The Complainant has filed this complaint against the O.Ps. under Section 12 of the Consumer Protection Act 1986 and praying for following Order / Relief :-

1. Direction against the O.P’s to refund the Complainant a sum of Rs. 3,31,531/- (Rupees Three Lakhs Thirty One Thousand Five Hundred Thirty One Only) which is the balance amount of the admitted claim amount of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only),
2.  Direction against the O.P. to pay the Complainant a sum of Rs. 1,00,000/- (Rupees Onw Lakh Only) for enormous pain and agony suffered by the Complainant and unprecedented harassment caused to the Complainant due to the negligent and irrational act of the O.P.
3. Direction against the O.P. to pay the Complainant a sum of Rs. 20,000/- (Rupees Twenty Thousand Only) towards the cost of litigation.
4. Direction against the O.P. to pay the Complainant the interest accrued on the awarded amount @ 12 % per month from the date of Cause of action till actual realization. Total claim amount is of Rs. 4,81,531/- (Rupees Four Lakhs Eighty One Thousand Five Hundred Thirty One Only).

  The case of the Complainant in brief is that, the Complainant is a consumer within the meaning of the Consumer Protection Act and Rules framed there under / this Commission has jurisdiction to try and adjudicate the present complaint / the Complainant is holding Jeevan Arogya (without profit) Policy No. 457355214 in his name valid from 28.11.2012 till 28.11.2049 / the Complainant has also stated apart from him his wife Rehana Sultana, his daughter Alisha Sultana are also covered under the said policy to the tune of cashless treatment with a sum assured / the wife of the Complainant fell sick and was firstly taken to Touch Nursing Home at Jalpaiguri with complaints of pain in her abdomen on 04.01.2019 attended by Dr. Sumantra Mukherjee, M.D. Physician / after brief conservative treatment Rehena Sultana was discharged on 05.01.2019 with a referral for attending any Surgeon for further treatment / his wife Rehena Sultana reported to Dr. Vivek Sarkar, M.S., at Paramount Hospital Pvt. Ltd. Siliguri on 05.01.2019 and was diagnosed having “sealed perforative peritonotis” and was advised for admission / Rehana Sultana was administered IV Fluids, Antibiotics, Analgesics and Nebulisation at the initial stage followed by inotropic infusion and other supportive measures / Rehana Sultana under went exploratory laparotomy under general anesthesia on 08.01.2019 and she was discharged on 25.01.2019 with a specific advice on discharge for review after one week / for Treatment of Rehana Sultana at Touch Nursing Home and thereafter at Paramount Hospital Pvt. Ltd., Siliguri the total medical expenses incurred was of Rs. 6,41,269/- (Rupees Six Lakhs Forty One Thousand Two Hundred Sixty Nine Only) and payment was made by the Complainant / intimation was given to the LICI Health in writing on 22.02.2019 by the Complainant with regard to treatment and discharge of his wife Rehana Sultana / Claim form was issued which was filled up and submitted along with all relevant documents on 22.02.2019 / by their letter dt. 30.05.2019 after a long scrutiny of the documents Heritage Health T.P.A. admitted the Claim to the tune of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only) and  several Complainant requests severally for disbursement of the claim amount of Rs. 6,41,269/- (Rupees Six Lakhs Forty One Thousand Two Hundred Sixty Nine Only). The further case is that the O.P. neither admitted the claim amount of Rs. 6,41,269/- (Rupees Six Lakhs Forty One Thousand Two Hundred Sixty Nine Only) nor admitted claim amount of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only) was remitted to him / subsequently while updating the Bank Account the Complainant noticed an amount of Rs. 95,200/- ( Rupees Ninety Five Thousand Two Hundred Only) was deposited in his account at Axis Bank, D.B.C. Road Branch, Jalpaiguri on 21.10.2019 by L.I.C.I. but no details of such partial payment was given to the Complainant nor any schedule of further payment was communicated / Rehana Sultana is still under treatment and Complainant requires the balance amount of Rs. 3,31,531/- (Rupees Three Lakhs Thirty three Five Hundred Thirty One Only) for the same / The Complainant sent a notice through Ld. Advocate on his behalf on 05.12.2019 to the O.P’s. which were receipt by the O.P’s. asking for supply of a copy of a statement appertaining to the remittance of the admitted claim amount of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only) / the O.P. No. 4 send a reply to the Ld. Advocate of the Complainant and refused to pay the expenses incurred by the Complainant for treatment of his wife though the same was admitted to the tune of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only) and to be more precise of Rs. 1,40,000/- (Rupees One Lakh Forty Thousand Only) towards the Major Surgery / the O.P’s. have paid an amount of Rs. 56,000/- (Rupees Fifty Six Thousand Only) towards Major Surgical Benefits which is 40 % of actual expenses of Rs. 1,40,000/- (Rupees One Lakh Forty Thousand Only), the matter was not clarified by the O.P;s. as to why the amount was reduced from the amount of Rs. 1,40,000/- (Rupees One Lakh Forty Thousand Only) to Rs. 56,000/- (Rupees Fifty Six Thousand Only) / during last few months till the filing of the Complaint the Complainant is undergoing pain and agony and an unprecedented harassment caused due to the negligent and irrational act of the O.P.s / the cause of action for the present complaint arose lastly on 19.12.2019 when the reply of the O.P’s. negating the claim of the Complainant was delivered to the Advocate of the Complainant and thereafter on several occasions as an when the discrepancies  in documentation of the claim of the Complainant came up and the same is still continuing.

Notice was issued from this Commission for the O.P’s. On receipt of notice the O.P. No. 1, 2 & 4 have appeared before this Commission through Vokalatnama , filed Written Version , denied all the material allegations of the Complainant and has stated that the Complainant has filed this case on some false allegations to harass the O.P’s.  and he is not entitled to get the relief as prayed for.  The O.P’s.  have also stated in their Written Version that, the case is not maintainable in law nor on facts, the Complainant has no cause of action to file the instant case / the Complainant is not a Consumer within the meaning of Consumer Protection Act and the case is bad for necessary parties since the concerned Hospitals are the necessary parties to this case. The O.P’.s have denied the allegations made in Para No. 1 to 23 of the Complaint, they have also stated that the Complainant purchased LIC’s Jeevan Arogya Policy (Table 903-37) from LIC Jalpaiguri Branch-2 Numbering 457355214 date of commencement being 28.11.2012, covering his wife Rehana Sultana for Health Insurance, option of initial Daily Cash given by the proposer in Proposal Form was Rs. 1000/- (Rupees One Thousand Only). The O.P’s. have also stated that in the Complaint the Complainant has stated that a brief and conservative treatment was done on this spouse of the Complainant at Jalpaiguri and thereafter, taken to Paramount Hospital Siliguri for surgery and the total expenses of the treatment may have cost the Complainant about  Rs. 6,41,269/- (Rupees Six Lakhs Forty One Thousand Two Hundred Sixty Nine Only) but while submitting the claim papers LIC’s T P A M/S Heritage Health Care Pvt. Ltd. had acknowledged and amount of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only) as the claim amount, reasons of which can be ascertain by the T P A. The O.P’s.  have also stated that the plaintive / principal insure has tried to mislead to the Forum by giving a wrong statement in Para No. 13 of the Plaint that “Heritage Health has admitted the claim to the tune of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only)” / the T P A did not admit the claim amount as stated herein above, it has only acknowledged the receipt of claim papers valued at Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only) / the plaintiff has failed to realize and recognize the difference between acknowledgement and admission / admitted amount is always governed by the terms and conditions laid down in the policies itself / the T P A is fully and explicitly bound by the terms and conditions of the original policy / claim amount may be of any tune but the actual admission and payment is limited to the terms and conditions of Jeevan Arogya Policy. The O.P’s. have also stated that , with the recommendation of the T P A and as per Policy conditions L I C has settled the claim of Rs. 95,200/- (Rupees Ninety Five Thousand Two Hundred Only) on 21.10.2019 / the details of admissible amount and calculations ware explained by the O.P’s. to the Ld. Advocate of the plaintiff in response to his letter dt. 05.12.2019 and the Complainant has admitted in his Plaint. The O.P’s. have also stated that the L I C’s Health Insurance Policies Jeevan arogya Table No. 903 is a defined benefit policy and the claim amount does not depend upon the actual cost of the treatment / operation and the claimant would get two defined benefit namely v i z Daily Cash Benefit and Major Surgical Benefit as per terms and conditions of the policy. The O.P’s. have stated the Daily Cash Benefit as follows:-

Hospital Cash benefit opted in the policy was of Rs. 1000/- per day and premium fixed on that basis, the daily hospital cash benefit increased at the rate of 5 % per year as per term of the policy and increased by ( 5% of 1000) x 6 = Rs. 300/- (as 6 years has already been completed of the policy at the time of claim) and there is and additional increase of daily benefit called no claim benefit, which is increased of daily hospital cash benefit 5 % for no claim for a block of 3 years, here 6 years has been completed without any claim, so increase is again by 5 % of 1000, i.e, (5 % of 1000) x 2= 100/- / it is also stated that, daily benefit in this policy on the date of claim was Rs. (1000+300+100) = Rs. 1400/-, and the daily benefit would be double for ICU treatment. Here ICU treatment of Rehana Sultana was for 7 days and non ICU Treatment was for 14 days. So, the daily cash benefit was payable ( 2 x 1400 x 7 for ICU) + ( 1400 x 14 for non ICU) = Rs. 39200/- MAJOR Surgical benefit as per terms of the policy is 100%, 60%, 40% or 20% of Applicable daily hospital cash benefit X 100 as per the category of the operation. Here the operation felt under the 40 % of the applicable daily hospital cash benefit of Rs. (1400 x 100) = Rs. 56000/- (please refer item no 51 of MSB mention in policy deed so the total benefit would be payable 39200 + 56000 = Rs. 95200/-. The definite benefit which was payable as per the terms of the policy has been paid. The O.P’s. have also stated that as per recommendation of its T P A M/S Heritage Insurance Pvt. Ltd.  which provide expert Medical Opinion on Health Insurance Calim matter of the O.P.  and correctly settled the claim within the limit of the terms and conditions of Jeevan Arogya Policy and as such there was no negligence or refusal of claim or cause of action has arisen.

By filing the Written Version the O.P’’s No. 1, 2 & 4 have praying for dismissal of this case. In support of the Written Version the O.P’s. No. 1, 2 & 4 files documents namely :-

1.  L  I C ‘s Jeevan Arogya Policy ( Table 903),
2. L I C’s Jeevan Arogya Condition and Privileges,
3. Admission summery of the patient,
4. Notification dt. 25.04.2017  in respect of Insurance Ombudsman Rules- 2017.

Having heard the Ld. Advocate of both the side and on perusal of the Complaint, Written Version as well as documents filed by the parties, the following points are taken to be decided by this Commission.

          Points for consideration                 

1. Whether the complainant is a consumer?
2. Whether the case is maintainable under the C.P. Act ?
3. Whether there is any deficiency in service on the part of the O.P. as alleged by the Complainant ?
4. Is the Complainant entitled to get any award and relief as prayed for as per the prayer of his Complaint?

                              Decision with reasons

All the points are taken up together for discussion to avoid unnecessary repetition and for the sake of convenience and brevity of this case.

In order to prove the case the Complainant has filed the written deposition in the form of an Affidavit and also filed some documents by a firisti .

To falsify the case of the Complainant the OP’s No 1, 2 & 4 filed deposition in the forms of an Affidavit . They also filed some documents by a firisti .

Ld. Advocate of the Complainant during argument has stated that, the Complainant has been able to prove the case against the O.P’s by adducing evidence in the form of an Affidavit and also by producing documents in support of its case. He also argued that the O.P’s. with a view to falsify the case of the Complainant has adduced evidence and produced some documents. But has failed to disprove the case of the Complainant. It is also the argument of the Complainant that the Complainant has specifically admits the contents of the Plaint by adducing written deposition in the form of an Affidavit .

Ld. Advocate of the Complainant during argument has also stated that, the Complainant has been able to prove its case by filing evidence where he specifically stated on Affidavit that his wife Rehana Sultana was taken to Touch Nursing Home at Jalpaiguri on 04.01.2019 when she fell sick with the Complaint’s of pain in her abdomen. It is also argument that, after conservative treatment she was referred for attending any surgeon for further treatment and therefore after she was taken to Paramount Hospital Pvt. Ltd Siliguri on 05.01.2019, underwent laparotomy on 08.01.2019 and discharged there from on 25.01.2019 and for which total medical expenditure was of Rs. 6,41,269/- (Rupees Six Lakhs Forty One Thousand Two Hundred Sixty Nine Only)’which was paid by the Complainant. It is also argument of the Complainant that, on 22.02.2019 the Complainant gave intimation to the LICI, Health in writing and on 22.02.2019 submitted the claim form along with the relevant documents. It is further argument of the Complainant that, the O.P. No. 3 on 30.05.2019 admitted their claim of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only) but the O.P’s did not pay that amount of money in spite of several requests of the Complainant. It is also the argument of the Complainant that on 05.12.2019 he sent notice upon the O.P’s through his Ld. Advocate asking for supply of a copy of statement regarding admitted amount of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only) and O.P. No. 4 sent a reply to the Ld. Advocate of the Complainant but the O.P’s. have refused to pay the expenses incurred by him but the O.P’s. have paid an amount of Rs. 56,000/- (Rupees Fifty Six Thousand Only) towards major surgical benefits , which is 40% of actual expenses of Rs. 1,40,000/- (Rupees One Lakh Forty Thousand Only) but they did not clarify the same as to why they paid Rs. 56,000/- (Rupees Fifty Six Thousand Only) instead of Rs. 1,40,000/- (Rupees One Lakh Forty Thousand Only). Ld. Advocate of the Complainant during argument submits that, the Complainant has been able to prove the case against all the O.P’s. and he is entitled to get the relief as prayed for.

At the time of argument Ld. Advocate of the O.P’s No. 1, 2 & 4 have stated that, the Complainant has filed this case against the O.P’s. knowing fully well aware that he has no cause of action to file this case and he has miserably failed to prove the case against the O.P’s. He also argued that as per terms of the Policy Bond and as per recommendation of the O.P. No. 3 L I C has settled the claim of the Complainant of Rs. 95,200/- (Rupees Ninety Five Thousand Two Hundred Only) and remitted the said settled amount of Rs. 95,200/- (Rupees Ninety Five Thousand Two Hundred Only) to the Complainant which was duly credited. Ld. Advocate of the O.P’s. also argued that, the O.P. No. 3 T P A did not admit the claim of the Complainant to the tune of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty One Only) and the T P A is bound by the terms & Conditions of the Policy Bond and the claim amount may be of any amount but the actual admission & payment is limited as per the terms, conditions of the Jeevan Arogya Policy. It is also argument of the O.P’s. No.1, 2 & 4 that, the O.P’s have explained to the Ld. Advocate of the Complainant in reply to the Notice dated 05.12.2019 about the details of the admissible amount as well as its calculations and the same has duly been admitted by the Complainant in the Complaint (Para No. 15). It is further argument of the O.P’s. that the L I C’s Jeevan Arogya Policy Table No. 903 is a defined benefit policy where the claim amount does not depend upon the actual cost of the treatment or operation. Ld. Advocate of the O.P’s No. 1, 2 & 4 by filing supplementary B.N. A. has explained the calculation and payment details which are given below :-

Initial Daily Benefit (IDB) opted at the time of proposal was ofRs. 1000/- (As agreed),

Date of Commencement of the Policy was on 02.11.2012, date Of Hospitalization was on 05.01.2019 (Duration is 6 Yrs+).

As per Policy Condition – 0.5% increase in IDB for each Year, for 6 Yrs increase is 3 %, i.e. Rs. 300/-,0.5 % increase in IDB for every 3 yrs., as “No Claim” benefit. In 6 yrs, for 2 occasion such increase is 1 %, i.e. Rs. 100/-.

So, total Applicable Daily Benefit (ADB) comes to Rs. 1400/- (1000 + 300 + 100).

Total Hospitalization was for 21 Days (ICU- 7days; Non- ICU- 14 days.), As per policy condition two times of applicable daily benefit is payable for ICU, so, applicable daily benefit payable for ICU is of Rs. 1400 X 2 (Double) X 7 days = Rs. 19,600/- and applicable daily benefit for Non ICU is of Rs. 1400 X 14 Days = Rs. 19,600/- and thereby the total applicable daily benefit payable = 19,600 + 19,600/- = 39,200/-It is also argued that as per Policy
Condition in case of Major Surgical benefit a sum assured 100 times of applicable daily benefit and for which Major Surgical Benefit for sum assured is Rs.14,00/- X Rs. 100/-= Rs. 1,40,000/- and exploratory Laprotomy done on 08.01.2019 and as per serial no. 51 of the Policy, the said surgery of exploratory Laprotomy falls under 40 % category and thus, Major Surgical Benefit payable is 40 % of Rs.1,40,000/- = Rs. 56,000/-. The total claim payable of Rs. 39,200/- + Rs. 56,000/- = Rs. 95,200/- which has already been paid on 21.10.2019 in the Bank Account of the Complainant.

By filing B.N.A. and producing the Jeevan Arogya Policy documents, Jeevan Arogya condition and privileges , admission summary of the patient Ld. Advocate of the O.P’s. No. 1, 2 & 4 submits that, the Complainant has failed to prove the case and the said case is required to be dismissed.

Having heard, the Ld. Advocate of both the sides and on perusal of the L I C’s Jeevan Arogya Policy, Legal Notice of the Complainant discharge summary at the patient, reply of the O.P. No. 4 in response to the Legal Notice dated 05.12.2019 it is admitted fact that, the Complainant is a Policy Holder of the O.P., holding Jeevan Arogya Policy being Policy No. 457355214 in his name, valid from 28.11.2012 to 28.11.49. It is also admitted fact by both the side that Rehana Sultana wife of the Complainant fell sick and she was firstly taken to Touch Nursing Home on 04.01.2019 with Complaints of pain in her abdomen and she was there after referred for attending any surgeon and thereby taken to Paramounts Hospital Pvt. Ltd., Siliguri on 05.01.2019. It is also admitted fact by both the side that the wife of the Complainant was admitted in the Nursing Home since 08.01.2019 to 25.01.2019. It is also not denied by the Complainant that the L I C did not pay a sum of Rs. 95,200/- (Rupees Ninety Five Thousand Two Hundred Only) (Para No. 15 of the Complaint) to him.

It is also the matter of record vide the Jeevan Arogya Policy (Table No 903) that, there are some Policy Conditions Which are specifically defined in the Policy. In the Policy condition it is defined that, Hospital cash benefit opted in the policy is of Rs. 1000/- (Rupees One Thousand Only) per day and premium was fixed on that basis. As per terms of that policy it is also narrated that the daily hospital cash benefit increased at the rate of 5 % per year which was increased by (5% of 1000/-) X 6 = Rs. 300/- as 6 years has been Completed. It is also reflected in the policy condition that, there would have an additional increased of daily benefit which is called as no claim benefit i.e. extra 5 % increase for a block of 3 years. On bare calculation it became (5 % X 1000) X 2 = 100/- and thereby the daily cash benefit would be calculated as Rs. 1000/- + 300 +100 = Rs. 1400/-. It is also admitted fact that the wife of the Complainant was in the ICU for 7 daysand Non I C U for 14 days and that’s why daily cash benefit was payable of Rs. 1400 X 2 X 7 for I C U ( As daily benefit is double for I C U i.e. 1400 X 2). For Non I C U daily cash benefit according to policy condition is Rs. 1400/- (per day) X 14 days. Totaling of Rs. (1400 X 2 X 7) + 1400 X 14 = Rs. 39200/-.

From the Policy Condition of Jeevan Arogya Policy it also reveals that, in case of Major Surgical benefit as per policy condition it may be 100 %, 60 %, 40 % or 20 % X 100 as per category of the operation. In the case of the Complainant, the operation of his wife felt under 40 % of the daily hospital cash benefit i.e. 40 % of 1400 X 100 = Rs. 56,000/- ( Rupees Fifty Thousand Only). From the bare calculation as per terms of the Policy Condition (Table No. 903) the admissible payable amount would be of Rs. 39200/- + 56, 000/- = 95, 200/- and the said sum of Rs. 95,200/- (Rupees Ninety Five Thousand Two Hundred Only) has already remitted in the Bank Account of the Complainant and the Complainant has admitted the said fact in Para No. 15 of his Complaint. Accordingly the O.P’s. No. 1, 2 & 4 are not liable to pay any amount of money to the Complainant as there was no deficiency of service on their part.

Notice was sent from the Commission for service upon the O.P. No. 3 also. Notice upon the O.P. No. 3 was duly served. But the O.P. No. 3 did not turned up before this Commission to contest the case of the Complainant. On the other hand the O.P’s. No. 1, 2 & 4 by filing their Written Version as well as B.N.A. admits that, as per recommendation of the O.P. No. 3 they settled the claim of Rs. 95200/- ( Rupees Ninety Five Thousand Two Hundred Only). The O.P’s. No. 1, 2 & 4 have also stated in the Written Version and Brief Notes of Argument that, the T P A ( O.P. No. 3) did not admit the claim amount of Rs. 4,26,731/- (Rupees Four Lakhs Twenty Six Thousand Seven Hundred Thirty OneOnly) and the T P A has acknowledge the receipt of claim papers of the Complainant. But the said T P A ( O.P. No. 3 ) neither appears before this Commission nor produced the original claim petition of the Complainant as well as other original medical documents including admission / discharge summary before this Commission though the T P A ( O.P. No. 3 ) issued a letter on the subject ( 1^st) Query Letter ( C C N: 11004848) on 30.05.2019 in favour of the Complainant. Keeping the original claim petition of the Complainant as well as medical documents received from the Complainant by the T P A (O. P. NO. 3) in their custody and non production of the same before this Commission and non making of reply to the Legal Notice dated 05.12.2019 of the Complainant are nothing but the deficiency in service as well as restrictive trade practice on the part of the O.P. No. 3. The Complainant through his Ld. Advocate sent notice to the O.P’s. on 05.12.2019 where the Complainant asked the O.P’s. for supply of copy of statement appertaining to the remittance of the admitted claim amount but the O.P. No. 3 despite receiving that notice make no reply to that and the same is nothing but the deficiency in service as well as restrictive trade practice.

Hence,

              it is therefore,

        O R D E R E D

That, the instant Consumer Case being in No. 09/2020 be and the same is dismissed on contest against the O.P. No. 1, 2 and 4 and partly allowed against the O.P. No. 3 on ex-parte. The O.P. No. 3 is directed to pay a sum of Rs. 20,000/- ( Rupees  Twenty Thousand Only) to the Complainant towards Compensation for pain and agony suffered by the Complainant due to negligent act of the O.P. No. 3 and for deficiency in service and the O.P. No. 3 is also directed to pay litigation cost of Rs. 5,000/- ( Rupees Five Thousand Only) to the Complainant and Rs. 10,000/- (Rupees Ten Thousand Only) in the Consumer Legal Aid Account.

The O. P. No. 3 is directed to pay the above amount of money within one month from this day. Otherwise the Complainant will have the liberty to take proper steps against the O.P. No. 3 as per law and in that case the O.P. No. 3 will have to pay interest @ 9 % per annum from this day till the date of making payment.

Let a copy of this order be given to parties free of costs.