BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAITHAL.
Complaint No.141/2017.
Date of instt.:25.5.2017.
Date of Decision:29.1.2018.
Om Parkash Garg s/o Shri Janaki Dass, r/o House No.282, Housing Board Colony, Kaithal.
……….Complainant.
Versus
- Medi Assist Insurance TPA Pvt. Ltd., Mumbai through its Managing Director.
- Life Insurance Corporation of India, Kaithal through its Chief Manager.
..……..Opposite Parties.
COMPLAINT UNDER SEC. 12 OF CONSUMER PROTECTION ACT, 1986.
Before: Shri Rajbir Singh, Presiding Member.
Smt. Harisha Mehta, Member.
Present : Shri K.L. Kashyap, Adv. for the complainant.
Shri Suresh Kumar Gupta, Authorized Representative for OP No.1.
Shri Sudeep Malik, Adv. for OP No.2.
ORDER
(RAJBIR SINGH, PRESIDING MEMBER).
The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986, with the averments that he was duly insured with OP vide policy No.120300/34/16/04/00000005. It is further alleged that he suffered from Dengue fever and admitted in Kalyani Hospital, Karnal on 11.11.2016 to 14.11.2016 and his treatment was done by the doctor of said hospital vide Patient No.161100729. It is further alleged that he also written letter to OP No.2 Chief Manager of LIC of India, Kaithal and duly authorize the OP No.1 who are the his TPA for the medi claim policy. It is further alleged that the OP vide its letter dt. 12.1.2017, received on 27.1.2017 demanding some documents for claim and he submitted all the required documents and a bill of Rs.36,986/- to the OP. It is further alleged that he visited the OP No.2 and also requested the OP No.1 through his mobile on toll free Nos.18004199598 & 18004259449 of OP No.1 time and again, but the OPs refused to make the payment on one pretext or other. This way, the Ops are deficient in service. Hence, this complaint is filed.
2. Upon notice, the opposite party No.1 appeared before this forum and filed reply submitting therein that OP No.1 assists the insurance companies in processing the claims as per the terms & conditions of the insurance policy; that the functions of the OP No.1 is to scrutinize the claim on behalf of the insurance companies and if any discrepancies is found, the same is to be intimated to the insured/claimant for compliance of the same by raising a query; that the complainant was having a Group Health Policy of The New India Assurance Company Limited and he was admitted in Kalyanai Hospital o 11.11.2016 for dengue fever and discharged on 14.11.2016; that the complainant preferred a reimbursement claom of Rs.36,989/-; that as documents were not provided by the complainant to OP No.1, a query was raised on 11.1.2017 for original prenumbered pre-printed paid receipt for final hospital bill, IPD papers during hospitalization, bank details as well as cancelled cheque; that a reminder was sent to the complainant on 23.1.2017; that the complainant sent bank deals and cancelled cheque, but he failed to produce other required documents and a query letter dt. 08.2.2017 was sent to him; that since the complainant failed to provide the those documents, his claim was closed on 10.2.2017; that OP No.1 is ready to process the claim of the complainant on behalf of The New India Assurance Co. Ltd. subject to receipt of those documents and approval of The New India Assurance Co. Ltd. The OP No.2 also appeared before this Forum and filed reply raising preliminary objections regarding jurisdiction; mis joinder and non joinder of necessary parties; that the claim of the complainant has been rightly closed by TPA due to submission of required documents. On merits, it is submitted that it is duty of the TPA to process the claim and in case, they are in need of certain documents or any query relating to claim, they asked from the complainant directly; that in the present case also, they raised an IR on 11.1.2017 for production of certain documents, but the complainant failed to provide all the required documents and again an query was raised on 08.2.2017 requesting the complainant to provide the remaining documents, but he failed to provide the same. The rest of the contents of the complaint are denied and prayed for dismissal the same.
3. In support of his case, the complainant tendered in evidence affidavit Ex.CW1/A; documents Mark C1 to Mark C19 and closed evidence on 26.10.2017. On the other hand, OPs tendered in evidence affidavit Ex.R1 & Ex.R2; documents Ex.R-3 to Ex.R-9 and closed evidence on 08.1.2018.
4. We have heard ld. counsel for both the parties and perused the case file carefully and minutely and have also gone through the evidence led by the parties.
5. From the pleadings and evidence of the parties, it is not disputed that the complainant had availed the insurance facility from OP No.2 vide policy No.120300/34/16/04/00000005 and reference No.CCN#93475830. It is also not disputed that the complainant suffered from Dengue fever and got admitted in Kalyani Hospital, Karnal from 11.11.2016 to 14.11.2016 vide Discharge Summary Mark C-7. As per the complainant, he paid Rs.36,986/- to the said hospital for his treatment vide bills Mark C8 to Mark C-12. He further contended that he submitted his claim with the OP No.2 alongwith all required documents and requested for payment of his claim, but they refused to make the payment. The OP No.2 contended that on raising query dt. 11.1.2017, the complainant provided bank details and cancelled cheque on 06.2.2017, but failed to provide the original pre-numbered pre-printed paid receipt for final hospital bill, IPD papers during hospitalization, for which, a query letter dt. 08.2.2017 was sent to him, but he failed to submit the required documents and his claim was closed on 10.2.2017.
6. From above, it is clear that the OPs had not denied the claim of the complainant, rather the OPs did not release his claim merely on the ground that the complainant had not provided the original pre-numbered pre-printed paid receipt for final hospital bill, IPD papers during hospitalization. Moreover, the OP No.1 also admitted in his reply that OP No.1 is ready to process the claim of the complainant on behalf of The New India Assurance Co. Ltd. on the receipt of said documents subject to approval of The New India Assurance Co. Ltd. In these facts and circumstances of the case, we are of the considered view that the matter in dispute can be settled between the parties if the complainant can provide the required documents to the OPs.
7. Thus, as a sequel of above discussion, we allow the complaint and direct the OPs to pay Rs.36,986/- to the complainant subject to submitting of the original pre-numbered pre-printed paid receipt for final hospital bill and IPD papers during hospitalization, by the complainant to the OPs. However, it is made clear that the complainant will submit the above said documents within 15 days to the OPs and thereafter, the order will be complied with within 30 days, failing which, the complainant shall be entitled interest @ 8% p.a. on the awarded amount from the date of commencement of this order till its realization. A copy of this order be sent to both the parties free of cost. File be consigned to the record room after due compliance.
Announced.
Dt.29.1.2018.
(Harisha Mehta), (Rajbir Singh),
Member. Presiding Member.
Present : Shri K.L. Kashyap, Adv. for the complainant.
Shri Suresh Kumar Gupta, Authorized Representative for OP No.1.
Shri Sudeep Malik, Adv. for OP No.2.
Remaining arguments heard. Order pronounced, vide our separate order in detail of even dated, the present complaint is allowed. File be consigned to record-room after due compliance.
Dated:29.1.2018. Member Presiding Member
