Chandigarh

DF-II

CC/378/2017

Harish Singla - Complainant(s)

Versus

The Oriental Insurance Company Ltd., - Opp.Party(s)

G.S. Thind Adv.

25 Sep 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	378 of 2017
Date  of  Institution	:	28.04.2017
Date   of   Decision	:	25.09.2017

 

 

 

 

Harish Singla son of Late Sh.Prag Raj Singla, resident of Flat No.204, Tower No.5, Royal Estate, Zirakpur, Distt. Mohali.  

                               …..Complainant

Versus

1]  The Oriental Insurance Company Ltd., Oriental House, 25/27, Asaf Alia Rod, New Delhi 110002.

2]  Medi Assist India TPA Private Limited, plot No.7, Excom House, North Wing, Sakivihar Road, Saki Naka, Andheri (East), Mumbai 400072, through its authorised signatory.  

                          ….. Opposite Parties

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                               

Argued by :     Sh.G.S.Thind, Adv. for complainant

Brig.B.S.Taunque (Retd.), Adv. for OPs.

  

PER PRITI MALHOTRA, MEMBER

 

 

          Briefly stated, the complainant availed medical insurance Policy No.124500/48/2016/8544-TopUP from Opposite Party No.1 valid from 1.10.2015 to 30.9.2016 (Ann.C-2) under which the complainant along with his dependents i.e. father, mother and wife, was covered and the premium of the policy was deducted from his salary account.  It is averred that the father of the complainant met with an accident on 14.11.2015 and was admitted in Hospital at Patiala and for that the claim was settled and paid by the OPs.  Later on again the father of the complainant was admitted in Amar Hospital, Patiala from 19.2.2016 to 23.2.2016 for the problem arisen due to accident.  It is averred that due to serious condition of his father, death of his grant mother and busy schedule of the complainant, he submitted the claim amounting to Rs.1,33,715/- with the OPs on 18.8.2016, but the same was rejected on ground of late submission of claim, whereas as per the terms & conditions of the policy (Ann.C-6), the claim cannot be repudiated on late submission of documents. Hence, alleging the said repudiation as illegal and deficiency in service, this complaint has been filed.

 

2]       The Opposite Parties have filed joint reply and while admitting the factual matrix of the case, stated that as per the terms & conditions of the policy, the claim form and list of documents should have been submitted to the company/TPA within 30 days of discharge from the hospital/nursing home. It is also stated that the complainant on 22.8.2016 has submitted the claim documents after a delay of 181 days whereas the date of admission was 19.2.2016 and discharge date was 23.2.2016, therefore, the claim was rightly repudiated.  Pleading no deficiency in service and denying rest of the allegations, the OPs have prayed for dismissal of the complaint.

 

3]       Parties led evidence in support of their contentions. 

 

4]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

5]       There is no objection in regards to the treatment undergone by the father of the complainant during the currency of the policy period w.e.f. 19.2.2016 to 23.2.2016.  It is also an admitted fact that the father of the complainant is duly covered under the policy in question as insured/beneficiary. 

 

6]       The repudiation letter issued by the Opposite Parties as Ann.C-5 reveals that the claim lodged for reimbursement of the expenses incurred during the treatment of the father of the complainant, was rejected merely on technical ground of delay in lodging of the claim and claiming it being not as per the Clause 5.5 of the policy terms & conditions. 

 

7]       On this subject, there are clear guidelines of the Apex body of the Insurance Companies i.e. IRDA (Insurance Regulatory and Development Authority) who issued Circular  bearing No.Reg-IRDA/HLTH/MISC/CIR/216/09/2011, dated 20.9.2011 whereby the Insurance Companies have been directed to take a liberal view in like cases of delay and not to reject the claim on technical grounds and to cater the need of the hour, when there is explained delay due to unavoidable circumstances.    

 

8]       Thus, it is clear in view of above guidelines of IRDA that the claim of the complainant should not have been rejected merely on the basis of delay in submission of claim.  Therefore, by rejecting the genuine claim of the complainant, the Opposite Party NO.1 not only acted against the guidelines issued by their Apex Body i.e. IRDA, but also superseded their own terms & conditions at Annexure A-6 (Page-104), wherein it is stipulated  that :-

“Employees to submit documents for reimbursement of claim amount within 30 days from the date of discharge.  However, no repudiation of claims to happen on basis of late submission of the documents.” 

 

9]       In view of the above discussion, we are of the opinion that the Opposite Party No.1 has wrongly & illegally repudiated the genuine claim of the complainant, which amounts to deficiency in rendering proper service.  Therefore, the present complaint deserves to be allowed against OP No.1. Accordingly, the complaint is allowed against Opposite party NO.1 with following directions:-

1. To reimburse an amount of Rs.1,33,715/- being the claim amount, to the complainant;

 

2. To pay Rs.10,000/- as compensation for the harassment suffered by the complainant due to deficient services rendered by the Opposite Party;

 

3. To pay litigation expenses to the tune of Rs.7,000/-.

 

         This order shall be complied with by Opposite Party No.1 within a period of 30 days from the date of receipt of copy of this order, failing which it shall also be liable to pay interest @9% per annum on amount as mentioned in sub-para (a) & (b) above from the date of filing this complaint till realization, apart from complying with direction as at sub-para (c) above.

 

10]      However, the complaint qua Opposite Party NO.2 stands dismissed.

        Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

25^th September, 2017            

                                                                                       Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

                                                Sd/-

 (PRITI MALHOTRA)

MEMBER