State Consumer Disputes Redressal Commission
N I Co vs Anil Khanna on 12 January, 2017
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UP C-1 Vikrant Khand 1 (Near Shaheed Path), Gomti Nagar Lucknow-226010 First Appeal No. A/2013/1466 (Arisen out of Order Dated in Case No. of District State Commission) 1. N I Co a ...........Appellant(s) Versus 1. Anil Khanna a ...........Respondent(s) BEFORE: HON'BLE MR. Vijai Varma PRESIDING MEMBER HON'BLE MR. Mahesh Chand MEMBER For the Appellant: For the Respondent: Dated : 12 Jan 2017 Final Order / Judgement RESERVED State Consumer Disputes Redressal Commission U.P., Lucknow. Appeal No. 1466 of 2013 The National Insurance Co. Ltd., Regional Office, Jeevan Bhawan Phase-II, Nawal Kishore Road, Lucknow through the Manager. ....Appellant. Versus Anil Khanna s/o Late Shri B.C. Khanna, House no.116/324, Kaushalpuri, Kanpur Nagar. ....Respondent. Present:- 1- Hon'ble Sri Vijai Varma, Presiding Member. 2- Hon'ble Sri Mahesh Chand, Member. Sri Alok Kumar Singh for the appellant. Sri Alok Sinha for the respondent. Date 23.1.2017 JUDGMENT
(Delivered by Sri Vijai Varma, Member) Aggrieved by the judgment and order dated 27.4.2013, passed by the Ld. DCDRF, Kanpur Nagar in complaint case No.01 of 2011, the appellant The National Insurance Co. Ltd. has preferred the instant appeal.
The facts leading to this appeal, in short, are that the respondent/complainant had taken a Mediclaim Policy from the appellant/OP on 29.12.2008. During the validity of the policy, the respondent/complainant was admitted in the Regency Hospital on the advice of the doctor on 7.8.2009 and was discharged on 9.8.2009 after the treatment. The respondent/complainant incurred the expenditure to the tune of Rs.40,663.00 and had spent Rs.1,441.00 in purchasing the medicines. The complainant, thereafter, pressed the claim with appellant/ (2) OP for reimbursement of the expenditure incurred by him on his treatment but the appellant/OP did not make the payment and hence, complaint case no.01 of 2011 was lodged in the District Forum, Kanpur Nagar wherein the appellant/OP filed their WS mentioning therein that the complainant was asked to submit certain documents but he did not submit those documents, hence his claim was closed as 'No Claim'. The OP had not committed any deficiency in service, hence complaint should be dismissed.
After hearing the parties, the ld. Forum below passed the following order on 27.4.2013.
"उपरोक्त कारणों से परिवादी द्वारा प्रस्तुत वाद विपक्षी के विरूद्ध स्वीकार किया जाता है। विपक्षी को निर्देशित किया जाता है कि निर्णय के 30 दिन के अंदन परिवादी को रू040,633.00 अदा कर देवे।"
Feeling aggrieved with this impugned order, this appeal has been filed by the appellant/OP.
The main grounds of the appeal are that the complainant was asked to submit certain documents by the TPA but as the same were not submitted, hence the complainant's claim was rightly closed as 'No Claim'. The finding of the District Forum is not based on the proper appreciation of the facts and evidence and is, therefore, perverse and is liable to be set aside and the appeal allowed.
The respondent/complainant has filed his objection against this appeal mentioning therein that the appeal is delayed. Secondly, there is no concealment of ailment by (3) the respondent/complainant and that the impugned order passed by the ld. District Forum is based on proper appreciation of evidence and therefore, this appeal deserved to be dismissed.
Heard ld. counsel for the parties and perused the entire record.
In this case, firstly it is to be ascertained as to whether the appeal has been filed with delay or not. In this regard, it is argued by the ld. counsel for the respondent/ complainant that this appeal has been filed with delay and hence, it should be dismissed on this score itself. The appellant has filed this appeal on 2.7.2013 whereas its copy was issued on 4.5.2013 though the judgment was delivered on 27.4.2013. So from the date of issuance of the certified copy on 4.5.2013, the appeal is delayed by 28 days. The appellant has filed application for condonation of delay supported with affidavit. The grounds for filing the appeal with delay are that the copy issued on 4.5.2013 was made available to the counsel for the appellant who after consulting with the officers could file the appeal on 2.7.2013. There is no counter affidavit filed to this affidavit specifically denying the contention of the appellant/OP made in their affidavit. Under the circumstances, the delay deserves to be condoned and the application for condonation of delay moved by the appellant is allowed.
Now it is to be seen as to whether the appellant/OP committed deficiency in service in not making the (4) payment of the claim on the ground that certain documents necessary for processing of the claim were not supplied and hence, no claim was made, if so its consequences.
In this case, there is no dispute that the complainant had taken a Mediclaim policy from the OP and during the validity period of such policy that he made a claim for reimbursement of treatment allegedly incurred by him in the hospital. The moot point according to the appellant is that the respondent/complainant did not submit documents pertaining to his illness which were asked for by the TPA and hence, the claim was treated as 'No Claim' and that the appellant did not commit any deficiency in service whereas according to the respondent/complainant, the appellant/OP did not make payment of the amount spent by him in his treatment in the hospital though all the papers required for processing of the claim were submitted by him and the OP were required to make payment under the Mediclaim policy but they committed deficiency in service in not allowing the claim.
In this regard, we find that the respondent/ complainant had submitted the documents pertaining to admission in Regency Hospital, a copy of which has been filed wherefrom, it is clear that the respondent/ complainant was admitted in the hospital on 7.8.2009 and that he was discharged on 9.8.2009. He has also filed photo-copies of the receipts etc. showing expenditure incurred in his treatment during the period of his admission in the hospital and also the receipts for the medicines purchased by him. So from the aforesaid, it is (5) clear that the respondent/complainant was admitted in the hospital where he was treated wherein he spent a sum of Rs.40,663.00. The appellant has on the basis of letter written by Alankit Health Care TPA Ltd. sent on 19.11.2009 to the complainant wherein, the certificate of treating doctor for history of bronchial asthma with supporting prescription and all lab report and film was demanded from the complainant, it is argued by the ld. counsel for the appellant that these documents were not submitted and hence, the claim was treated as 'No Claim' and therefore, there is no deficiency in service on the part of the appellant/OP. While arguing on this point ld. counsel for the appellant/OP stressed that these documents were necessary for finding out as to whether the claim was genuine one or not but it is to be noted that the complainant had submitted all the documents pertaining to illness and the treatment in the hospital. If at all, the OP doubted the documents, it was for them to investigate the matter at their end and to procure documents to prove that the complainant's claim was false or not genuine or that it breached certain conditions of the policy but unfortunately, this onus which lies on the appellant/OP, the appellant wanted to get it discharged by the respondent/complainant. The appellant/OP can not burden the complainant in procuring the evidence which might be used against him. No complainant can be compelled to discharge such burden. It is for the appellant/OP to discharge such burden of proof which we are afraid has not been done in the instant case therefore, there is no (6) justification for the appellant/OP for treating the claim as 'No Claim' and therefore, they have committed serious deficiency in service. Ld. District Forum has passed the order after proper appreciation of evidence and find that the appellant/OP to have committed deficiency in service therefore, there is no need to interfere in the findings of the Forum below. The appeal deserves to be dismissed with costs.
ORDER The appeal is dismissed with cost of Rs.5,000.00.
Certified copy of the judgment be provided to the parties in accordance with rules.
(Vijai Varma) (Mahesh Chand) Presiding Member Member Jafri PA-II Court No.5 [HON'BLE MR. Vijai Varma] PRESIDING MEMBER [HON'BLE MR. Mahesh Chand] MEMBER