This case has arisen out of an application U/s 35 of the Consumer Protection Act, 2019.
The case of the complainant is that in the year 2018 complainant purchased HDFC ERGO Accident & Health Insurance Family Plan (Mediclaim policy) from O.P.No-1 who is a corporate agent of O.P.No-2 vide Policy No:2811203779985101000, wherein his wife, daughter and himself were included.
That on 12.10.2020 suddenly a road accident took place with his wife Mousumi Roy who was firstly admitted to Raiganj Medical College & Hospital and then referred to Siliguri & she was admitted in Dr. Malay’s Hospital & Neurosciences Centre Pvt. Ltd and after treatment she was discharged on 19.10.2020, still she is under treatment. The complainant spent Rs.55,000/- + Rs.85,989/-=1,40,989/-. Before her release from hospital complainant contacted with O.P.No-2 several times and he filed claim form on 10.11.2020 along with all documents as per demands of O.Ps but they did not provide any amount.
That on 12.04.2021 he sent a legal notice demanding claim money, several times met with the O.Ps sent several E-mails, whatsapp messages, mobile messages but all efforts done in vain. Lastly on 06.01.2022 he filed a complaint before CA & FBP, Raiganj but the O.Ps did not turn up. Being compelled he lodged the complaint for deficiency of service and unfair trade practice claiming Rs.1,40,989/- with interest, compensation of Rs.1,00,000/- for mental pain & agony and Rs.20,000/- as litigation cost.
O.P.No-1 did neither appear nor contest the case.
O.P.No-2 contested the case by filing W.V stating that the complainant was issued a Group Assurance Health Plan Policy bearing Policy No:150100/12586/2020/A020484/PEO1968974, w.e.f 17.01.2020 till 16.01.2021 to cover himself (insured) along with his wife Mousumi Roy Das and daughter Manali Roy, for a sum insured Rs.2,00,000/- subject to policy terms and conditions.
That a claim was registered for the alleged hospitalization of Mousumi Roy Das for the period from 13.10.2020 to 19.10.2020 for diagnosis of Acute Hemorrhagic Contusion in Bifrontal Lobe with Hypothyroidism at Dr. Malay’s Hospital & Neuroscience Centre Pvt. Ltd and O.P.No-2 sought necessary medical documents in respect of her, required for processing claim on merit vide requirement letter dated 18.02.2021 & 23.08.2021 but in vain, as the complainant did not furnish required medical documents viz
- Pre-numbered payment receipt against the final bill submitted
- Treating doctor’s certificate for exact duration of the ailment (Hypothyroidism) from 10.10.2020 to 19.10.2020 formal along with past consultation papers and treatment reports. After receiving clarification for Hypothyroidism query was revised by waiving Hypothyroidism, however the original receipt of payment against rest final bill for amount of Rs.51,000/- was still pending. Since no reply was received, even on final reminder dated 23.08.2021 hence claim got closed dated 07.09.2021, on non-submission of payment receipt of Rs.51,000/- of final bill. The impugned claim was not processed due to non-submission of necessary documents by the complainant. O.P.No-2 prays for dismissal of the case.
Points for consideration are:-
- Whether the complainant, has complied with the process as required, by submitting documents?
- Whether there was any deficiency in service on the part of the O.Ps which gives cause of action to file the complaint and the complainant is entitled to get the claim?
D e c i s i o n w i t h r e a s o n s
Both the issues are taken up together being interlinked.
Admittedly, the complainant had obtained a Group Assurance Health Plan Policy bearing Policy No:150100/12586 /2018/A009612 extending policy coverage valid from 17.01.2018 to 16.01.2019 to himself along with his wife Mousumi Roy Das and daughter Manali Roy for a sum insured Rs.2,00,000/- subject to policy terms and conditions and in the FY2020, this policy was ported from Appollo Munich to HDFC Ergo Gen. Ins. Co. Ltd (Health) vide enrolment for the complainant through Bandhan Bank, subsequently the existing policy was renewed on 11 January 2020 vide Policy No:-150100/12586/2020/A020484 coverage period 17.01.2020 to 16.01.2021 & on 13th January 2021 vide Policy No:2999203669163500000 coverage period 17.01.2021 to 16.01.2022.
It is also admitted that a claim was registered on 25.11.2020 for the hospitalization of insured Mousumi Roy Das for the period from 13.10.2020 to 19.10.2020 for diagnosis of Acute Hemorrhagic Contusion in Bifrontal Lobe with Hypothyroidism at Dr. Malay’s Hospital & Neuroscience Centre Pvt. Ltd wherein claim for treatment expense was claimed for a sum of Rs.85,989/- only.
It appears that O.P.No-2 sought necessary medical documents in respect of victim/insured Mousumi Roy Das, required for processing claim on merit vide First requirement/deficiency letter dated 18.02.2021.
It also appears that on 12.04.2021 complainant claimed re-imbursement of Rs.85,989/- from O.P.No-2 and in enclosing his letter for re-imbursement of claim, Advocate Prabir Kumar Choudhuri forwarded letter dated 12.04.2021 to look into the matter as early as possible with hope that O.P.No-2 will not insist his client to take legal proceeding against the Company before the Consumer Forum under Consumer Protection Act.
Further it appears that after resolution of one requirement i.e treating doctor’s certificate for exact duration of the ailment(Hypothyroidism) from 13.10.2020 to 19.10.2020 along with past consultation papers and treatment reports, O.P.No-2 sent second, third and forth requirement/deficiency letters on 08.07.2021, 23.07.2021, 07.08.2021 respectively & subsequently the final reminder letter on 23.08.2021 for procurement of Pre-numbered payment receipt against the final bill amount of Rs.51,000/- (Item No:-9 of Claim Form dated 19.10.2020) & since no reply was received even on final reminder dated 23.08.2021 the claim got closed on 07.09.2021 for non-submission of payment receipt of Rs.51,000/-.
The complainant stated that on 12.04.2021 he demanded claim money through a legal notice and several times met with the O.Ps, sent several e-mails, whatsapp messages, mobile messages but all efforts gone in vain. Xerox copies of the messages are submitted by the complainant but we are not in a position to find whether said payment receipt of Rs.51,000/- was submitted to the O.Ps as required, only we find that scanned copy in pdf form were sent regarding submission of documents as per O.P’s mail.
According to O.P.No-1 in spite of receipt of letters the complainant did not comply with the mandatory requirements & filed this complaint, thus it did not get an opportunity to process the claim on merit and the complaint is pre-matured and liable to be dismissed and complainant be directed to submit required document(s) to process the claim as per terms and conditions of the policy.
It appears that the complainant filed a complaint before CA & FBP, Raiganj against O.P.No-1 who dropped it as no reply has reached its end so far vide letter dated 06.01.2022 and thereafter lodged this complaint case on 18.01.2022.
Under above facts and discussion, we are of the considered view that the O.P.No-2 never in any of its communication repudiated the claim of the complainant. The claim settlement process has yet to be finalized on compliance of the query by submitting the required document(s) afresh & it is therefore cannot be termed as deficiency of service on the part of the O.P.No-2 and no cause of action has arisen to file the instant case & the case is liable to be dismissed being premature.
O.P.No-1 has played no role regarding settlement of claim, so it has no deficiency of service in the matter.
The complainant ought to have comply the queries to finalize the claim settlement process by O.P.No-2 and if complainant filed required document(s) O.P.No-2 ought to have considered/finalize the claim.
In the result the case fails.
Hence, it is
O R D E R E D
that the C.C-05/2022 be and the same is dismissed on contest but without any cost.
Let a copy of this order be given to the parties free of cost.
