JUDGEMENT
Complainant by filing this complaint has submitted that he is the holder of the op’s since 2008 having present policy No. 311500/48/2013/9591 of the National Insurance Company and one Sri Ajay Deb Mondal in-charge of the Oriental Insurance Co. Ltd., Magma Cell Branch approached the complainant to switch over the policy to the complainant’s company with the assurance of better facilities and service and accordingly complainant purchased the mediclaim policy from the Oriental Insurance Co. Ltd. at the end of the first year and during the first renewal complainant noticed that the Oriental Insurance Co. Ltd. was not giving any claim bonus which complainant was getting from National Insurance Company.
Even from the second year after repeated reminder ops issued the card for which complainant had contacted personally and collected from their office and since 2011 ops are collecting his renewal premium but not issuing the mediclaim card. Moreover complainant submitted a small claim on 22.01.2013 for an amount of Rs. 6,648/- with all relevant documents but after several persuasion ops did not give any claim neither they had given the complainant any reply. So the complainant lodged a complaint with the Asstt. Director, CA & FBP, Kolkata office of West Bengal and after hearing both the parties on 30.01.2014 where the ASSTT. Director of CA & FBP instructed the insurance company to reply to his claim and handed over the card to the complainant in the hearing on 14.02.2014. Ultimately insurance company handed over the mediclaim card without any photographs affixed on it, though complainant also handed over the claim repudiation letter in front of the Asstt. Director of CA & FBP Kolkata and the insurance company took more than one year to hand over the card almost just before the expiry of the policy which will expire on 17.03.2014 midnight and they took more than one year to given the repudiation letter for claim. But in the above context complainant has filed this complaint for causing harassment and did not bother to provide any service inspite of paying the premium regularly in time. In the result complainant has filed this complaint for redressal.
On the other hand op by filing written statement submitted that the present complaint is barred by limitation and liable to be rejected. But op admitted that complainant prayed for Rs. 6,648/- as mediclaim made on 22.01.2013 which was under process of consideration and review on receiving the relevant papers and documents for the purpose of processing of the complainant’s said claim in accordance with the terms and conditions in force as enumerated in the Mediclaim Policy in question and this op finally through a letter dated 12.02.2014 repudiated the claim of the complainant according to law and valid ground that the hospitalization expenses are admissible only if hospitalization is for a minimum period of 24 hours. But in this case complainant only stayed for 3 hours. So as per Exclusion Clause 2.3 and Exclusion Clause 4.10 of the Mediclaim Policy was repudiated and denied all other allegations and submitted that they are giving proper service to the complainant, so the complaint should be dismissed.
Decision with reasons
On proper hearing of the complaint and also the documents including the written version of the op and further considering the argument as advanced by the op and also relying upon the documents and clause of mediclaim, it is clear that the repudiation was made ultimately on 12.02.2014 whereas complainant submitted the claim for Rs. 6,648/- on 12.02.2013. But in view of the Clause 2.3 and Exclusion Clause 4.10, complainant is not entitled to the said claim which was repudiated. No doubt repudiation was not unjustified and illegal. But fact remains that for one year the op authority did not dispose of the same. But as per provision of IRDA any claim of the insured must be disposed of within 3 months. So, in this regard it is found that op did not act and render proper service.
Truth is that complainant paid regular premium and op received it. But no identity card was issued and ultimately after the matter was placed before the Asstt. Director of CA & FBP, Kolkata, op subsequently issued the card without affixing any photo of the complainant and his family members. It indicates that it was also the negligent manner of service on the part of the op and op has not denied the reason for delay in disposing of the said claim and reason for handover the identity card after lapse of one year to the complainant by the op. So apparently the service was not properly rendered which is proved and fact remains in such a manner the insurance companies are only collecting premium and sending the policy documents but they are not giving identity card and for which cashless benefits are not being enjoyed by so many policy holders and that is no doubt an negligent manner of service and in this case it is proved that complainant has been harassed and truth is that complainant after filing this complaint against the op before the Asstt. Director of CA & FBP, Kolkata op disposed of all the matters which simply proves that no service was properly rendered and negligent manner of service was rendered by the op for which invariably the complainant is entitled to get some compensation.
Accordingly the complaint succeeds in part.
Hence, it is
ORDERED
That the complaint be and the same is allowed on contest with cost of Rs. 2,000/- against the op.
Op shall have to pay compensation of Rs. 5,000/- to the complainant within one month from the date of this order along with litigation cost i.e. total Rs. 7,000/- within one month from the date of this order for causing pain, sufferings and mental harassment to the complainant and also for rendering negligent and deficient manner of service to the complainant.
If op fails to comply this Forum’s order fully within the stipulated period in that case op shall have to pay penal interest at the rate of Rs. 100/- per day till full satisfaction of the decree and even penal proceeding may be started against him for which he shall be liable to pay fine and other punitive damages as per provision of Section 27 of C.P. Act 1986 and same shall be deposited to this Forum’s Account.
