Date of Filing:-09/12/2015
Order No. -12 Dt.- 17/06/2016
Shri Asoke Kumar Das,President
F I N A L O R D E R
Complainant’s case in short is that he purchased one mediclaim policy bearing no. 153900/48/15/8500000089 from National Insurance Company Ltd. (O.P.1) for himself and his family members on 06/04/2015 which was valid from 08/04/2015 to 07/04/2016 and total sum assured was Rs.1,76,500/- for each insured person. He paid extra charge @ of 6% in addition to his usual premium to get cashless service. His son Sri Mayukh Basak aged 15 years was suffering from high fever from 10/08/2015. He was treated by local Doctor but he didn’t get any relief and so he was admitted in Neotia Getwel Healthcare Centre, at Siliguri on 14/08/2015 for better treatment. On that very date Neotia Getwel Healthcare Centre sent request to R.M.M.D. India Healthcare Service Ltd.(TPA)(O.P.2) through e-mail for cashless service for treatment cost of complainant’s son and they received sanctioned amount of Rs.21,560/- from O.P.2 through an authorisation letter dt.15/08/2015. His son was cured at N.G.H.C., Siliguri. The Complainant sent the final bill and discharge summary of his son to O.P.2 through e-mail on 17/08/2015 on the date of discharge of his son throughout the day by N.G.H.C. authority. But O.P.2 denied to receive the said e-mails. Thereafter he again sent the said final bill and discharge summary to O.P.2 through e-mail by N.G.H.C. and thereafter they made several discussions with the O.P.2 over this matter but no fruitful result came out. For this complainant was compelled to discharge his son at 5.00pm on 17/08/2015 from N.G.H.C., Siliguri on payment of cash arranged by him as he was deprived to get cashless service/benefit from O.Ps. 1 and 2. On 19/08/2015 evening O.P.2 acknowledged his cashless request and intimated him that his request was under process. On 20/08/2015 the official of N.G.H.C. intimated him regarding denial of his cashless request by TPA(O.P.2) on the plea that the patient was already discharged from the hospital. Hence, this case.
Notice was issue upon both the O.Ps. but only O.P.1 i.e. National Insurance Company has contested this case by filing a Written Version denying and disputing the claims and contention of the complainant with prayer for dismissal of the case with cost.
Specific stand of O.P.1 is that on 22/01/2016 claim of the complainant has been settled and Rs.25,520/- was transferred in the account of the complainant by NEFT and they never repudiated the claim of complainant and there is no deficiency in service on their part.
On 17/05/2016 complainant has intimated this Forum by filing a petition that the O.Ps. have credited Rs.25,520/- to his Savings bank account on 22/01/2016 after receiving notice of this Forum and that he has no grievance about settled amount of Rs.22,520/- except delay payment and cashless benefit.
POINTS FOR CONSIDERATION
- Is the case maintainable?
- Is the complainant is a consumer?
- Are the O.Ps. guilty for Deficiency in Service and/or Unfair Trade Practice for delayed payment and for depriving the complainant from cashless service/benefit as alleged?
- Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
All points are taken up together for consideration and decision.
Seen and perused the materials on record i.e. petition of complaint, Written Version, documents filed by the parties, complainant’s petition dt.07/05/2016 and the B.N.A. filed by the O.P.1. We have also heard the arguments of both the parties in full.
After due consideration of all these we find that admittedly this case is well maintainable and the complainant is a consumer of O.P.1
Admittedly O.Ps. have paid Rs.25,520/- to the complainant on 22/01/2016 i.e. after filing of this case and that the complainant is satisfied with that settled amount against his claim of Rs.32,741.50/-.
It is the positive case of the complainant that there was cashless facility in his said mediclaim policy and he had to pay extra 6% in addition to usual policy premium to get/avail that cashless facility and the O.ps. are guilty for deficiency in service for not providing him cashless facility on the date of discharge of his son from NGHC, Siliguri despite receiving final bill and discharge summary by e-mail sent by the authority of NGHC, Siliguri,
As against this the specific stand of O.P.1 is that on 22/01/2016 they have settled the claim of the complainant at Rs.25,520/- and transferred the said amount of money in the account of the complainant by NEFT and the complainant had received that amount without raising any objection and they never repudiated the claim of the complainant and there was no deficiency in service on their part.
From the materials on record we find that the O.Ps. have sent Rs.25,520/- in the account of complainant on 22/01/2016 i.e. after filing of this case although the complainant had sent the final bill and discharge summary of his son to O.Ps. by e-mails on 17/08/2015 i.e. on the date of discharge of his son from NGHC, Siliguri.
Now from the annexure ‘G’ i.e. copy of Denial of Additional Authorization letter dt.19/08/2015 issued by O.P.2(TPA) and filed by the complainant we find that there is clear indication in this document that there was cashless facility in the said mediclaim policy of the complainant. It is written in the second paragraph of this document that, “the Cashless Hospitalization” is denied, as the patient is already discharged from the hospital” Ld. Lawyer for O.P.1 didn’t challenge the authenticity of this statement in this document.(Annexure-G) Therefore we have no hesitation to hold that there was cashless service/benefit in the said mediclaim policy of the complainant and despite receiving final bill and discharge summary of complainant’s son by e-mail from the authority of N.G.H.C., Siliguri on the date of discharge of Complainant’s son i.e. 17/08/2015, the O.Ps. took no step to provide the complainant cashless service/facility and due to such inaction on the part of the O.Ps., the complainant was compelled to arrange for money to pay the dues of the hospital on 17/08/2015 to discharge his son. Furthermore the complainant had sent the final bill and discharge summary of his son to O.Ps. on 17/08/2015 by e-mails for payment of hospital dues but the O.Ps. have settled the claim of the complainant and sent Rs.25,550/- in the account of the complainant by NEFT on 22/01/2016 i.e. after five months approx and that was done after filing of this case. The aforesaid conduct of O.ps. i.e. denial of providing cashless relief/facility and five months delay of payment after filing of the case, certainly comes within the purview of deficiency in service.
It this view of the matter we find and hold that the case is maintainable , the complainant is a consumer and the O.Ps. are guilty for deficiency in service . Therefore the complainant is entitled to get the reliefs specified below.
All point are disposed of.
In the result the case succeeds.
Hence, it is
O R D E R E D
that this case/application is allowed on contest against National Insurance Co.Ltd. (O.P.1) on contest and ex-parte against M.D.India Health Care Services(TPA) O.P.2 with litigation cost of Rs.1000/-(One Thousand.).
The complainant do get an award of Rs.2,000/- against the O.ps. for their aforesaid deficiency in service.
The complainant do get further award of Rs.2,000/-(Two Thousand) against the O.Ps. in the head of his mental pain and agony, harassment etc.
The O.Ps. are jointly and severely liable to pay to the complainant the aforesaid litigation cost and the awarded sums.
The O.Ps. are hereby directed to pay to the complainant aforesaid litigation cost of Rs.1,000/- + awarded sums of Rs.2,000/-+Rs.2,000/-=Rs.5,000/- (Five Thousand) in total within 30days hereof failing which it will carry interest @ 8% p.m. till realization and the complainant shall be at liberty to realize the same by putting this order into execution in accordance with law.
Let copy of this final order be supplied free of cost forthwith to the parties/ their Ld. Advocates/agents on record by hand under proper acknowledgement/sent by ordinary post, in terms of Rule 5(10) of West Bengal Consumer Protection Rules 1987.
