Order No. 20 dt. 09/06/2017
The case of the complainant in brief is that the complainant being the account holder of Indian Overseas Bank had the tie up with the Universal General Insurance Co. for covering the insurance facility to the account holders. The complainant availed of that benefit and paid the premium and the policy was issued. On 14.2.13 the complainant suffered fractured of left humour bone and he was admitted to Belle Vue Clinic and he was operated. The complainant incurred an expenditure of Rs.1,09,113/- and after recovery the complainant provided the bills to the o.p. insurance company for medical reimbursement of the bills, but o.p. insurance company failed to disburse the amount for which the complainant filed this case praying for direction upon the o.p. insurance company to disburse the fund in favour of the complainant as well as compensation of Rs.10 lakhs and litigation cost of Rs.10,000/-.
The o.p. nos.1 and 2 contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that o.p. no.3 repudiated the claim of the complainant by stating the reason that since the complainant failed to file the documents viz. original x-ray, C.T. Scan, MLC copy, all investigation report and narration of incident, etc. for which o.p. no.3 had no other alternative but to repudiate the claim of the complainant. On the basis of the said fact o.p. nos.1 and 2 prayed for dismissal of the case.
The o.p. no.4 contested this case by filing w/v and stated that the bank had no role to pay in respect of the claim of the complainant, therefore the case is to dismissed against o.p. no.4.
In spite of receipt of notice the o.p. no.3 did not contest this case and as such, the case has proceed ex parte against the o.p. no.3.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with o.p. insurance company.
- Whether the policy was valid at the relevant point of time.
- Whether the complainant suffered fracture in left humour bone.
- Whether the bill submitted by the complainant was repudiated by o.p. no.3.
- Whether there was any deficiency in service on the part of o.p. insurance company.
- Whether the complainant will be entitled to get the relief as prayed for.
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant being the account holder of Indian Overseas Bank had the policy with o.p. insurance company and during the subsistence of the said policy the complainant sustained fracture for which he was treated at Belle Vue Clinic and after his release he submitted a bill of Rs.1,09,113/- for reimbursement of the medical bills, but o.p. insurance company did not take any action for which the complainant had to file this case praying for direction upon the o.p. insurance company for releasing the said fund as well as compensation.
Ld. lawyer for the o.p. insurance company argued that the complainant alleged that he suffered fracture of left humour bone and he was admitted to Belle Vue Clinic for treatment. The complainant after submission of bills was informed for providing the necessary documents viz. original x-ray, C.T. Scan, past history of duration of ailment, certificate from the treating doctor to rule out influence of alcohol of the patient at the time of incidents in case of accident. The complainant did not provide those documents; as such o.p. no.3 did not allow the bills in favour of the complainant for payment of the said amount. Since there was no deficiency in service on the part of insurance company, they prayed for dismissal of the case.
Considering the submissions of the respective parties it is admitted fact that the complainant had the policy at the relevant point of time, he suffered the injury as stated in the petition of complaint. It is also an admitted fact that the complainant paid premium to the insurance company and the policy was valid at the time of undergoing treatment. It is also an admitted fact that the complainant after recovery from the said treatment submitted a medical bill of Rs.1,09,113/-. The complainant has stated that o.p. no.3 did not infirm anything to the complainant regarding the fate of the claim made by him regarding the reimbursement of the medical bills. In their w/v insurance company stated that o.p. no.3 did not contest this case but TPA made some queries to the complainant which were not provided by the complainant resulting in repudiation of the claim of the complainant. The o.ps. have also stated that there was no deficiency in service on their part. It appears from the materials on record that the complainant sent several letters to the insurance company asking for disbursement of the amount but insurance company did not reply those letters. In order to avoid of the payment of the medical bills insurance company made some stray queries which were not relevant for the purpose of the disbursement of the medical bills of the complainant and unnecessarily sat tight over the claim of the complainant and failed to disburse the amount in favour of the complainant in respect of the amount of Rs.1,09,113/-. The insurance company in order to evade their responsibility failed to give any reply to the letter of the complainant as well as made some stray queries which were not relevant for the purpose of disbursement of the amount. In view of such facts and circumstances of the case we hold that there was deficiency in service on the part of o.p. insurance company and the insurance company will be liable to pay the amount claimed by the complainant regarding the medical expenses incurred by him for the said treatment.
Having regard to the facts and circumstances of the case we hold that the complainant will be entitled to get the relief and thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.481/2013 is allowed on contest with cost against the o.p. nos.1 and 2 and dismissed ex parte without cost against the o.p. no.3 and dismissed on contest without cost against the o.p. no.4. The o.p. nos.1 and 2 are jointly and/or severally directed to pay to the complainant a sum of Rs.1,09,113/- (Rupees one lakh nine thousand one hundred thirteen) only along with compensation of Rs.10,000/- (Rupees ten thousand) only for harassment and mental agony and litigation cost of Rs.2000/- (Rupees two thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
