PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

1)        By this complaint the Complainant has prayed the Opposite Parties be directed to pay Rs.3,75,000/- towards the mediclaim lodged on 25/09/2010 to the Opposite Party No.2.  It is also prayed that the Opposite Parties be directed to pay Rs.25,000/- towards mental torture, harassment and inconvenience suffered by the Complainant for deliberate default in providing the services to the Complainant.  It is also prayed to grant an amount of Rs.59,062/- towards interest for the period 25/09/2010 till 21/06/2011 @ 21% p.a. on the amount of Rs.3,75,000/- by the Opposite Parties and further interest as deemed fit from the date of filing of the complaint till realization of the amount awarded by this Forum. It is also prayed that amount of Rs.50,000/- be granted towards Advocate’s fees and Rs.5,000/- towards the cost of this proceeding against the Opposite Parties.

 2)        According to the Complainant, he obtained the Mediclaim Policy from the Opposite Party No.1 for the period 10/05/2010 to 09/05/2011 as per Exh. ‘A-1’.  The premium receipt of Rs.12,141/- in respect of the said policy is at Exh. ‘A-2’.  The Complainant had obtained the Mediclaim Policy since for more than 10 years from the Opposite Party No.1 and renewed the same without any gap. 

 3)        According to the Complainant, on 18/09/2010 for the first time he was admitted in the hospital at Criticare Multispeciality Hospital, Andheri (W), Mumbai – 59, due to suffering of heart attack and thereafter specialize treatment of the said ailment.  The Complainant then admitted in Asian Heart Hospital at B.K.C. Bandra (E), Mumbai – 51, on 19/09/2010 and was discharged on 21/09/2010.  The copies of medical papers for the aforesaid dates are filed at Exh.‘B’ & ‘C’ issued by the aforesaid hospitals. 

 4)        It is submitted that on or about 20/09/2010 i.e. within 24 hrs. from the time of hospitalization at Asian Heart Hospital the Complainant had intimated Opposite Party No.2, the copy of which is marked at Exh.‘D’. The Complainant on 25/09/2010 lodged the claim for reimbursement under Claim No.5452101190404 for sum of Rs.3,86,662/- with Opposite Party No.2 alongwith all relevant papers. The Complainant however, restricted the claim as the sum assured under the policy obtained by him including accrued bonus being Rs.3,75,000/-.               

 5)        It is alleged that the Opposite Party No.1 rejected the claim vide letter dtd.13/10/2010 on the ground that it is against the clause 5.3 of the policy.  The copy of the said letter is marked as Exh.‘E’.  It is alleged that the reason given for rejection of claim of the Complainant is improper as the Complainant had intimated about the hospitalization of him to the Opposite Party No.2 on 20/09/2010 and the claim documents were submitted to the Opposite Party No.2 on 25/09/2010.  It is alleged that the Opposite Parties rejected the lawful claim of the policy holder on one or other pretext. The rejection of the claim is contrary to the documents submitted by the Complainant. The Opposite Parties are negligent in providing service to the customer and act against interest of bonafide policy holders.  It is submitted that the said rejection of valid and lawful claim of the Complainant by the Opposite Parties is illegal which amounts to gross deficiency of service.  The Complainant therefore, issued notice dtd.03/11/2010 through his advocates which is marked at Exh.‘F’.  The Opposite Parties did not reply to the notice of the Complainant.  The Complainant therefore, filed the present complaint for the reliefs prayed in para 1 of this order. 

6)        The Opposite Party No.2 though served remained absent. The complaint therefore, proceeded ex-parte against Opposite Party No.2.  However, on 25/08/2011 the Opposite Parties No.1 & 2 appeared through Advocate – Sanil and filed Vakalatnama.  The Opposite Party No.1 was granted time to file written statement till 11/10/2010.  The Opposite Party No.1 did not file written statement on the same date and the matter was fixed for the affidavit and written argument of the Complainant.  The Opposite Party No.1 thereafter filed application to accept the written statement by setting aside No Written Statement order, however, the said application was rejected by order dtd.04/01/2012. The said order was challenged by the Opposite Party No.1 before the Hon’ble State Commission.  The Hon’ State Commission however, rejected the Revision Petition No.32 of 2012 vide order dtd.03/05/2012.

 7)        The Complainant filed affidavit of evidence.  The Complainant has also filed written argument.  The advocate for the Opposite Party Shri. Sanil was allowed to make his oral submission/argument.  We heard Smt. Sneha Bohara, the Ld.Advocate for the Complainant and Shri. K.C. Sanil, the Ld.Advocate for the Opposite Parties.  Smt. Bohara Advocate submitted that the Opposite Parties wrongly rejected the claim lodged by the Complainant on technical ground vide letter dtd.13/10/2010.  She made submission that the Complainant has obtained the mediclaim polices from the year 2002-03 till 2012-13 from the Opposite Parties. The copies of which are placed on record vide application dtd.22/03/2013 before this Forum.  She made submission that there is no violation on the part of the Complainant while submitting the claim to the Opposite Parties. She also submitted that the Complainant relative vide letter dtd.20/09/2010 had informed the Opposite Party No.2 that the Complainant was hospitalized in Criticare Multispeciality Hospital, Andheri, for the reason of heart attack on 18/09/2010. She submitted that as per policy clause no.5.3 the Complainant gave intimation immediately to the Opposite Party No.2.  She submitted that the said intimation according to the Opposite Parties may not be within the ambit of clause 5.3 of the policy but the same cannot be the ground for rejection of the claim as informed by the Opposite Party by their letter dtd.13/10/2010. She submitted that the Complainant had submitted his claim to the Opposite Party No.2 within the period of 7 days from discharge of this hospital and as per clause no.5.4 all supporting documents related to the claim must be filed with TPA within 7 days from the date of discharge from the hospital. The Complainant had complied atmost required conditions as per the policy clauses.  The rejection on the part of Opposite Party is totally improper and unjustifiable.  She made submission that such technical attitude of the Opposite Party is nothing but the unfair trade practice adopted by the Opposite Parties.  She made submission to avoid such attitude by the Insurance Companies, recently the Insurance Regulatory and Development Authority issued circular dtd.20/09/2011 to all Life Insurers and Non Life Insurers and informed that it has been receiving several complaints that claim are being rejected on the ground of delayed submission of intimation and documents.  She also pointed out that in the said circular it is intimated that the Insurers decision to reject such claims shall be based on sound logic and valid grounds and it may be noted that such limitation clause does not work in isolation and it is not absolute. It is also advised that the insurers must not repudiate such claims unless and until the reason for delay are specifically ascertained, recorded and the Insurers should satisfy themselves that the delayed claim would have been rejected even if reported in time. She made submission that the claim made in the complaint needs to be allowed.

 8)        Shri. Sanil, Advocate for the Opposite Party submitted that the repudiation on the part of the Opposite Party is just and proper in view of the non compliance of clause no.5.3 by the Complainant.  As per the said clause intimation should be given within 24 hours of admission in the Hospital.  The Complainant was admitted in Criticare Multispeciality Hospital from 18/09/2010 to 19/09/2010 and then transferred to Asian Heart Institute where he was admitted from 19/09/2010 to 21/09/2010.  The Opposite Party had received claim documents on 25/09/2010 with prior intimation on 24/09/2010 as mentioned in the letter of the Opposite Party No.2, dtd.13/10/2010.  He made submission that as the Complainant himself violated the terms and conditions of the policy the claim made in the complaint is liable to be rejected. 

 9)        While considering rival contentions  of  the  parties, it appears that on behalf of the Complainant his relative had informed to Opposite Party No.2 that the Complainant was admitted on 18/09/2010 for the reason of heart attack and the said intimation was given to the Opposite Party No.2 on 20/09/2010 as per Exh.‘D’. However, the Opposite Party No.2 wrongly mentioned in repudiation letter at Exh.‘E’ issued to the Complainant as “Now we have received your claim documents on 25/09/2010 with prior intimation on 24/09/2010.”  The said reason given in Exh.‘E’ i.e. in repudiation letter itself is wrong in view of the document at Exh.‘D’. The Opposite Parties therefore, in our view have not scrutinized the documents placed before them properly and wrongly rejected the claim lodged by the Complainant on the basis of clause No.5.3 of the policy.  As per policy clause No.5.4 “Note”, the Opposite Parties have given discretion regarding waiver of such condition in “extreme cases of hardship” where is it proved to the satisfaction of the Company that under the circumstances in which the Insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit.  The Opposite Parties ought to have taken into consideration that even as mentioned in the policy clause 5.4 “Note” the claim made by the Complainant can be granted as he was admitted for the reason of heart attack and thereafter for better and specialize treatment he was admitted in Asian Hospital at Bandra. The Opposite Parties ought to have considered that the case of the Complainant comes into the terms in “extreme cases of hardship”.  We therefore, hold that the rejection of the claim vide letter dtd.13/10/2010 is totally unjustifiable.  Furthermore, because of such attitude of the Insurance Companies, the Insurance Regulatory and Development Authority vide circular dtd.20/09/2011 which is relied by the advocate for the Complainant was required to advice the Insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the Insurers should satisfy themselves that the delayed claim would have otherwise been rejected even if reported in time.  In the present case the Opposite Parties have not disputed that the Complainant had incurred expenditure for his treatment as mentioned in the claim lodged to the Opposite Parties.  We therefore, hold that on that count also the rejection of the claim by the Opposite Parties is nothing but the deficiency in service on the part of the Opposite Parties. 

 10)      On the point of controversy set out by the Opposite Parties in our view the observations of the Hon’ble Consumer Disputes Redressal Commission, Punjab, reported in 2009 CTJ 1308 in the case of Life Insurance Corporation of India V/s. Smt. Usha Rani are required to be considered while allowing the genuine claim, if rejected by the Insurance Company.  The said observations are as under –

“The right of repudiation cannot be granted to the Insurance Companies on flimsy grounds or sketchy evidence. After all the Insurance Companies insure a person, take the premium and when it comes to making the insurance claim, they find out one or the other ground to reject the claim.  Courts, therefore, have to be cautious while determining the rights of the parties and has to insure that the right of repudiation is exercised by the Insurance Companies judicially and on sound principles.”                

 11)            The Hon’ble Supreme Court also in the case of Oriental Insurance Co. Ltd. V/s. Ozma Shipping Co., reported in 2009 CTJ 1887 have condemned the attitude of the Insurance Companies as under –

Before parting with this case we would like to observe that the insurance companies in genuine and bona fide claims of the insurers should not adopt the attitude of avoiding payments on one pretext or the other. This attitude puts a serious question mark on their credibility and trustworthiness of the insurance companies.  Incidentally by adopting honest approach and attitude the insurance companies would be able to save enormous litigation costs and the interest liability.”

 Considering the aforesaid observations as the Opposite Parties have wrongly rejected the claim lodged by the Complainant by pointing out one isolated clause of the policy and that too without verifying the intimation letter given to the Opposite Parties on behalf of the Complainant regarding his hospitalization on 18/09/2010 which was served it to the Opposite Party No.2 on 20/09/2010.  We therefore, hold that the submissions made by the Ld.Advocate for the Complainant are just and proper.  The Complainant is entitled for the amount of Rs.3,75,000/- towards the medical treatment claim in view of the sum assured as per Exh.‘A-1’ with interest @ 6% p.a. from 25/09/2010 till its realization. The Complainant is entitled for compensation from the Opposite Parties towards the deficiency in service and causing mental torture, harassment and inconvenience to the Complainant to the tune of Rs.10,000/- and cost of this proceeding to the tune of Rs.5,000/-.  In the result the following order is passed –

O R D E R

i.                    Complaint No.204/2011 is partly allowed against Opposite Parties.

ii.                 Opposite Parties are directed to pay Rs.3,75,000/- (Rs. Three Lacs Seventy Five Thousand Only) to the Complainant towards the medical treatment charges with interest @ 6% p.a. from 25/09/2010 till its realization.

iii.              Opposite Parties are directed to pay Rs.10,000/- (Rs. Ten Thousand Only) as compensation to the Complainant towards deficiency in service and mental torture and inconvenience caused to the Complainant

iv.               Opposite Parties are directed to pay cost of Rs.5,000/- (Rs. Five Thousand Only) to the Complainant towards this proceeding.  

v.                  The Opposite Parties are directed to comply with the above order  within one month from the date of service of this order.  

vi.               Certified copies of this order be furnished to the parties.