Assam

Tinsukia

CC/11/2015

Anant Kumar Verma - Complainant(s)

Versus

THE ORIENTAL INSURANCE CO. LTD. - Opp.Party(s)

Munna Kr. Singh

11 Apr 2017

ORDER

BEFORE THE PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL FORUM : :   TINSUKIA : :  ASSAM

           District: Tinsukia

 

   Present:           Smti M. Nandi,

                           President,

               District Consumer Disputes

                           Redressal Forum,  Tinsukia

 

               Smti J. Gogoi,

                           Member,

               District Consumer Disputes

                           Redressal Forum,  Tinsukia

 

               Sri K.K. Das,

                           Member,

               District Consumer Disputes

                           Redressal Forum,  Tinsukia

 

                   Consumer Case No. 11  of 2015

Sri Anant Kumar Verma,

S/o Sri R.N. Verma,

R/o Makum Road,

C/o Anant Agro Stores,

P.O., P.S. & Dist: Tinsukia (Assam)…………..……...…..….………..Complainant

• Versus –

The Oriental Insurance Co. Ltd.,

Divisional Office,

Thana Road, Tinsukia,

P.O., P.S. & Dist: Tinsukia (Assam)………………………….……….…Opposite Party

         

Appearance:

                   Sri M. K. Singh,

                   Advocate……………………………….For the Complainant

                   Sri A.C. Borah,

                   Advocate……………………………….For the O.P.

 

                   Date of Argument     :         23.03.2017   

                   Date of Judgment     :         11.04.2017

J    U    D    G    M    E    N    T

 

This is a petition u/s.12 of Consumer Protection Act, 1986 filed by the complainant Anant Kumar Verma.

2.       It is stated in the petition that on 22.1.2010, the complainant while doing his business, subscribed a mediclaim insurance policy called “Mediclaim Insurance Policy (Individual) being Policy No.322500/48/2010/1579, covering the lives, from the O.P. i.e. Oriental Insurance Company Limited with sum insured of Rs.1 lakh only each for himself, his wife, namely Smti Asha Verma and his daughter Miss Tania Verma for a period of six years, from 22.1.10 to 21.1.2011 and in the same manner continued till 29.1.16. Under this mediclaim policy, the complainant was covered for availing medical benefit including for pre-existing diseases. The said insurance policy indemnified the complainant along with his wife and  daughter against the medical charges.

3.       The complainant continued the mediclaim policy by renewing the said Policy No.322500/48/2010/1579 from time to time covering the period from 22.1.2010  and continued till 29.1.16.  On 22.9.14 in the evening at about 7.30 P.M., while the complainant was proceeding towards his residence, situated at Makum Road through his scooty being No.AS-23-J-3792 on the extreme left side of the road, one unknown truck coming from opposite direction, driven in a very rash and negligent manner hit the scooty of the complainant near FCI godown, Makum Road, Tinsukia. As a result, the complainant sustained grievous injury. He was taken to Archana Hospital, Dibrugarh and admitted on 23.9.14 and discharged on 27.9.14. He was treated continuously on 27.10.14 to 28.10.14. During the period of his treatment, he was covered by the mediclaim policy of the O.P./insurance company. After the accident, the complainant also informed the accident to the Officer-in-Charge, Tinsukia P.S. by filing ejahar. The complainant also informed about his accident to the O.P. along with all medical documents and medical bills along with a written prayer to reimburse his claim and same was duly received by the O.P., but the claim of the complainant was disposed of with an observation “No claim”. The complainant several times went to the office of the O.P. claiming the insurance benefit of the said mediclaim, but nothing was paid to him. The complainant received the letter of no claim dated 30.3.15 and after that he went to the office of the opposite party for understanding the matter and the statement of the letter, but the officials of the insurance company did not pay heed to his request. The opposite party has committed serious deficiency in service being the complainant a consumer by not compensating the damages/loss to the complainant as prayed by him. Through this petition before the Forum, the complainant has claimed an amount of Rs.91,854.50 being the mediclaim amount of the complainant along with interest @ 18% per annum, an amount of Rs.5,000/- on account of travelling expenses, an amount of Rs.10,000/- being the loss incurred by the complainant for non-payment of the mediclaim amount and an amount of Rs.25,000/- for mental pain and agony suffered by the complainant.

4.       Against the petition, the O.P. submitted written statement wherein the O.P. admitted that the complainant filed a claim for reimbursement of Rs.91,854.50, but the policy referred being  No.322500/48/2010/1579 does not cover to claim any compensation. As such, he is not entitled to get compensation, as claimed for. It is further stated that the complainant has failed to submit some documents i.e. attested copy of indoor case papers with nursing chart of hospitalization, detailed case summary certified by treating doctor, original laboratory reports, all investigation reports in support of final diagnosis, duly signed claimed form and original discharge summary with mentioning the admission, discharge etc. As the complainant has failed to submit the aforesaid documents, his prayer was not considered and the O.P. was compelled to repudiate the claim with remark “No claim”. So, there is no deficiency in service on the part of the O.P., rather there is lack of cooperation of the complainant to settle the matter. As such, he is not entitled to get any relief, as prayed for and prayed to dismiss the petition.

5.       In this case, though no formal issues were framed, but for convenience of discussion, following issues have been formulated:

(i)       Whether the complainant was the subscriber of mediclaim policy and whether he met with an accident during subsistence of the said policy?

(ii)      Whether the O.P. has wrongly closed the file of the complainant with observation “No claim”?

(iii)     Whether there is deficiency in service on the part of the O.P. in repudiating the claim of the complainant?

6.       The complainant was examined in the case as CW1 and he stated the same thing, what he had stated in his petition that he had subscribed a mediclaim insurance policy vide Policy No.322500/48/2010/1579 covering the lives with sum insured of Rs.1 lakh each for himself, his wife Asha Verma and his daughter Tania Verma for six years i.e. from 22.1.10 and continued till 29.1.16 and he regularly paid the premium.  On 22.9.14, he met with an accident. He was admitted in Archana hospital, Dibrugarh and incurred expenditure of Rs.91,854.50 and when he approached before the insurance company to pay the said amount, they refused to pay the same, rather they repudiated the claim with an observation “No claim”. According to the O.P., due to non-submission of some requisite documents, they failed to pay the amount, as claimed by the complainant.

7.       On behalf of the O.P., Senior Divisional Manager Sri R. Brahma has submitted his affidavital evidence, wherein he admitted that the complainant is the subscriber of the mediclaim policy being Policy No.322500/48/2010/1579 covering with sum assured of Rs.1 lakh each for himself, his wife Asha Verma and his daughter Tania Verma, continued for a period of five years, from 24.1.11 -2012 to 2014-15 and not for six years as stated in the petition and evidence of the complainant. It is also admitted that the complainant met with an accident on 22.9.14 and he took treatment at Archana hospital, Dibrugarh and admitted in the hospital on 23.9.14 and stayed there up to 27.9.14, but in regard to the expenditure of the treatment, the witness stated that the expenditure  should be Rs.75,665/- instead of Rs.91,854.50 as per the vouchers submitted by him. Apart from that, the complainant has failed to submit some documents, for which his claim has not been considered and it is also stated by the witness that there is no deficiency in repudiating the claim of the complainant by the insurance company, rather the complainant has failed to submit all requisite documents to the company to settle the compensation.

8.       I have heard the argument advanced by ld. counsel of both sides.

9.       It is not in dispute that the complainant is the subscriber of the mediclaim policy vide Policy No.322500/48/2010/1579 and he regularly paid the premium from the date of commencement of the policy, to the date of accident. It is also an admitted fact that the complainant met with an accident on 22.9.14 and after the accident, he was treated at Archana hospital, Dibrugarh and was admitted in the hospital twice, from 23.9.14 to 27.9.14 and 27.10.14 to 28.10.14.  It reveals that the accident occurred during the subsistence of the policy. According to the complainant, he incurred expenditure amounting to Rs.91.854.50, but the O.P. stated that from the vouchers submitted by the complainant,  it appears that he spent Rs.75,665/- for his treatment. As the original documents relating to treatment of the complainant are not available in the record, as such it can be assessed that the complainant had incurred expenditure amounting to Rs.75,665/- for his treatment, as admitted by the O.P. Hence, the O.P. is liable to pay the said amount. The O.P. is also liable to pay Rs.20,000/- for mental pain and agony suffered by the complainant and Rs.10,000/- for cost of litigation. Accordingly, all the issues are decided accordingly, in favour of the complainant.

O     R     D     E     R

10.     In the result, the complaint petition is partly allowed. The O.P./insurance company is directed to pay a total amount of Rs.1,05,665/- (Rupees One Lakh Five Thousand Six Hundred Sixty Five) (i.e. Rs.75,665/- for treatment + Rs.20,000/- towards mental pain and agony + Rs.10,000/- towards cost of litigation) to the complainant within two months from the date of passing of this order.

Given under my hand & seal of this Forum on this the 11^th day of April,  2017.

Dictated & corrected by me.

                                                                       (M. Nandi)

            President                                                 President

District Consumer Disputes                          District Consumer Disputes

Redressal Forum,  Tinsukia                          Redressal Forum,  Tinsukia                   

We  agree:   

 

 

              Member                                               Member   

District Consumer Disputes                      District Consumer Disputes

Redressal Forum,  Tinsukia                      Redressal Forum,  Tinsukia