Page 82 - Suri’s - NCDRC ON LIFE INSURANCE 2017 V1.3

Suri’s - NCDRC ON LIFE INSURANCE 2017 82

tion and the petitioner from the respondents to receive the expenses incurred an
amount of Rs.3,06,058/- for the treatment of his wife, by not making the payment of
which the respondents have done deficiency in service.
4. Respondent no. 1 and 2 before the District Forum in their version by submit-
ting a written statement had stated that the petitioner in relation to the claim had sub-
mitted incomplete documents which the respondents have submitted as per rules to
the TPA and the information of which was given to the petitioner. The petitioner for
the disposal of the claim had not submitted the necessary and desired documents to
the respondents because of which the claim file by the division office as per the rule
for its disposal, on 31.12.2012 submitted the same to the TPA with incomplete docu-
ments. TPA provided the list of the desired documents and requested for the docu-
ments within 10 days from the petitioner on 12.12.2012 and on 09.02.2013. The re-
quested documents, however, were not submitted by the petitioner and thus, on
28.03.2013 the claim of petitioner as per the conditions of the policy and as the claim
did not fall within the privileges allowed the claim was dismissed by TPA. The re-
maining documents were submitted by the petitioner on 22.01.2013 were submitted to
TPA on 03.05.2014. The respondents by not paying the medi-claim amount of the
petitioner has not done any deficiency in service and neither of the acts of the respon-
dents come under the category of unfair trade practice. Petitioner was not liable to
receive Rs.3,06,058/- from the respondents and 15% interest on the amount. There-
fore, the complaint of the petitioner in the interest of law may please be dismissed
with cost.
5. The District Consumer Disputes Redressal Forum, Koria, Baikunthpur
(Chhattisgarh) vide its order dated 26.08.2014 while allowing the complaint observed
as under:
―We find that the complaint preferred by the complainant is liable to be al-
lowed and thus, this complaint of the complainant is allowed and it had been di-
rected to the opposite party nos. 1 and 2 that the opposite party no. 1 & 2 shall
jointly and severally deposit with the office of Forum a sum of Rs.2,80,000/- to-
wards the major surgery benefit sum insured (MSB) and Rs.1,400/- towards the
initial daily hospital cash benefit.‖
6. Aggrieved by the order of the District Forum, the respondents filed an appeal
before the State Commission. The State Commission while allowing the appeal and
dismissing the complaint observed as under:
―The opposite parties/ appellants insurance company has submitted a copy of
the insurance terms of Health Protection Plan 902 in the records other than this
under this plan the list of illness and surgeries that are covered, the list is pro-
vided. The above list was perused by us. Nowhere in the above list surgery of
Ovarian Carcinoma, i.e., Cancer of Ovary‘ was mentioned. According to this list
the surgeries that are covered under this plan of the insurance company is as be-
low:
Heart and Blood communication system
Nervous system
Respiratory system
Digestive system
Secretion system

INDEX