Haryana

Yamunanagar

CC/685/2013

Anil Ghai S/o. Krishan Kumar - Complainant(s)

Versus

United India Insurance Company Ltd. - Opp.Party(s)

V.K.Malhotra

20 Sep 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA   NAGAR

                                                                                    Complaint No.685 of 2013.

                                                                                    Date of institution: 20.9.2013.

                                                                                     Date of decision: 20.9.2017.

 

Anil Ghai s/o late Sh.Krishan Kumar Ghai, age 50 years r/o House No.545, Model Town, Yamuna Nagar.

                                                                                                            …Complainant.

                                    Versus

1.         The Senior Branch Manager, United India Insurance Company Ltd. Railway Road, Yamuna Nagar 135001.

2.         The Regional Manager, United India Insurance Co. Ltd. Regional Office, Ambala Cantt. 133001.

            3.         The United India Insurance Company Ltd. New Delhi 110002.

 

                                                                                                             … Respondents.

 

BEFORE:       BEFORE:   SH.SATPAL, PRESIDENT,

          SH.S.C.SHARMA, PRESIDING MEMBER.     

                     SMT. VEENA RANI SHEOKAND, MEMBER.

 

Present:  Sh. V.K.Malhotra, Advocate, counsel for complainant.   

               Sh. Rajiv Gupta, Advocate, counsel for respondents.

 

ORDER:     (SATPAL, PRESIDENT)

 

1.                     The complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 against the respondents (herein after the respondents shall be referred as Ops)

2.                     Brief facts of the present complaint, as alleged by the complainant, are that the complainant purchased the medi-claim policy No.11010148109700000927 on 17.12.2011 from OP No.1 for the period from 17.12.2011 to 16.12.2012 and the same was again renewed by the OP No.1 from 15.12.2012 to 16.12.2013.  As the health of the complainant was deteriorating day to day, his family decided to shift him to Delhi on 9.12.2011, he was admitted in Pushpawati Singhania Research Institute for Liver, Renal and Digestive Disease, New Delhi where he remained admitted up to 12.12.2011 and on 12.12.2011, he was transferred by Pushpawati Singhania Research Institute of Liver, Renal and Digestive Disease, New Delhi where to Fortis Escorts Heart Institute, New Delhi which was not fully equipped with cardiology care.  Thereafter, after examination of the complainant at Fortis Escorts Heart Institute, New Delhi on 12.12.2011 there and then he was discharged and was shifted to MAX Medcenter, New Delhi.  The complainant was the holder of Medi-claim Cash less policy but the Pushpawati Singhania Research Institute refused to accept the cash less policy and assured the complainant that the amount will be got refunded to him from the insurance company as the Pushpawati Research Institute refers the case to Fortis Escort Heart Institute, New Delhi. Thereafter when the complainant was shifted to Max Medcenter New Delhi on 12.12.20111 and was hospitalized in the same hospital for one week i.e. 12.12.2011 to 19.12.2011, he had to stay in Delhi as advised by Max Medcenter New Delhi for regular check up till 7.1.2013 and made huge expenses during his stay at Delhi up to 7.1.2013.  However, the account of expenses of Max Medcenter New Delhi was satisfied and paid and square off against cash less policy of respondent company.  Intimation of ill health of complainant was given to OP on 12.12.2011 against valid acknowledgement. The acknowledgement of the information and shifting from Fortis Escorts Heart Institute, New Delhi to Max Medcenter New Delhi was also given to respondent-company on 12.12.2011 which was duly acknowledged by the OP-company.  However, all the bills were submitted to the Ops by the complainant.  Since 14.8.2012, no reply of the condonation letter was given to the complainant whereas it is a basic law that one year condonation is exceptional under the law.  The complainant submitted all the bills for Rs.43,598/- paid by the complainant besides having mediclaim policy.  Thereafter, the complainant got served a legal notice upon the Ops through his counsel on 22.8.2013 but till date no reply has been given, which amounts to deficiency in service on the part of the Ops and prayed for directing the Ops to pay Rs.2,00,000/- for mental agony, Rs.50,000/- mental torture, Rs.67505/- for medi-claim bills already submitted to OP No.1 of Pushpawati Singhania Research Institute for Liver, Renal & Digestive Disease, New Delhi, Rs.43,598/- medical claim bill already submitted to Op No.1 of Fortis Escort Heart Institute, New Delhi, Rs.40,000/- for transport expenses, Rs.1,00,000/- expenses for staying in Delhi for three weeks and Rs.21,000/- legal expenses.

3.                     Upon notice, the Ops appeared and filed their written statement by taking some preliminary objections alleging therein that the complaint is not maintainable against the answering Ops; there is no negligence or deficiency in service on the part of the Ops; the complainant has no locus standi to file the present complaint; the complainant has not come to this Forum with clean hands.  True and material facts, it is settled preposition of law that a person who is claiming relief under a contract (Insurance Policy) must comply with its terms and conditions.  As per the terms and conditions of the Individual Health Insurance Policy taken by the complainant from the Ops w.e.f.17.12.2010 to 16.12.2011 for a sum of Rs.3,00,000/-, every notice or communication is to be given or made in this policy which must be delivered in writing at the address of the TPA (Third Party Administrator).  As per policy condition no.5.3 upon the happenings of any event which may give rise to a claim under this policy, notice with full particulars shall be sent to the TPA named in the schedule immediately and in case of emergency/hospitalization within 24 hours from the time of hospitalization.  Further, as per policy condition No.5.4 all supporting documents relating to the claim must be filed with TPA within 7 days from the date of discharge from the hospital.  Further, as per policy condition No.5.5 the Insured Person shall obtain and furnish the TPA with all the original bills, receipts and other documents upon which a claim is based and shall also give the TPA/company such additional information and assistance as the TPA company may require in dealing with the claim.  However, in this case, the complainant did not submit the claim papers well in time in spite of the repeated letters of the TPA and finding no other alternative the TPA vide its letter dated 26.12.2011 closed the file of the complainant as no claim on account of not receiving the documents.  It is worthwhile to mention here that the complainant had earlier lodged a claim under the policy in question and the same was paid to him, which clearly reflects the bonafide of the company and the fact that the complainant knew the claim procedure and process.  Hence, on the grounds stated above, no claim is payable to the complainant.  The complaint is without any merits and the same is liable to be dismissed. On merits, the Ops have controverted the plea taken by the complainant and reiterated the stand taken in the preliminary objections.  There is no deficiency in service on the part of the Ops and prayed for dismissal of complaint with costs. 

4.                     To prove his case the complainant tendered into evidence affidavit of complainant as Annexure CW/A, and documents such as copy of policy as annexue C.1, copy of letter dated 12.12.2011 as annexure C.2, copy of letter dated 14.8.2012 as annexure C.3,  copy of cash memo for Rs.100/- as annexure C.4, copy of final bill as annexure C.5 & C.6, copy of transfer summary as annexure C.7, copy of summary as annexure C.8, copy of receipt of Rs.25000/- as annexure C.9, copy of bill C.10 & C.11, copy of legal notice as annexure C.12, copy of postal receipt as annexure C.13 and closed his evidence.

5.                     On the other hand the learned counsel for the Ops tendered into evidence affidavit of Shri Ajay Sareen, Assistant Manager and documents such as copy of no claim letter as annexure R.1, copy of policy as annexure R.2 and closed the evidence on behalf of Ops.

6.                     We have heard the learned counsels for the parties and have gone through the pleadings as well as documents placed on file minutely & carefully.

7.                     After hearing the learned counsel for the parties and going through the pleadings as well as  documents placed on the file, it has been found the plea taken by the Ops that the complainant has not submitted his claim within time before the TPA as per terms and conditions contained in the policy is not tenable as the complainant has informed the Ops in time vide annexure C.2 about getting the treatment in the Escort Hospital and the said letter is duly received by the OP on 12.12.2011.  Receipt of said letter is nowhere controverted by the Ops during the trial of the complaint.  The claim of the complainant has been rejected only on the ground that as per condition No.5.4 of the policy all the supporting documents relating to the claim were not filed with the TPA and that the complainant did not provide all the original bills, receipts and other documents to the TPA as required vide condition No.5.5. of the policy. This contention of the OPs is not tenable and justifiable as the complainant had already informed the Ops vide annexure C.2 and keeping in view the seriousness of his ailment, the claim of the complainant should not have been discarded on technical grounds.  During the course of arguments the counsel for the Ops draw the attention of this Forum towards letter dated 26.12.2011 (Annexure R.1) vide which the documents were demanded from the complainant.  The said letter Uannexure R.1) has been perused which is under:-

            This is with reference to our earlier letters dated Dec 10, 2011 wherein following documents/information was demanded from you in respect of the above mentioned claim:

            1.         DOCUMETNS NOT RECEIVED.

We still have not received the complete documents/information called for which are essential for us to further pay claim in spite of three query letters.

In view of above, we are left with no option to mark your claim as ’No Claim’.

 

                        This letter speaks about the earlier letter dated 10.12.2011 copy of which has not been placed on record by the Ops. Further, complainant as discussed above has informed the Ops who in turn could have informed the TPA about the treatment/admission etc. of complainant.  From the above discussion, this Forum is of the considered view that the complainant cannot be denied reimbursement of the expenses incurred by him during the treatment, as mere technicalities should not be allowed to come into way of imparting justice. 

                        Resultantly, we are of the considered view that following directions are being issued to meet the ends of justice:-

  1. The Ops are directed to decide the claim of the complainant within a period of 60 days from the date of preparation of copy of this order.
  2. They are further directed to pay Rs.5500/- as cost of litigation to the complainant within 30 days from the date of this order.

Copies of this order be supplied to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court.20.9.2017

                                                                                            

                                                                              (SATPAL)

                                                                             PRESIDENT.

 

(VEENA RANI SHEOKAND)                        (S.C.SHARMA)

MEMBER.                                                         MEMBER.

 

 

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