Order dictated by:
Sh. Anoop Sharma,Presiding Member
1. Sandeep Nayyar, complainant has brought the instant complaint under section 11, 12 , 13 & 14 of the Consumer Protection Act, 1986 on the allegations that he got renewed his mediclaim policy bearing policy No. 255300/48/2015/925 and present policy is bearing No. 255300/48/2016/938 for the period from 22.11.2015 to 21.11.2016 by making premium of Rs. 19,065/- with sum assured Rs. 7 lacs. The said mediclaim policy was under “Gold Plan-Happy Family Floating Policy”. In the said policy complainant Sandeep Nayyer, his wife Tanu Nayyar, his father Tarsem Kumar Nayyar, his mother Shama Rani and his minor son Saransh Nayyar. In the month of December 2015, mother of the complainant undergone treatment at Ohri Hospital and an amount of Rs. 36300/- was incurred on her treatment vide bill No. 936 dated 30.12.2015. The complainant requested the opposite parties to pay the claim amount under the policy. The mother of the complainant was again admitted to Escort Fortis Hospital and incurred an expenditure of Rs. 2,01,780/- on her treatment. The complainant requested the opposite parties number of times for the settlement of the claim , but till date the claim has not been given to the complainant . The complainant also served a legal notice dated 1.8.2016 upon the opposite parties but the opposite parties did not give any reply to the legal notice. Vide instant complaint, complainant has sought for the following reliefs:-
(a) Opposite parties be directed to make payment of the claim amount as per the policy alongwith interest @ 18% p.a. from the date of filing of the claim till the date of actual payment ;
(b) Compensation to the tune of Rs. 1,00,000/- may also be awarded to the complainant.
(c ) Opposite parties be also directed to pay litigation expenses to the tune of Rs. 10000/- to the complainant.
Hence, this complaint.
2. Upon notice, opposite parties No. 1 to 3 appeared and filed written version in which it was submitted that the detail of various dates of hospitalization of patient namely Shama Rani and the claim registered against those hospitalizations are as under:-
S.No | Date of Admission | Date of Discharge | Hospital | Claim No. | Date of Receipt | Claim Amount |
1. | 6.2.2016 | 8.2.2016 | Ohri Hospital | 103021600063 | 18.3.2016 | 21,689/- |
2. | 25.12.2015 | 30.12.2015 | Ohri Hospital | 103011600204A(Post Hospitalization | 18.3.2016 | 66,852/- |
3. | 25.12.2015 | 30.12.2015 | Ohri Hospital | 103011600204 | 27.1.2016 | 59,925/- |
Thereafter the TPA i.e. opposite party No.4 has sought some documents alongwith information from the complainant in order to decide the abovestated claims. The detail of documents/information sought against each claim from the complainant are reproduced hereunder:-
S.No. | Claim No. | Discrepancy raised | Dates |
1. | 103011600204 | 1.Kindly provide total claim amount. 2. Kindly provide original discharge summary. 3. Kindly provide reports of investigations done & in support of final diagnosis in original. 4. Kindly provide duration of presenting complaints with first consultation paper certified by the treating doctor in original. 5. Kindly provide reason for delay in intimation & submission of documents. | 3.2.2016, 6.3.2016 & 19.3.2016 |
2. | 103011600204A | 1.Kindly provide all original Investigation reports done in this case for which you are claiming Rs. 1800/-, Rs.2250/-, Rs.1450/-, Rs.199/-, Rs.2200/-. 2. Kindly provide policy of year 2011-2012, 2012-2013, 2013-2014, 2014-2015. | 21.3.2015, 15.4.2016, 8.5.2016 |
3. | 103021600063 | 1.Kindly condone the delay for 32 days and arrange the discrepancy reply. 2. Lab investigation reports in support of final diagnosis. 3. Original paid receipts against the final bill. 4. Reason for delay in submission of claim. | |
It was submitted that letters had been written to the complainant seeking aforesaid information/documents from the complainant, but till date the complainant has failed to provide the relevant documents/information . As such the lapse is on the part of the complainant himself for non processing of the claims. However, any other hospitalization of patient namely Shama Rani is denied for want of knowledge. While denying and controverting other allegations dismissal of complaint was prayed.
3. During the proceedings counsel for the opposite parties stated at bar that the claim is premature as the complainant has failed to provide the relevant information/documents and hence we have perused the averments made by the parties . Perusal of the file shows that the complainant though has submitted that he raised the mediclaim regarding treatment of his mother with the opposite party, but has failed to produce any documents allegedly submitted to the opposite party and in the absence of relevant documents, the opposite parties are unable to process the claim of the complainant. In such a situation, we direct the complainant to submit the claim alongwith all the relevant documents as demanded by the opposite party within 30 days from the date of receipt of copy of this order and thereafter opposite parties shall process the claim of the complainant within a further period of 45 days of receipt of documents from the complainant . In case the complainant is not satisfied with the decision of the opposite party, the complainant shall be at liberty to file fresh complaint , if he so desires. Keeping in view the peculiar circumstances, the parties are left to bear their own costs. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated : 14.7.2017
