THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 859-13
Date of Institution : 27.12.2013
Date of Decision : 4.06.2015
Kashmir Singh Patial son of Sh. Punjab Singh Patial resident of H.No. 3, OCM Block A.B.C.D.E.F. Nagar, Municipal Corporation, Amritsar
...Complainant
Vs.
Branch Manager, United India Insurance Co.Ltd., 11-A, Lawrence Road, Amritsar
M/s. Alankit Health Care, TPA Ltd., 378-A, Silver Plaza, Madan Mohan Malviya Road, Amritsar through its Principal Officer
....Opp.parties
Complaint under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainants : Sh. Rajesh Bhandari,Advocate
For the opposite party No.1 : Sh.Sandeep Khanna,Advocate
For opposite party No.2 : Ex-parte
Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member &
Sh.Anoop Sharma,Member
Order dictated by :-
Bhupinder Singh, President
-2-
1 Present complaint has been filed by Kashmir Singh under the provisions of the Consumer Protection Act alleging therein that he obtained mediclaim policy bearing No. 200301/48/10/06/00000543 dated 19.8.2010 from the opposite party No.1 for the period from 20.8.2010 to 19.8.2011 covering the risk of his wife Anita Patial and his children. Wife of the complainant namely Anita fell ill and was admitted in Carewell Heart and Super Speciality Hospital, G.T.Road, Amritsar on 18.7.2011 and remained hospitalized from 18.7.2011 to 27.7.2011. Complainant informed the opposite parties regarding hospitalization of his wife but the opposite parties denied cashless facility to the complainant. The complainant incurred an expenses of Rs. 49,720/- on the treatment of his wife . The claim then immediately lodged claim with the opposite party No.1 by submitting all the bills on 19.9.2011 . But the opposite party No.1 vide letter dated 30.12.2011 repudiated the claim of the complainant. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite parties to reimburse the amount of Rs. 49720/- alongwith interest @ 18% p.a. Compensation of Rs. 50000/- alongwith litigation expenses were also demanded.
2. On notice, opposite party No.1 appeared and filed written version in which it was submitted that as per exclusion clause 5.4 of the mediclaim policy the claim documents are required to be submitted within 15 days from the date of discharge from the hospital. As the complainant has failed to comply with the said condition of the policy, as such he is not entitled to any relief. It was submittd that opposite party vide letters dated 11.11.2011, 29.11.2011 and 17.12.2011 sought an explanation from the complainant as to why the claim documents were not submitted within 15 days , but the complainant failed to give any explanation. The opposite party vide its letters also requested the complainant to provide the full case sheet and Lab reports , but complainant also failed to do so. As such the opposite party has rightly repudiated the claim of the complainant vide letter dated 30.12.2011.
3. Opposite party No.2 did not appear despite service, as such it was proceeded against ex-parte vide order dated 3.2.2014.
4. Complainant tendered into evidence his affidavit Ex.C-1, copy of Insurance Policy Ex.C-2, copy of invoice Ex.C-3, copy of certificate issued by hospital Ex.C-4, copy of application for repudiation Ex.C-5, copy of letter dated 26.12.2012 Ex.C-6, copies of Lab reports Ex.C-7, copy of pre-hospitalization form Ex.C-8, copy of record of hospital Ex.C-9, copy of policy of Alankit Healthcare Ex.C-10, copy of claim bill detail Ex.C-11, copy of letter dated 19.10.2011 Ex.C-12, copy of letter dated 19.9.2011 Ex.C-13, copy of application for denial of claim dated 18.10.2011 Ex.C-14, copy of description dated 18.7.2011 Ex.C-15.
5. Opposite party No.1 tendered into evidence copy of letter dated 11.11.2011 Ex.OP1/1, copy of letter dated 29.11.2011 Ex.OP1/2, copy of letter dated 17.12.2011 Ex.OP1/3, copy of order dated 30.12.2011 Ex.OP1/4, affidavit of Sh. Baldev Singh,Divisional Manager Ex.OP1/5.
6. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by the parties with the valuable assistance of the ld.counsel for the parties.
7. From the record i.e.pleadings of the parties and the evidence produced on record by the parties, it is clear that complainant got mediclaim policy bearing No. 200301/48/10/06/00000543 dated 19.8.2010 from the opposite party No.1 for the period from 20.8.2010 to 19.8.2011 covering the complainant, his wife Anita Patial and children Ex.C-3. The complainant alleges that his wife Anita Patial became ill and was admitted in Carewell Heart and Super Speciality Hospital, G.T. Road, Amritsar on 18.7.2011, where she remained hospitalized and was discharged on 27.7.2011 . Opposite party was informed regarding the admission of Anita in the aforesaid hospital. However, opposite party denied cashless facility as per terms and conditions of the policy on the ground that the hospital in which the patient is admitted is not on the panel of the opposite parties. After discharge from the hospital, complainant lodged claim with the opposite parties for the amount he had spent on the treatment of his wife in the aforesaid hospital amounting to Rs. 49,720/-. The complainant submitted all the bills alongwith claim form with opposite party No.1 on 19.9.2011 but the opposite party No.1 repudiated the claim vide letter dated 30.12.2011 on the ground of delay in submission of the claim and the documents. Ld.counsel for the complainant submitted that repudiation of the claim is totally illegal and arbitrary which amounts to deficiency of service on the part of the opposite parties.
8. Whereas the case of opposite party No.1 is that as per exclusion clause 5.4 of the mediclaim policy in question, claim documents are required to be submitted within 15 days from the date of discharge from the hospital. But the complainant submitted the claim form as well as the relevant documents to the opposite party after a lapse of a period fo about two months. Apart from this opposite party No.1 vide letter dated 11.11.2011 Ex.OP1/1, 29.11.2011 Ex.OP1/2 and 17.12.2011 Ex.OP1/3 sought explanation from the complainant as to why the claim documents were not submitted within 15 days from the date of discharge from the hospital. But the complainant failed to give any explanation/clarification . The opposite party also asked the complainant vide aforesaid letter to provide full case sheet and Lab reports , but the complainant also failed to do so. So the opposite party repudiated the claim of the complainant vide letter dated 30.12.2011 Ex.OP1/4. Ld.counsel for opposite party submitted that there is no deficiency of service on the part of the opposite parties qua the complainant.
9. From the entire above discussion, we have come to the conclusion that no doubt Anita Patial, wife of the complainant was insured with the opposite party vide policy Ex.C-2 for the period from 20.8.2010 to 19.8.2011 . It is also not disputed that Anita, insured fell ill and was admitted in Carewell Heart and Super Speciality Hospital,G.T.Road, Amritsar for the period from 18.7.2011n 27.7.2011 As per record of the aforesaid hospital Ex.C-9 the complainant spent about Rs. 49720/- on the medical treatment of Anita insured in the aforesaid hospital. After discharge from the hospital, the complainant lodged claim with the opposite party No.1 on 19.9.2011. This fact has also been admitted by opposite party No.1 vide their letter dated 19.10.2011 Ex.C-12 that they had received the claim intimation from the complainant on 19.9.2011 alongwith claim bills from the insured and they forwarded the same to opposite party No.2 vide this letter Ex.C-12 dated 19.10.2011 which was received by opposite party No.2 on 20.10.2011 . As per terms and conditions of the policy clause 5.4 claim documents are required to be submitted within 15 days from the date of discharge from the hospital. The opposite party wrote as many as three letters to the complainant i.e. letter dated 11.11.2011 Ex.OP1/1, letter dated 29.11.2011 Ex.OP1/2 and letter dated 17.12.2011 Ex.OP1/3 asking the complainant that the complainant has failed to submit the claim documents within 15 days from the date of discharge from the hospital and the complainant was requested to provide the necessary explanation/clarification within 10 days of the receipt of the letter and also to provide full case sheet and Lab reports. But the complainant did not submit any explanation/clarification nor submitted case sheet and Lab reports nor even submitted any reply to these letters to the opposite party. Opposite party was,therefore, justified to repudiating the claim of the complainant as per terms and conditions of the policy clause 5.4.
10. Consequently we hold that complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
4.06.2015 ( Bhupinder Singh )
President
( Kulwant Kaur Bajwa) (Anoop Sharma)
