UNITED INDIA INSURANCE COMPANY LIMITED Vs. INDU JOSHI

JUDGEMENT

(1.) THIS appeal is by Insurance Company against the order dated 14. 9. 2006 passed by the District Forum, Udham Singh Nagar, partly allowing the consumer complaint No. 101 of 2004, for reimbursement of expenses of Rs. 2,08,554 under the Mediclaim policy. Interest @ 8% p. a. w. e. f. 9. 7. 2004 till payment and Rs. 2,000 as cost were also awarded.

(2.) THE facts of the case, as disclosed from the evidence and material on record, are as under: sh. R. P. Joshi and his wife Smt. Indu Joshi, purchased for the first time Mediclaim policies for sum of Rs. 1,50,000 each for the period 11. 3. 1997 to 10. 3. 1998. For the next year, the policies were renewed from 30. 3. 1998 to 29. 3. 1999 for sum of Rs. 2,00,000 each and for the same amount, the policies were renewed from 30. 3. 1999 to 29. 3. 2000. Policies were again renewed for the said sum for the period 20. 4. 2000 to 19. 4. 2001 and again for the period from 20. 4. 2001 to 19. 4. 2002 and lastly for the period from 20. 4. 2002 to 19. 4. 2003. During the currency of the policy for the period 20. 4. 2000 to 19. 4. 2001, Sh. R. P. Joshi fell sick and continued to be so and even hospitalized at Kashipur and New Delhi even during the period of the renewal policy of the period 20. 4. 2002 to 19. 4. 2003. He died on 19. 8. 2002. Sh. R. P. Joshi had on 26. 7. 2002, submitted an application to the Insurance Company requesting for the payment of the entire amount of expenses incurred in his treatment and the total sum claimed was Rs. 2,75,649. 28. In the application, it was mentioned that the insured had been getting treatment for his ailment from Apollo Hospital, New Delhi and Prashant Nursing Home, Kashipur and in connection with his disease, remained admitted in Prashant Nursing Home, Kashipur from 18. 4. 2001 to 20. 4. 2001; from 19. 8. 2001 to 20. 8. 2001 and from 19. 10. 2001 to 21. 10. 2001. After the death of Sh. R. P. Joshi, his son Sh. Mayank Joshi sent information of the death on 3. 9. 2002 and submitted original bills of the treatment on 26. 12. 2002. Claim having not been finalized and paid, complaint alleging deficiency in service was filed by Smt. Indu Joshi, widow of Sh. R. P. Joshi (insured) for indemnification of the expenses amounting to Rs. 3,00,000 together with interest @ 15%. The complaint was filed on 9. 7. 2004.

(3.) THE complainant having not completed required formalities and lodging the claim in prescribed form, despite various letters of the Insurance Company, the Divisional Manager of the Insurance Company, by way of his affidavit dated 12. 1. 2005, submitted on the record of the case, informed that due to non-cooperation of the complainant, the claim has been closed as "no CLAIM' by the Company. The District Forum, however, on 8. 2. 2005, directed the complainant to submit claim form by 7. 3. 2005, which was to be finalized for payment by the Insurance Company by 7. 4. 2005. Complainant vide her application dated 4. 3. 2005 submitted claim form. Per claim form, disease / ailment of Sh. R. P. Joshi was detected on 17. 8. 2001, who was hospitalized w. e. f. 18. 4. 2001 to 19. 8. 2002. Names of the hospitals, mentioned are those, as referred above.