cccccPBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of December 2012.
Filed on : 05-06-2012
Present :
Shri. A Rajesh, President.
Smt. C.K. Lekhamma, Member
C.C. No. 336/2012
Between
Tini Varghese, : Complainant
W/o. Varghese Paul, (By Adv. K. Treasa Rani George,
Eralil house, Green Avenue, 1st Floor, Eralil Enclave,
Palarivattom, Basin road, Kochi-682 031)
Ernakulam-682 035.
And
1. The Reliance General Insurance, : Opposite parties
Regd. Office, Reliance Centre-19, (O.P.1 and 2 by adv.
Walchand Hirachand Marg, Saji Isaac K.J., 311 H.B.
Ballar Estate, Mumbai-400 000, Flats, Panampilly Nagar,
rep. by Authorized Officer. Kochi-682 036.)
2. The Service Manager,
Reliance General Insurance Co. Ltd.,
XI/3599, IV Floor,
Elizabeth Alexander Memorial
Building,Shanmugham road,
Marine Drive, Cochin-682 031.
3. Medi Assist India TPA Pvt. Ltd., (3rd Opposite party
49, Shilpa Vidya, Absent)
1st Main J.P. Nagar,
3rd phase, Bangalore-560 078,
rep. by Authorized Officer.
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant is an insured in a policy issued by the 1st and 2nd opposite parties for the period from 23-02-2010 to 22-03-2011. As per the policy a sum of Rs. 1,00,000/- for each insured is covered for hospitalization, post hospitalization and cost of health check up. The complainant underwent treatment for Carcinoma Breast in Well Care Hospital, Ernakulam. Thereafter the complainant duly submitted insurance claim application before the 1st and 2nd opposite parties claiming Rs. 93,362/-. Since there is delay in non-disbursement of insurance claim the complainant caused to issue a lawyer notice to the opposite parties to pay the insurance amount. The 1st and 3rd opposite parties received the notice but they have not taken any action yet. The complainant is entitled to get the insurance claim of Rs. 93,362/- together with compensation of Rs. 50,000/- and costs of the proceedings. This complaint hence.
2. The version of the 1st and 2nd opposite parties is as follows:
The complainant has not produced the necessary documents to process her claim application in spite of four letters reminding her of the same. The opposite parties had requested certificates like prescription of doctor, investigation report, claim form duly signed by treating doctor, lab report etc. But she failed to do so. The complainant had submitted 4 claims before the opposite parties. The complainant did not produce the necessary documents as required by the opposite parties and the opposite party had to close the claims of the complainant. There is no deficiency in service on the part of the 1st and 2nd opposite parties. The complaint lacks merits and is liable to be dismissed.
3. Despite service of notice of this complaint from this Forum the 3rd opposite party opted to remain absent during the proceedings. The complainant was examined as PW1 and Exts. A1 to A9 were marked on her side. No oral evidence was adduced by the 1st and 2nd opposite parties Exts. B1 to B4 were marked. Heard the counsel for the contesting parties.
4. The points that came up for consideration are as follows:
i. Whether the complainant is entitled to get insurance claim
from the opposite parties?
ii. Whether the complainant is entitled to get compensation and
costs of the proceedings from the opposite parties?
5. Points Nos.i & ii. Admittedly the complainant was holding a valid insurance policy of the 1st and 2nd opposite parties for the period from 23-02-2010 to 22-03-2011 evident from Ext. A1. During the currency of Ext. A1 policy the complainant underwent treatment at Well Care, Hospital at Ernakulam and her disease was diagnosed as Carcinoma Right Breast. She was admitted to the Hospital on 07-02-2011 and discharged on 15-02-2011 evident from Ext. A2 certificate. According to the complainant she duly submitted the insurance claim application before the 2nd opposite party and the 2nd opposite party did not consider the same for their own reasons. She maintains that in spite of service of Ext. A3 lawyer notice the opposite parties did not pay any attention towards the claim of the complainant. The opposite parties vehemently refuted the allegations of the complainant and submitted that in consequence of the receipt of the insurance claim the complainant was called upon to submit various documents to process the claim application of the complainant. According to them they have issued Exts. B1 to B4 letters to the complainant and since she failed to respond to the same, they could not process the claim application and it was closed.
6. It is pertinent to note that Exts. B1 to B4 letters issued to the complainant were admitted in evidence without demur which goes to show that the complainant failed to produce the documents as stated in Ext. B1 to B4 before the opposite party. So at this stage we could not find any deficiency in service on the part of the opposite parties in processing the claim application of the complainant. In the above circumstances in the interest of justice we feel that a direction be given to the opposite parties 1 and 2 to process the insurance claim of the complainant if the complainant submits the relevant documents called for through Exts. B1 to B4.
7. In the result, we partly allow the complaint and direct that the opposite parties shall process the insurance claim of the complainant provided the complainant submits the relevant documents as required by the opposite parties.
The above said order shall be complied with within a period of 30 days from the date of receipt of the documents which shall be submitted by the complainant within 15 days from the date of receipt of a copy of this order.
Pronounced in the open Forum on this the 31st day of December 2012.
Sd/-
A Rajesh, President.
Sd/-
C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : Copy of a reliance Capital
Company
A2 :; Copy of claim form
A3 : Lawyer notice dt. 09-03-2012
A4 : A.D. card
A5 : A.D. card
A6 : Copy of claim form
A7 : Copy of letter dt. 17/10/2011
A8 : Copy of letter dt. 17-10-2011
A9 : Copy of letter dt. 17/10/2011
Opposite party’s Exhibits : :
Ext. B1 : Copy of letter
dt. 17-10-20011
B2 : Copy of letter dt. 17-10-2011
B3 : Copy of letter dt. 17-10-2011
B4 : Copy of letter dt. 22/03/2012
Depositions:
PW1 : M/s. Tiny Varghese
