1. This is a petition filed by one Sri Pratap Kumar Saikia and one another (hereinafter referred to as the petitioners) against the Regional Manager, National Insurance Company Ltd. and one another (hereinafter referred to as the opposite parties) U/S 12 of the Consumer Protection Act, 1986 praying for recovery of money, compensation and other reliefs.
2. Facts and circumstances for filing of the aforesaid petition as narrated by the petitioner are as follows:-
The complainant No.1 Sri Pratap Kumar Saikia being an Indian citizen opened a Mediclaim policy for himself and his family members, namely, complainant No.2 Mrs. Ruma Saikia and his children, namely, Miss Priyanki Saikia and Sri Kaushik Saikia with the National Insurance Company Ltd. Nagaon Branch. The term and condition of the policy was duly followed and also accepted by the opposite parties without any objection at the time of opening the policy. After accepting and satisfying the proposal form/ application of the policy holder Pratap Kumar Saikia, the opposite parties/Company had received an amount of Rs.3236/- and also issued a premium deposit receipt as well as policy certificate to the policy holder Pratap Kumar Saikia. The rider benefit of the said policy is that 1- personal efforts of the insured and family members with him plan-I, Plan-III-Personal accident, Plan-IV- Mediclaims (Modified)- Hospitalization.
The policy holder Pratap Kumar Saikia and his wife complainant No.2- Smt.Ruma Saikia were admitted in the Nemcare Hospital, Guwahati on last 06/11/2015 for medical treatment of various illness as indoor patients. The Doctor of said Nemcare Hospital treated both the complainants as indoor patients for various illness and prescribed medicine. The total amount of medical expenditure for the complainant No.1 was Rs.14,957/- and for the complainant No.2 was Rs.6619/- in total Rs.21,576/- for both of them which was paid to the Hospital by the complainants at the time of discharge. The complainants are entitled to reimburse all the medical expenditure paid by them to the Hospital as per terms and condition of the Mediclaim policy opened with opposite parties/Company and hence, the policy holder presented claim before the opposite parties along with all relevant documents including policy certificate for obtaining the benefit of the policy but opposite parties without disposing his claim benefit, simply intimated him on last 12.01.2016 that all the claim benefit shall be forfeited with explanation that the patient admitted in Nemcare Hospital on 06.11.2015 at 11:24 with hypertension and, they underwent conservation medication and discharged on 07.11.2015 at 8:31 and patients were not treated for 24 hours, so, justification of conservative treatment was void.
Complainants stated that there was no such condition in the Mediclaim policy that the patient must be treated minimum 24 hours as indoor patient and opposite parties have violated the condition of policy as well as contract between policy holder and Insurance Company and thereby committed deficiency of service. Hence, this claim petition before this Commission seeking for relief.
3. Opposite parties filed their written version denying all the allegation levelled against them by the complainants. By their written version opposite parties inter alia pleaded that there is no cause of action for the complainant to file this petition before this commission, that the complaint case is not maintainable , that the petitioner No.2 has no locus stadi to file the petition, that the petition of the complainants does not attract the provision of Section 12 of the Consumer Protection Act and that there is no deficiency of service on the part of the opposite parties while repudiate the claim of the complainant.
The opposite parties stated that although relevant insurance policy proposal by the insured was accepted and policy of insurance was issued to the insured by them, yet as per decision and direction by the IRDA (Insurance Regulator Development Authority), the National Insurance Company does not settle the Mediclaim of the insured and E-Medibek (Third Party Administration) Service Limited was entrusted with the responsibility of settlement of any such claim. It is stated that the claim of the complainant was repudiated in accordance with the norms/provisions of Section IV of Mediclaim (Modified) in as much as Sub-Section-1 of said section specifically provides that expanses for hospitalization is admissible only in cases where patient treated in the hospital as indoor patient for a minimum 24 hours and in the instant case the complainants were not treated in the hospital as indoor patient for 24 hours. The opposite parties vide their written version further submitted that the complaint petition did not reveal the true state of affairs and did not state for which specific ailment, the complaints were admitted in the hospital, they were not treated in hospital for 24 hours and hence, the aforesaid E-Medibek (Third Party Administration) Service Limited rightfully recommended to repudiate the claim of complainants. The opposite parties stated that the claimants were not entitled to obtain any Mediclaim benefit and hence, they did not commit any deficiency of service. Under such circumstances, the opposite parties pray for dismissal of the complaint petition.
4. On basis of pleadings of both the contesting parties the following points have come out for discussion and decision:-
- Whether the complainants suffered mental and financial loss for the act of the opposite parties denying to extend the benefit of the mediclaim policy of the complainant which he duly insured for himself and his family members and whether such act on the opposite parties amounts to deficiency in service.
- Whether the complainants are entitled for the relief as prayed for?
- The complainant side filed evidence in affidavit of one witness and also exhibited several documents in support of their claim. The opposite parties on the other hand neither cross examined the P.W.1 nor examined any witness in support of their pleas.
- Written argument filed by the complainant side and perused the same.
7. Decision and reasons thereof:-
8. For the sake of brevity both the Point (i) & (i) are taken jointly for discussion and decision.:-
The claim of the claimants is that complainant No.1-Pratap Saikia opened a Mediclaim policy for himself and his family members with the National Insurance company Ltd. and paid premium for that, both the complainants were admitted in the Nemcare Hospital for different ailment and they were treated there for which they incurred medical expanses of Rs.21,576.00 at the time of discharge from the hospital. The complainant No.1 filed claim before the opposite parties but they repudiate his claim. In support of their claim, the complainant side examined complainant No.1 as P.W.1. In his evidence P.W.1 deposed to the effect that on 19.08.2016 he opened a Mediclaim policy for himself, his wife and two children by paying a premium of amount Rs.3236.00 with the National insurance company through agent Tapan Kr. Deb and on being satisfied with all relevant documents furnished by the complainant No.1 the Company issued a policy in his favour being policy No.200901/48/13/3500000378 with effect from 21.08.2015 to 20.08.2016. He further deposed that on last 06.11.2015, he himself and his wife Ruma Saikia were admitted in the Nemcare Hospital, Guwahati for different ailment and treated there as indoor patients and he had to incur medical expenditure of Rs.14,957.00 for himself and Rs.6619.00 for his wife Ruma Saikia in total Rs.21,576.00 for both of them. His further evidence is that thereafter, he placed his claim with the opposite party No.2 to obtain the benefit of his Mediclaim policy but on 12.01.2016, the opposite party No.2 informed him that as he and his wife were not treated for 24 hours in the Hospital as indoor patients, hence, he is not entitled to receive any benefit from his Mediclaim policy. This P.W. also deposed that opposite parties deprived him and his wife to obtain the benefit of his Mediclaim policy by making false assertion and he suffered from mental and economical loss due to their act and as such, conduct of opposite parties amount to deficiency in service and he is entitled to receive the total amount of Hospital expenditure with compensation from them.
The opposite party No.1 to 2 while filing their written version submitted that E-Medibek (Third Party Administration) Service Limited was entrusted with the responsibility of settlement of the claim of the complainant No.1 and the same was repudiated in accordance with the norms/provisions of Section IV of Mediclaim (Modified) in as much as Sub-Section-1 of said section specifically provides that expanses for hospitalization is admissible only in cases where patient treated in the hospital as indoor patient for a minimum 24 hours and in the instant case the complainants were not treated in the hospital as indoor patients for 24 hours. The opposite parties further stated that the complaint petition did not reveal the true state of affairs and did not state for which specific ailment, the complaints were admitted in the hospital, they were not treated in hospital for 24 hours and hence, the aforesaid E-Medibek (Third Party Administration) Service Limited rightfully recommended to repudiate the claim of the complainants. However, the opposite party No.1 and 2 neither cross-examined the P.W.1 nor adduced any evidence in support of their written version. Hon’ble Apex Court in many judicial pronouncement has specifically stated that mere filing of written statement is not sufficient unless supported by any evidence. In the instant case the opposite parties neither cross-examined the P.W.1 nor adduced any evidence in support of their written version for reasons best known to them. In view of above we are of the opinion that the that the complainants have successfully established that there was a deficiency of service on the part of the opposite parties.
In result both the points for discussion and decision are answered in affirmative and go in favour of the complainants.
O R D E R
9. In view of the above discussion, it is found that the complainants have succeeded to prove that there was a deficiency of service on the part of opposite party No.1 and 2.
Accordingly, the prayer made by the complainants U/S 12 of the Consumer protection is allowed on contest. Issue direction to the opposite party No.1 and 2 to pay the complainants immediately the medical expenditure incurred by them for their treatment at the hospital as per terms and condition of the Mediclaim Policy in the name of the complainant No.1 being NO.200901/48/15/3500000378 along with compensation of Rs.5,000/- with interest @ 12 per annum from today till payment.
Inform all the parties concern.
Given under the hand and seal of this Commission, we signed and delivered this Judgment on this 27th Day of April 2021.
