THE KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION
VAZHUTHACAUD, THIRUVANANTHAPURAM.
APPEAL NO- 27/2015
JUDGMENT DATED. 29/07/2016
PRESENT:-
SMT. A.RADHA : MEMBER
SRI.K.CHANDRA DAS NADAR : JUDICIAL MEMBER
APPELLANT :
The Branch Manager,
LIC of India, Pulimoottil Plaza,
P.B.No. 26, Thodupuzha P.O,
Idukki District.
(By Adv. G.S. Kalkura)
RESPONDENTS:
- T.J. Benny,
Thottiyil House,
Maniyarankudy P.O,
Pin. 685602,
Idukki District.
- Sajan Kunnel,
LIC Agent, Kunnel House,
Thadiyampadu P.O, Idukki District.
JUDGMENT
SMT . A. RADHA, MEMBER
1. This appeal is preferred by the opposite parties against the impugned order passed in CC.No. 104/2014 on the file of Consumer Disputes Redressal Forum, Idukki.
2. The brief facts of the case are that the complainant who had joined the insurance scheme of the first opposite party paid the premium on 07-06-2010 and was continuing. As per the policy the second opposite party assured daily benefit of 1,000/- and major surgical benefit worth Rs.2,00,000/- to the complainant, Rs. 750/- and Rs. 1,50,000/- to his wife and Rs. 500/- and Rs.1,00,000/- to his child. It is the case of the complainant that the complainant’s wife was admitted in hospital for a period from 03-07-2013 to 06-07-2013 and 09-07-2013 to 20-07-2013 and incurred treatment charges amounting to Rs. 20,000/-. The claim was submitted to the first opposite party through the second opposite party. The complainant paid the premium
for the last 4 years without fail. So far the claim amount was not disposed of by the opposite parties and filed the complaint for direction to allow the claim amount along with compensation of Rs.25,000/- and Rs. 5,000/- as cost of proceedings.
3. In the version filed by first opposite party the Health Insurance scheme of the complainant was admitted. The principal insured, the complainant herein, had not submitted the requirements till date. The opposite party is settling the claim based on the advice of the 3rd party- administrator . On 19-10-2013 the opposite party had sent a letter to the complainant in order to submit the required documents for claiming the insured amount. Thereafter on 20-08-2014 a reminder was sent to the complainant requesting the complainant to send the requirements to be forwarded to the TPA. It is due to the laches on the part of the complainant that the first opposite party was unable consider the claim. Hence there is no deficiency in service on the part of the first opposite party and the complaint is to be dismissed. The contentions raised by the second opposite party is that the complainant had joined the Health Insurance through this second opposite party and he had already submitted the claim papers of the complainant to the office of the first opposite party at Thodupuzha. The delay in getting the claim was also brought to the notice of the first opposite party . Hence there is no laches on the part of second opposite party.
4. The complainant was examined as Pw1 and documents were marked as Exbts.P1 to P3 and on the part of opposite party DW1 was examined and Exbts.R1 to R5 were marked. On considering the evidence and documents the District Forum allowed the complaint and directed the opposite party to pay Rs. 20,000/- with 9 % interest which is challenged in this appeal.
5. It is submitted by the counsel for the appellant that the respondent had not produced the required documents as directed by this appellant and was not in a position to verify the details of the treatment records. The counsel pointed out that as per Exbts.B1 and B2 appellant had sought for production of documents which was not heeded by the respondent resulted in not settling the claim. The respondent is responsible for the delay in settling the claim and it does not amount to deficiency in service. This act of the respondent shows that the respondents kept away from submitting the document sought for and in every probability to suppress the material facts and to make unjust enrichment. The District Forum without considering the contentions of the appellant allowed the complaint.
6. Though notice was served on the respondents, the respondents remained absent.
7. We have heard the counsel for the appellant and had gone through the available documents. Admittedly the first respondent is having valid Health Insurance for himself and for his family members and was continuing from 2010 onwards. The respondent filed the claim form with the first appellant claiming Rs. 20,000/- for the treatment of wife who is having a valid insurance policy and claimed the hospital charges during the period from 03-07-2013 to 6-07-2013 and from 09-07-2013 to 20-07-2013. The relevant documents were produced before the first appellant’s office at Thodupuzha through the second respondent. The submission of the documents before the first appellant is not challenged. The contentions raised by the second respondent has to be admitted that the claim form was accepted by the first appellant’s office. This contention remained unchallenged as the appellant subsequently claimed to send a letter dated 19-10-2013. It is clear from the deposition of PW1 that he had submitted all the documents in August 2013 itself to the appellant’s office through second respondent. The letter issued is after the submission of the documents. Exbt.P3 series submitted by the respondent clearly shows that the relevant documents were already submitted in August 2013 itself and Exbt.P3 series are the copies of the hospital records pertaining to the respondent’s wife’s treatment. The matter being so, the appellant cannot raise the contention that the respondent had not submitted the hospital records. The appellant is at liberty to inspect the documents already submitted by the first respondent. Exbt.R2 filed by the appellant to produce the required documents does not find any further submission as the appellant can verify with the hospital details. Hence we are of the considered view that the appellant’s letter dated 28-03-2014 has no relevance as the documents were already submitted by the respondent. We find that there is delay in settling the claim and the requirement of certain documents relating to treatment does not find any relevance in not settling the claim and the appellants could have processed the documents and settle the claim.
In the result, appeal is dismissed upholding the order passed by the Forum Below.
Office is directed to send a copy of this order along with LCR to the Forum Below.
A.RADHA : MEMBER
K.CHANDRA DAS NADAR: JUDICIAL MEMBER
Sh/-
