-.  However, the demand of opposite party to explain reason for not availing cashless facility in network hospital. In this regard complainant has alleged that as he has not received the cashless cards at the time of hospitalization and the same were issued later on. In this regard opposite party has not proved on record that they have sent the cashless cards alongwith the cover note as they have not filed any such document to prove the delivery of the cashless cards to the complainant alongwith the cover note. So this plea of the opposite party for explaining the reason for not availing the cashless facility in network hospital and the reason for non intimation  at the time of hospitalzation is not tenable as the complainant has not received the list of network hospitals at that time.

8.       Since the claim filed by the complainant was repudiated  vide letter dated 1.3.2016 on the ground of non supply of certain documents. As the complainant has already supplied copy of hospital bill Ex.C-14 as well as copies of medicine bills Ex.C-3 to Ex.C-13, but the opposite party kept on demanding such documents which the complainant has already deposited with the opposite party . As such the complaint is allowed accordingly and the opposite party is directed to decide the claim of the complainant to the tune of Rs. 29,748/- vide bills Ex.C-3 to Ex.C-14 . The opposite party is legally bound to decide the claim of the complainant within 30 days  as per IRDA guidelines from the receipt of requisite documents , which the complainant has deposited . So the complaint is also entitled to compensation to the tune of Rs. 5000/- while the litigation expenses are assessed at Rs. 2000/-. Compliance of this order be made within 30 days from the date of receipt of copy of this order ; failing which complainant is at liberty to get the order enforced through the indulgence of this Forum.   Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Dated: 21.3.2017