PER SHRI. S.M. RATNAKAR – HON’BLE PRESIDENT
1) By this complaint the Complainant has prayed that the Opposite Parties be directed to pay Rs.54,300/- with interest @ 18% p.a. from cause of action till the realization of the said amount. The Complainant has also prayed that the Opposite Parties be directed to pay Rs.1,00,000/- for mental agony caused to the Complainant by making frivolous allegations and for not settling the genuine claim of the Complainant. The Complainant has also prayed Rs.50,000/- towards the cost of this litigation.
2) According to the Complainant, he is insured person of the Opposite Parties and he was hospitalized during the validity of coverage. He was suffering from temperature and accordingly he was admitted for the treatment as per the advise of the doctor. The Complainant thereafter submitted his claim for reimbursement but the Opposite Party No.3 rejected the claim by saying that it is considered as a fraud claim and therefore, falls under exclusion clause no.5.9 of the policy and the Complainant is not entitled for the same. The Complainant has alleged that he had submitted the relevant documents regarding his treatment but the Opposite Party No.3 who is the agent of Opposite Party Nos.1 & 2. The Opposite Party No.3 however, has wrongly repudiated the claim lodged by the Complainant. It is submitted that thus, there is deficiency on the part of the Opposite Party which amounts to unfair trade practice, the Complainant has therefore, prayed that the Opposite Parties be directed to pay the claim as mentioned in para no.1 of this order.
3) The Opposite Party Nos.1 & 2 appeared through Advocate Smt. Lata Shanbhag on 10/07/2013. However, she failed to file Vakalatnama and written statement on behalf of Opposite Party Nos.1 & 2. The Opposite Party No.3 though served remained absent the complaint therefore, proceeded ex-parte against Opposite Party No.3. The Complainant has filed affidavit of evidence and written argument. We have perused the documents filed with the complaint. We heard the oral argument of Shri. Kiran Patil, Ld.Advocate for the Complainant.
4) The Opposite Party has repudiated the claim as per letter at Exh.‘F’, dtd.15/12/2011 by quoting the exclusion clause 5.9 of the policy issued in favour of the Complainant. The Complainant was insured during the period of treatment as per the policy document at Exh.‘B’ is not dispute in the said letter. The Complainant has filed on record the letter of Dr. Sandeep Kher at page 51 addressed to Das Hospital stating that the Complainant should be admitted in the said hospital. The discharge summary document placed on record at Exh.‘C’ shows that when the Complainant was admitted he was admitted with the history of fever high grade since 3 days and he was having fever on 1st day. He was also suffering from headache and cough and he was admitted in the hospital during the period 13/05/2011 to 20/05/2011. The Complainant has placed on record the documents of the treatment obtained by him at Das Hospital and also the expenditure bills of said hospital at Exh.‘D1’ & ‘D2’. From the said bills the Complainant had incurred expenditure of Rs.54,300/- at Das Hospital for his medical treatment is brought on record. Thus, the claim made in the complaint against the Opposite Parties in view of non appearance of the Opposite Parties goes unchallenged. The Opposite Parties have though issued repudiation letter and repudiated the claim as per policy clause no.5.9 but the Opposite Party No.3 has not clarified as to how the claim filed by the Complainant is fraudulent or what was misrepresented by the Complainant or what material fact was not disclosed/declared by the Insured (Complainant). Considering these facts as the Opposite Parties have not brought on record any evidence in support of the reason stated in the repudiation letter at Exh.‘F’, we find that the Opposite Parties did not apply their mind while repudiating the claim of the Complainant. We therefore, hold that there is deficiency in service on the part of Opposite Parties and proved that the Opposite Parties had adopted unfair trade practice in repudiating the Complainant’s claim. In our view thus, the Opposite Parties are liable to reimburse the medical expenditure incurred by the Complainant. The Opposite Parties are therefore, directed to pay Rs.54,300/- with interest @ 6% p.a. from 15/12/2011 till it’s realization. The Opposite Parties thus, being guilty of unfair trade practice are liable to compensate the Complainant for the mental agony and harassment caused to him. The Complainant has claimed compensation of Rs.1,00,000/- on that count. In our view the said claim is exorbitant and an amount of Rs.8,000/- would be justified. The Complainant has prayed cost of Rs.50,000/- towards this complaint. In our view an amount of Rs.4,000/- is required to be granted towards the cost of this complaint. In the result the following order is passed –
O R D E R
i. Complaint No.235/2012 is partly allowed against Opposite Parties.
ii. The Opposite Party Nos.1 to 3 jointly and/or severally do pay an amount of Rs.54,300/- (Rs. Fifty Four Thousand Three Hundred
Only) towards the medical reimbursement incurred by the Complainant with interest @ 6% p.a. from 15/12/2011 till its realization to
the Complainant.
iii. The Opposite Party Nos.1 to 3 jointly and/or severally do pay Rs.8,000/- (Rs. Eight Thousand Only) towards compensation for
causing mental agony and harassment to the Complainant by adopting unfair trade practice and cost of Rs.4,000/- (Rs. Four
Thousand Only) towards this complaint.
iv. The Opposite Party Nos.1 to 3 are directed to comply with the above order within one month from the date of service of this order.
v. Certified copies of this order be furnished to the parties.
