Repudiation of Insurance claim by the OPs has invoked fury to the complainant to lodge this complaint for redressal u/s 12 of the CP Act, 1986.
The complaint may be epitomized that the complainant has claimed Rs.5,910/- for cost of treatment of his daughter which is covered by the insurance company with the OP No.1. The OP No.1 has forwarded the claim to the OP No. 2 for settlement, but the OP No. 2 on 29.1.2018 informed the complainant showing their inability to release the claim and actually repudiating the same on ground of four reasons. Though, before that they claimed additional documents of treatment in original. One of the reasons shown in the letter of repudiation that the claim has been submitted to the OPs 40 days after, though, the complainant in his statement with documents has proved that he has submitted the claim on 13.9.2017 and before that he intimated on 1.9.2017 about the treatment of his daughter for the period from 27.8.2018 to 29.8.2018. The complainant has claimed Rs.20,000/- as compensation and Rs.5,000/- as litigation cost in addition to his principal claim of Rs.5,910/-, which was spent for treatment of his daughter.
The OP in his written statement has claimed that due to some laches on the part of the complainant the claim could not be settled. It was stated more that the complainant has failed to provide all the necessary documents in time even after it was asked to submit by the OP in writing. So repudiation is not intentional, it is rooted to the laches of the complainant.
On argument the Ld. Lawyer appearing for the OP informed with documents that the claim has been settled and it is already sent to the account of the complainant through NEFT on 10.5.2018.
On argument the Ld. Lawyer appearing for the complainant admitted that the principal amount of claim has been received by the OP in his Bank A/c. But, he raised the question what is the mystery of settling of dispute once repudiated by the OP. He argued that as the complainant has been lodged with this complaint it has been proved his claim as proper with documents, so the OP in a haste have sent the claim amount to the Bank A/c of the complainant. But, as the OP has obliged the complainant, one of the respectable customers of the OP, who has been maintaining medical insurance policy since 2009, is eligible to get the compensation and the litigation cost. The complainant also stated more to this Forum he is a policyholder of the National Insurance Company i.e. OP No. 1 not the OP No. 2. The OP No. 2 is the TPA of OP No. 1 for settling the medi-claim of OP No. 1. He is liable to OP No. 1, so he has submitted his documents and claim to OP No. 1. Then how the OP No. 2 dare to repudiate the claim on ground of late submission of claim as he has submitted all his papers to the OP No. 1 within 15 days from the date of treatment.
Points for decision:
- Is the complainant a consumer, if yes, of which company?
- Is there any deficiency in service on the part of OPs or not?
DECISION WITH REASONS
Point Nos. 1 & 2:
From the above discussion it is revealed that OP No. 1 has not denied that the complainant as his bona fide insurance policyholder. It is the internal affairs of the OP No. 1 to appoint the OP No. 2 as TPA for settling medical insurance claim. So, the complainant is the direct consumer of the OP No. 1.
It is also proved that the complainant has submitted his claim along with documents. He is also cooperative with the OP No. 1 by providing documents as and when claimed. In this regard, the important point “the bona fide claim could not be repudiated by the insurance company” observed by the National Commission in the case of National Insurance Company Ltd. v Uma Kanta Kashyap {2017(3) CPR 112 (NC)}” may be mentioned. The above discussion has also proved the observation of the National Commission in the case of Oriental Insurance Company v Bankaram. “Insurance Company being in a dominant position, often act in an unreasonable manner” {2015(4) CPR4 (NC)}. It should be kept in mind by the insurance company that rejection of the claim on purely technical ground in a mechanical manner will result in loss of confidence of policyholder in the insurance industries. Though, the OPs have settled the claim and deposited the money to the Bank A/c of the complainant but it is not clear about the magic change of views in settling the dispute after the complaint being lodged. So, the gross negligence as well as deficiency in service on the part of OP is profound.
Hence, it is
O R D E R E D
that the complainant is eligible to get the compensation amount of Rs.10,000/- and litigation cost of Rs.2,000/-. The OP No. 1 is directed to pay the amount within 30 days from the date of judgment, failing which the complainant will be entitled to get interest @ 8% p.a. on the compensation amount till the full realization of the amount.
The complainant is directed to deposit Rs.5,000/- to the State Legal Aid Fund under this Forum immediately after receiving the compensation amount.
The case and the same succeeds on contest.
Let a plain copy of this order be furnished to the parties forthwith free of cost.
