Reserved

State Consumer Disputes Redressal Commission

U.P. Lucknow.

Appeal  No.2014 of  2008

The Oriental Insurance Co. Ltd., Court Road,

Muzaffar Nagar through its Branch Manager.     …Appellant.

1- Dr. Saroj Gupta w/o Sri Diwakar Gupta

2- Km. Vidushi Gupta (Minor) d/o Sri Diwakar Gupta

    through her guardian/mother & co-policy holder

    Dr. Saroj Gupta w/o Sri Diwakar Gupta,

    R/o H.No.5, Green Avenue Devpuram, Link

    Road, Adarsh Colony, Muzaffar Nagar.

3- M/s Mad Save Health Care Litd., F-701, A

    Lodi Road, Sarai behind Golf Course,

    New Delhi-100301                                  .…Respondents.

Present:-

1- Hon’ble Sri Rajendra  Singh, Presiding Member.

2- Hon’ble Sri Sushil Kumar, Member.

Sri Deepak Mehrotra,Advocate for appellant.

Sri A.K. Mishra, Advocate for the respondents no. 1 & 2.

None for the respondent no.3.

Date : 6.4.2022

JUDGMENT

Per Mr. Rajendra Singh, Member: This appeal has been preferred under section 15 of the Consumer Protection Act 1986 ,against judgment and order dated 26.08.2008  passed by the Learned District Consumer Commission, Muzaffar Nagar in complaint case no.380 of 2003, Dr. Saroj Gupta Vs. The Oriental Insurance Co. Ltd.

          In brief the facts of the appeal are that, that the impugned judgment is absolutely illegal, unjust and arbitrary. The impugned judgement is highly unreasonable and lacks application of mind. The learned Forum has failed to understand the actual controversy involved in the complaint

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case and also failed to interpret the pleadings and the stand of insurance company. The learned Forum was of the view that the consumer has no liability to submit his claim along with complete and relevant papers. This is absolutely wrong and partisan view. It is wrong to say that it is duty of insurance company or its surveyor to collect the papers. The documents and supporting papers (in the instant case it was discharged summary of Escorts Hospital) are required to be submitted by the insured and the surveyor’s job is to verify such documents and supporting papers and to conduct the investigation. The surveyor conducted survey/investigation only on the basis of documents and supporting papers related to the claim presented/submitted by the claimants/insured. Unless the papers are submitted by insured, the survey can’t be done and also it is very well settled that the insurance has right to reject or refused to entertain the claim if supporting and relevant papers are not produced by the complainant.

The complainant no.2 was amitted to Yashoda Hospital on 14.03.2003 and she was treated there till 19.03.2003. The complainant submitted a bill of Rs.19,430/– with respect to expenses incurred at the said hospital along with relevant papers, discharge summery et cetera and since the papers submitted by the complainant were complete and sufficient, this bill of Rs.19,430/was paid by the opposite parties. The appellant after/informed the complainant to approve the opposite party no.2 i.e. M/S Med Save Healthcare Limited, whose services were hired and who was engaged by the Appellant’s  Insurance company, to process and settle the claims related to Mediclaim  Policy. The respondent no.3/

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opposite party no.2 was assigned the job of processing/ investigating into the case related to mediclaims and hence complainant’s case/claim was also sent to him. But when no information was received by the appellant, he issued a letter dated 12.01.2004 seeking the explanation for delay. At th