Fact of the case of the Complainant in short is that the Complainant took a Mediclaim Policy bearing no.313400/48/2016/315 covering claim for himself and his wife Smt. Santana Banerjee for Rs.5,00,000/- (Five Lakhs) at a yearly premium of Rs.6,930/- policy and same was deducted from Savings Bank Account no.08672191010513 stands in the joint name of Complainant and his wife Smt. Santana Banerjee, for the period 04-09-2014 to 03-09-2015 and same was renewed for the period 04-09-2015 to 03-09-2016.  After that the Smt. Banerjee wife of the Complainant admitted in Asian Institute of Gastroenterology Hospital at Hyderabad for her treatment for the period 17-08-2015 to 14-09-2015 and 20-09-2015 to 27-09-2015 and Rs.3,99,832/- was expended for her treatment during that period of hospitalization.

Thereafter, this Complainant submitted claim to the O.P. no.1 Divisional Manager, Insurance Company on 30-10-2015 after that O.P. no.2 who is a T.P.A. sent a letter and made queries about the some documents which was received by the Complainant on 19-12-2015 and thereafter, this Complainant submitted original documents of treatment of his

Wife ; but O.P. no.2 informed by sending SMS to the Complainant that the claim made by him has been closed for non-receipt of documents.  After that Complainant made request several times to meet his claim of amount for cost of treatment of his wife but all are in vain.  So, this Complainant has filed this case and has made prayer to direct O.P. no.1 to reimburse Rs.3,99,832/- as cost of treatment of his wife co-insured in respect of mediclaim policy along with interest and also made further prayer to direct O.P. no.1 & 2 to pay compensation of Rs.80,000/-  for his mental agony and harassment, etc. and cost of litigation.

In this case notice of this case was issued and served upon all O.Ps. but they did not appear.  So, this case was heard exparte.  No relief has been prayed against O.P. no.3.

  In this case affidavit evidence have been tendered by Complainant, which has been treated as evidence of P.W.1.  The following documents are marked as :-

Exhibit – 1 is the photocopy of Pass Book.

Exhibit – 2 (a) is the copy of insurance policy.

Exhibit – 2(b) is the copy of mediclaim policy.

Exhibit – 3 is the Xerox copy of Insurance Card.

Exhibit – 4 series the Discharged Summary.

Exhibit – 5 series the Summary of final bills collectively.

Exhibit – 6 series are the letters.

Exhibit – 7 is the mediclaim policy claim form.

Exhibit – 8 is the letter of reminder for information.

                                                               Points for determination

1).  Whether the complaint is maintainable ?

2).  Whether there was any deficiency in service in the matter of repudiated the claim

        made by the Complainant ?

3).  Whether the Complainant is entitled to compensation as prayed for ?

                                                                   Decision with reason.

In this case we find from the affidavit evidence filed by the Complainant Sunil Kr. Banrjee Complainant / P.W.1 and a documents exhibited in this case and materials on record that this Complainant took / purchased a mediclaim policy for the period from 04-09-2014 to 03-09-2015 exhibited 2(b) at first.  Thereafter, said policy was renewed for further period from 04-09-2015 to 03-09-2016 exhibit 2(a) for himself and for his wife Smt. Santana Banerjee.  It also reveals from the evidence of P.W.1 as well as petition of complaint that Santana Banerjee wife of the Complainant co-insured was admitted for her treatment in Asian Institute of Gastroenterology Hospital for the period 17-08-2015 to 14-09-2015 and 20-09-2015 to 27-09-2015 and this Complainant had to expend Rs.3,99,832/- as cost of treatment of his wife / co-insured of the case policy.

We find from exhibit – 2(a)  and 2(b) that this Complainant had valid insurance mediclaim policy during the period of hospitalization of his wife.  It also reveals that the insured amount of the mediclaim policy was Rs. 50,000/-.

In view of the circumstances we hold that the Complainant has been able to prove that during the period of hospitalization of his wife this Complainant had valid insurance policy. So it proves that Santana Banerjee / co-insured indemnified by O.P. no.1 Insurance Company to pay the Rs.3,99,832/- expended by Complainant for treatment for his wife co-insured of the case policy.  So, O.P. no.1 insurance company is bound to act in the matter of payment cost / expenses for treatment of the co-insured wife of the Complainant as per terms & conditions of the case policy.  It also reveals from exhibit – 5 series those are the final receipts showing payment of Rs.3,99,832/- for purchasing of medicines and other cost for the treatment of wife of Complainant and it also reveals from the evidence of P.W.1 that this Complainant submitted claim for reimbursement of Rs.3,99,832/- expended for treatment of his wife to O.P. No.1 / Insurance Company ; but O.P. no.1 did not pay any heed to pay the same to insured / Complainant.

It has been observed by the Hon’ble National Commission reported in 2016(3) C.P.R. page – 89 (N.C.) inter alia that a bona fide claim cannot be repudiated by the insurance company.

In this case this Complainant has been able to prove that he had valid insurance policy

during the period from 04-09-2014 to 03-09-205 and from 04-09-2015 to 03-09-2016 to the extent of Rs. 5,00,000/- and the Complainant and his wife Santana Banerjee were jointly insured in the said policy issued by O.P. no.1 / insurance company.

Complainant has also been able to prove that he had expend Rs.3,99,832/-  during the  hospitalization  of his wife within the valid period of insurance policy.

Moreover, we do not find any reason to disbelieve the unchallenged testimony of the P.W.1.  So, we hold that the claim of the Complainant was bona fide and in view of the observation of the Hon’ble National Commission that the said bona fide claim of the Complainant cannot be repudiated by insurance company.

We also find that this O.P. no.1 insurance co. did not respond about the payment of amount of claim submitted by the Complainant and same has been kept pending for long time by O.P. no.1, without taking any action.

It has been observed by the Hon’ble National Commission reported in 2016(3) C.P.R. page  10(N.C.) inter alia that insurance co. cannot keep claim pending for the long time.

In view of the above observation of Hon’ble National Commission and facts & circumstances we hold that this O.P. no.1 insurance co. did not pay any heed to meet the claim of the Complainant ; which O.P. no.1 cannot do.

In view of the above facts & circumstances and in view of observation of Hon’ble National Commission referred to above we hold that this Complainant is entitled to reimburse Rs.3,99,832/- from the O.P. no.1 insurance co., which he said / expended for the treatment of his wife co-insured of case policy.

Considering the other facts & circumstances we hold that if Rs.3,168/- is awarded as cost of litigation as well as harassment in favour of the Complainant for interest of justice then none would be prejudiced.

We also find that principal O.P. no.2 is a TPA.  He has no role in the matter of payment of claim amount and repudiation of the claim submitted by the Complainant to O.P. no.1, Insurance Company and O.P. no.1 / Insurance Company is only responsible for repudiation of the claim made by Complainant.  So, we hold that there is no cause of

action against O.P. no.2.  So, this case is liable to be dismissed against O.P. no.2.

We also find that no relief has been claimed against proforma O.P. no.3.

So, this case is also liable to be dismissed against proforma O.P. no.3.

Hence, it is

                                                                             Ordered

That Complaint Case no.13 of 2016 be and same is hereby allowed exparte against O.P. no.1 and dismissed against the rest.

O.P. no.1 Divisional Manager of Oriental Insurance Company Ltd. is hereby directed to pay Rs.3,99,832/-  to the Complainant which he expended for the treatment of his wife ; co-insured of the policy involved in this case.

O.P. no.1 / Insurance Company is also further directed to pay Rs.3,168/- as cost of litigation and harassment, etc. in total Rs.4,03,000/- to Complainant / joint insured of case policy by thirty (30) days from the date of receipt of copy of this Judgement ; failing which it will carry simple interest @ 9% p.a. from the date of receipt of copy of Judgement till it’s  full realization.

If O.P. no.1 / Insurance Company fails to pay the amount awarded above with in the period  mentioned above then Complainant is at liberty to realize the same with due course of law.

Thus this complaint is hereby disposed of exparte.

Let a plain copy of this Judgement be supplied to the parties free of cost.