HON’BLE PRESIDENT : SHRI SWAPAN KUMAR MAHANTY
HON’BLE MEMBER : SMT. SAHANA AHMED BASU
FINAL ORDER/JUDGEMENT
SHRI SWAPAN KUMAR MAHANTY , PRESIDENT
This is an application Under Section 12 of CP Act 1986.
Brief facts of Consumer Complaint :-
Complainant Sri Susanta Kumar Das filed the instant consumer complaint Under Section 12 of Consumer Protection Act, 1986 pleaded therein that he took Group Health Insurance Policy (Tailor-made Group Mediclaim Policy, Retirees) being Policy No.5001002818P112620234 from United India Insurance Company Limited. Period of Insurance was 00.00 hrs of 01.11.2018 to midnight of 31.10.2019. His wife namely deceased Saswati Das was admitted at Peerless Hospitex Hospital & Research Centre Ltd. with ailment of CKD on MHD, DM-2, HTN and CAD. Complainant submitted claim applications along with original Pharmacy bills, OT charges, Consultation fees of attending Doctors and Ayah Charges for reimbursement. The Insurer and TPA have refused payment illegally and arbitrarily manipulated Clause Nos. 4.10 and 4.12 of the policy document. Therefore, such act on the part of the Ops tantamount to unfair trade practice, deficiency in service and negligence. OPs have violated the basic principles of health insurance. Complainant sought relief of payment of Rs.1,49,380/- as pharmacy bills, Ayah charges, Non medical expenses and interest.
Despite service of notices the OPs did not turn up to contest the case. As such, the case has proceeded ex parte against the OPs.
DECISION WITH REASONS
We have heard the Complainant in person and have carefully gone through the e-chief of the complainant coupled with documents on record. The overwhelming evidence on record make it clear that complainant took a Group Health Insurance Policy No. 5001002818P112620234 (Tailor-made Group Medical Policy, Retirees without Domiciliary Treatment Cover) from OP United India Insurance Company Limited and the period of insurance was 00.00 hrs of 01.11.2018 to midnight of 31.10.2019. Fact also remains that Complainant’s wife namely deceased Saswati Das was admitted at Peerless Hospitex Hospital & Research Centre Ltd. with ailment of CKD on MHD, DM-2, HTN and CAD. The Claim Forms for Health Insurance Policy available with the record speaks that Complainant had submitted reimbursement of medical treatment of his wife to the Insurer but the Insurer and TPA had refused payment in terms of Clause Nos. 4.10 & 4.12 of the policy document. It is quite clear from the reading of Clause Nos. 4.10 & 4.12 that “ All non-medical expenses including convenience items for personal comfort such as charges for telephone, television barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses, unless and otherwise they are necessitated during course of treatment” and “Expenses on purchase of medicine not supported by bills/ receipts / cash-memos with valid GST No. of the issuer of such bills / receipts / cash-memos”.
It is true that in the original pharmacy bills GST No. were not printed but GST No. has been affixed with rubber stamp. Thus, rejection of medicine charges is not justified in terms of Clause No. 4.12 and the Complainant is entitled to get Rs.89,491/- as medicine charges.
In terms of Clause No. 4.10 of the Policy document Complainant is not entitled to get relief regarding Ayah charges and Non medical expenses fully mentioned in para 9 (A) of the Consumer Complaint. Thus, disallowed of Ayah Charges and Non medical expenses is justified. It is well settled that the Insurance Policy is totally based on utmost good faith of both parties Policy was accepted along with its terms & conditions by the complainant. Therefore, neither the OP / Insurer nor the complainant can go beyond the said terms & conditions of the Policy. Complainant has a grievance with respect of
Clause Nos. 4.10 & 4.1.2 of the terms & conditions of the Policy amount. In our opinion, the Consumer Forum is not appropriate Forum for this purpose. The allegation of complainant with respect to cheating and fraudulent manipulation of Clause Nos. 4.10 & 4.12 of the policy guidelines is not entertain by us as this Forum is not appropriate Forum for this purpose.
In view of the above discussion, the Consumer Complaint is allowed ex parte against the Ops1 (i) & (ii) United India Insurance Company Limited in part and dismissed ex parte against the OPs 2 & 3 with the following directions :-
- The OPs1 (i) & (ii) are directed to pay Rs.89,419/- (Rupees Eighty-nine thousand four hundred ninety one) only to the Complainant as medicine charges along with simple interest at the rate of 04 percent (four) percent P.A from the date of order till actual payment,
- The OPs1 (i) & (ii) are directed to pay Rs.10,000/- (Rupees ten thousand) only as Compensation on account of mental agony and physical harassment suffered by the Complainant,
- The OPs1 (i) & (ii) are also directed to pay Rs.2,000/- (Rupees two thousand) only towards litigation expenses to the Complainant.
The above directions be complied by the OPs1 (i) & (ii) within a period of 45 (forty-five) days from the date of the order, failing which the Complainant shall be at liberty to execute the order by filing application Under Sections 25 & 27 of the C.P. Act, 1986 against the OPs1 (i) & (ii).
Order be communicated to the Complainant as per rules
