JUDGEMENT

          Complainant by filing this complaint has alleged that he is a medi-claim policy holder of the op no.2 bearing Policy No.031100/48/11/97/00005425 by filing this complaint submitted that complainant fell ill and accordingly he was consulted with the Dr. DipankarDutta on 06.12.2012 and said doctor after examination advised him to be admitted under op no.1 on 21.12.2012 for the surgery of Right Thyroyid Nodule in the neck and as because the complainant was under the coverage of Mediclaim policy, complainant intimated such hospitalization and operation to the op no.2 vide letter dated 18.121.2012.

          Thereafter the complainant was admitted at the op no.1/Nursing home on 21.12.2012 under the treatment of Dr. DipankarDutta who conducted the operation of the patient and after treatment the complainant was discharged from the Nursing Home on 25.12.2012 and for the purpose of treatment complainant spent of expenditure to the extent of Rs.61,097/- including charges of nursing home, pharmacy, doctor’s fees etc and complainant paid the amount to the op no.1 but op no.1 issued money receipt only for Rs.16,624/-

           Complainant through his letter dated 07.01.2013 submitted claim from op no.2 along with all the treatment paper and bills/vouchers and claim for reimbursement of medical expenditure of Rs.69,814.25/- including post hospitalization treatment cost also.

          Op no.2 after receiving the said claim application intimated the complainant that proper money receipt is required for the entire amount of Rs.61,097/- otherwise they will not settle the claim.

          On receiving such intimation the complainant immediately requested the op no.1 for issuance of final bill showing payment of Rs.61,097/- under different heads vide letter dated 27.02.2013.  Thereafter the op no.1 issued an informal receipt showing payment of Rs.61,097/- under heading (To Whom It May Concern) but deliberately denied to issue proper and valid money receipt/bill against of Rs.61,097/-.

          Then complainant again sent another letter dated 14.03.2013 whereby complainant requested the op no.1 for submission of final bill for Rs.61,097/- incorporating doctor’s and anesthetist fees.  But op no.1 did not comit and thereby they committed unfair trade practice and is avoiding payment of government revenue the complainant also intimated such incident to the local Beliaghata Police Station.  Having no other alternative the complainant sent one legal notice upon the op no.1 on 15.04.2012 whereby requested to furnish final bill and further intimated that due to such deliberate delay and negligence on the part of the op no.1 the Insurance Company withhold the claim amount and did not disburse the medical expenditure as claimed till date.  As the complainant is a Cancer patient and doctors of TATA Memorial Centre, Kolkata advised for further operation which required huge money for such treatment, the complainant earnestly requested the op no.1 to provide the final bills so that the complainant will get reimbursement of the medical expenditure as claimed from the Insurance Company.  Op no.1 received the said letter and kept silent till date.

          By such an act op no.1 practically committed an unfair trade practice in performance of their business, though it is mandatory duty of the op no.1 nursing home to issue proper and valid bill and money receipt to it’s customers but in the instant case the op no.1received an amount of Rs.61,097/- from the complainant but did not issue money receipt.

          Due to non-issuance of proper and valid bill and money receipt by the op no.1 the complainant is financially suffered mental pain and agony and being harassed by the op no.1 and for the unfair trade practice of the op no.1 the complainant’s claim has not been settled by the insurance company and in the above circumstances complainant prayed for issuance of the final bill including interest over the said amount and further compensation.  

          Whereas op no.1 the Nursing Home Authority by filing written statement has submitted that op no.1 already issued money receipt for Rs.16,624/- and op no.1 provided all the money receipts to the complainant as per his demand including the money receipt of treating doctor and the complainant for the illegal gains suppressed the fact and falsely alleged about non-receipt of money receipt of doctors.

          As per request of the complainant, op no.1 issued one certificate of payment of medical expenditure to the complainant but the op no.1has already issued proper money receipts of doctors and original receipt was handed over to the complainant and it is pertinent to be mentioned that for the purpose of settlement of insurance claim payment of medical expenditure is necessary rather particulars of payments.  Complainant just to lower down the reputation of the op no.1 falsely submitted this complaint and the entire allegation of the complainant is false.

          Op no.2 has not contested this case.  So the case is finally closed after hearing the argument of the Ld. Lawyers of the parties.

Decision with reasons

          After hearing the Ld. Lawyers of both the parties and also considering the entire complaint, particularly the prayer portion, it is found that complainant has prayed for refund against op no.1 only not against op no.2 Insurance Company and no doubt op no.1 has appeared and contested and submitted in the written statement that they supplied all the material papers.

          Particularly from the complaint it is found that complainant main allegation is that no final bill was granted or handed over to the complainant in respect of Rs.61,097/-.  But op’s version is that they have supplied all the documents in this regard we have gone through the complainant’s own document wherefrom it is found that in respect of certificate issued by the Divine Nursing Home, it is found that in the said certificate it is noted “Nursing Home Rs.16,624/-, Pharmacy – Rs.7,743/-, Dr. DipankarDutta fees- Rs.35,000/-, Dr. S. Mukherjee Rs.5,000/- i.e. total Rs.61,097/-.  Complainant’s main allegation is that in details bill was not submitted and handed over to the complainant.  In this regard we have gathered from the complainant’s own document at page-27 that Money Receipt was granted by Dr. DipankarDutta to the complainant Samir Kumar Ghosh on 25.12.2012 vide Register No.399 in respect of fees of Rs.35,000/- only.  Next bill of Samir Kumar Mukherjee dated 07.01.2013 vide Bill No.134 was also issued for a sum of Rs.5,000/-.  Detailed status report was also issued on 25.12.2012 by the Divine Nursing Home in details in short Divine Nursing Home Rs.16,624/-, Drs’ fees Rs.40,000/-, Pharmacy Rs.4,473/- i.e. total Rs.61,097/- and from the complainant’s own document it is found that Divine Nursing Home also supplied details of the final bill on 25.12.2012 in respect of Rs.16,624/- and in respect of pharmacy charges of Rs.4,473/- in detail bill has also already been handed over to the complainant along with final bill with break-up and in respect of Dr. DipankarDutta Rs.35,000/-  and Dr. S. Mukherjee Rs.5,000/- separate bill have already been supplied.  Then what more shall be supplied by the Divine Nursing Home to the complainant.

          Probably for some receipts or  for other cause this complaint was filed on the ground that Divine Nursing Home did not send any genuine bill to the Insurance Company for which the claim of the complainant was not settled by the Insurance Company.  But, we have gathered from the record that Divine Nursing Home supplied all papers to the complainant and if any genuine bill is required in that case at best we can direct the Divine Nursing Home to send all required documents to the Insurance Company if it is asked by the Insurance Company.  But no deficiency on the part of the op Divine Nursing Home is found at this stage.  In the above circumstances, we are convinced to hold that complainant has failed to prove any deficiency on the part of the op Divine Nursing Home and no doubt against the op no.2 Insurance Company but against Insurance Company there is no claim.  So, in the circumstances, the entire complaint is dismissed without any cost.

Accordingly, the case is dismissed.

          Hence, it is

ORDERED

          That the complaint be and the same is dismissed on contest without any cost against the op no.1 Divine Nursing Home and same is dismissed against op no.2 United India Insurance Company Pvt. Ltd.

          But Divine Nursing Home Pvt Ltd. is directed to supply all genuine and original documents if required by the Insurance Company United India Insurance Company Pvt. Ltd. in respect of Mediclaim policy of the present complainant being Policy No.031100/48/11/97/00005425 in that case the op no.1may ask Divine Nursing Home supply it and at the same time the United India Insurance Co. Pvt. Ltd. is hereby directed not to harass the complainant to settle the claim after receiving all documents through their office from Divine Nursing Home Pvt. Ltd in support of the claim of Samir Kumar Ghosh for his medical treatment cost for the period from 21.12.2012 to 25.12.2012 and other charges that is a pre-hospitalisation and post-hospitalisation etc.

          Op nos. 1 & 2 shall comply this part of order otherwise the matter shall be taken with heavy hands and even penal action shall be taken against themif for Divine Nursing Home’s negative attitude mediclaim of any insured are not being settled by the Insurance Company for want of original documents etc. from the Divine Nursing Home Pvt. Ltd. which is found in so many cases.