Present complainant by filing this complaint has alleged that complainant including his family members are the holder of Mediclaim Insurance Policy vide No.5128003407/14/00003217 valid from 12.10.2007 to 12.10.2008 issued by the op no.1.

          While holding the said valid mediclaim policy, the daughter of the complainant who is also covered under the aforesaid policy namely Payel Agarwal suddenly fell ill and she was admitted to Bansal Nursing Centre 20, DOBSON Road, Howrah-711101 on 24.04.2008 and was medically treated by the Dr. M.L. Bhanshali. M.B.B.S. MD and finally it was detected that she was suffering from lower Respiratory tract infection, gastritis, transient loss of consciousness and for her treatment some amount was spent and for which the complainant submitted mediclaim to the op no.1 along with all necessary papers as required by the op no.1 and thereafter suddenly on 09.07.2008 op no.1 informed the complainant that his claim has been repudiated and against them complainant raised objection by his letter dated 04.08.2008.  Thereafter also the claim was not finally settled and no fund was released for which the complainant sent a demand letter through his Ld. Advocate Kunal Sengupta for payment of Rs.14,481/- and even then op did not respond the plea, therefore, the complaint is filed for redressal.

          Against the above allegation, op no.1 Insurance Co. by filing written version submitted that matter was decided by the expert doctors of TPA and in the opinion of the doctors the provisional cause of convulsion at the age of only 16 years of the patient has not been explained in the treatment sheet and no history of disease was there and there are anomalies regarding opinion of the treating doctor and lower respiratory treatment of the patient and considering all the available documents and on the basis of the opinion of the expert doctors Claim Adjudication Department   i.e. op no.2 repudiated the claim.  Moreover, the claim was being for the first year policy and so it was not entertained.  In fact op no.2 vide its letter dated 04.02.2010 sent a letter stating the receipt for repudiation of the estimate claim liberally on the ground that the expert doctors of the op no.2 deffered with the opinion of treating doctor of the patient regarding analysis but on the ground of treatment as conducted by him and ultimately it was rejected and fact remains patient has been suffering from convulsing episodes but doctor did not mention the history or seizure and for which there was no fault on the part of the op.  Op no.2 also filed another written version and practically op no.2 the TPA stated everything as per file of the insurance company because TPA is an agent of op. So, they never say anything against the op no.1.

          Accordingly after end of the entire proceedings, argument was heard from the Ld. Lawyers of both the parties and now we shall have to proceed to decide the Consumer Dispute of this case.

                                        Decision with reason

          In reality we have studied the complaint and written statement, documents as filed by both the parties and also considering the admitted position that the complainant is a family members are covered by the aforesaid insurance policy under the op no.1 and TPA is the agent of op no.1 for determining the claim submitted by the policy holders in case of their treatment cost or any other cost for treatment.

          Fact remains the complainant filed claim in respect of only Rs.14,481/- and no doubt the complainant deposited all relevant documents as required by the ops for settlement of the claim.  But unfortunately, the ops repudiated the claim on the ground that the doctor of the patient did not mention the history behind such disease and treatment as adopted by the doctor of the patient was not as per medical science and further it was decided and was opined by the very doctors of the TPA is as follows:-

          “Regarding the diagnosis of the Lower Respiratory Tract inspection the Chest xray is within normal limits.  The Leucocyte Count is normal and so is ESR.  There is no way we can and even the treating doctor could have commented that ailment is lower respiratory tract infection.  Even the case papers mention that the chest on Auscultation is not suggesting any spasm, Rhonchil wheeze and/or crepts.  Hence the diagnosis of LRTI is not substantiated”.

          It is further decided that diagnosis of Gastritis is absurd because no GI Endoscopy was done and USG was not diagnosed or test for that.  Further Midazolam is definitely a treatment of convulsive episodes and for all the above ground the claim was repudiated.  After comparative study of the document and papers that is mediclaim treatment sheet issued by the doctor of the patient it is found that this patient aged about 16 years suddenly suffered from the prevailing troubles, spasm etc for which she was treated by her doctor and after treatment she recovered.  Fact remains that op has failed to produce any document to prove that prior to that the patient had ben suffering from any existing disease like convulsion or any other matter and another factor is that she was treated under the doctor on 12.04.2008.  Thereafter no mediclaim was made by the complainant in respect of that patient.  Then it is clear that for some reasons she suffered from such prevailing trouble and spasm and after treatment she recovered and thereafter she is O.K.  Then how the ops came to a conclusion that she had been suffering from existing convulsion, spasms disease.  It is the whims of the op and it is peculiar that op did not examine the patient about that not only that these papers were not sent to any expert doctor of Medical College of Kolkata for opinion.  But it is known to all TPA were borne and their only purpose to repudiate the claim of the policy holder in case of filing any such medicalim and it has become a history that TPA is always here and there to tap any claim and practically TPA is appointed by the insurance companies only to submit before the Court, Tribunal, Forum to discharge the insurance companies’ liability by the TPA stating similar fact that they relied upon the report of the TPA and as they repudiated, the insurance company has nothing to do and we feel such sort of insurance company should be penalized at first.  A very meager amount of treatment cost for which the claim was submitted that was also rejected.  Then we can say that at first insurance company in India and their such activities should be stopped at first.  Otherwise it would be an establishment for squeezing money by collecting premium from the customers and their final result is zero that means TPA is here and there to sent zero result against claim and this type of company shall be a capitalist in term and they shall have to invest for further profit.  But social approach of the ops is zero.  Their activities should be condemned from all corners and our experience is that TPA are paid more by the insurance company when number of claim cases are repudiated by the TPA and there is nexus between the op and the TPA.  Such sort of tactical business should be controlled at first otherwise the insured shall be deprived by all the insurance companies in case of filing any claim.  Whatever it may be the entire finding of the TPA is absurd, groundless, having no foundation and as per dictum of op insurance company TPA is acting in such a manner so this Forum is not willing to rely upon the TPA report when doctor who treated the patient was able to make the patient stable and practically after treatment the said patient Payel recovered and she is in sound health and there was no back history of any sort of ailment and it is truth that op have failed to prove any pre-existing disease of Payel Agarwal by any documents.

          In this aspect we shall have to say that TPA is not a medical research institute but it is practically a unit of the op for the purpose of repudiating of the claim after so called investigation and enquiry after submission of the claim application by the insured.

          In the light of the above observation we are convinced to hold that Payel Agarwal a patient had never suffered from pre-existing disease.  There is no such proof and ops also have failed to prove it, but the reason for repudiation as mentioned by the op no.2 is baseless and without any foundation having no opinion from any medical college.  In the above circumstances, we are convinced to hold that repudiation as made by the ops is uncalled for, illegal without any basis and having no foundation and for which op insurance company is liable to pay the entire claim amount of Rs.14,481/- and also compensation to the extent of Rs.5,000/- for harassing the complainant in such a fashion and also for contesting such sort of case before Forum against a meager amount of claim of Rs.14,481/- by spending huge public money for litigation and it indicates that the insurance company is ready to spend huge amount for litigation but they are not willing to release meager amount of mediclaim and if it is the theory of the management of the insurance company, then we are convinced that management shall ultimately fail and all the insurance companies in India shall be closed for illegal decision of the management out right reject or repudiate the claim of the insurer.

          Thus the complaint succeeds.

          Hence, it is

                                                   ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs.5,000/- against the op no.1 and same is allowed against op no.2 also with cost of Rs.5,000/-.

          Op no.1 is hereby directed to pay a sum of Rs. 14,481/- as settled claim amount in respect of the present claim to the complainant and also Rs.5,000/- as compensation for causing and harassing the complainant and also for causing mental pain and agony to the complainant and so op no.1 is directed to issue a cheque of Rs.24,481/- to the complainant in the name of the complainant within one month from the date of this order failing which for each day’s delay op no.1 shall have to pay a sum of Rs.250/- per day as punitive damages till full satisfaction of the said decree.

          For adopting unfair trade practice by the op nos. 1 & 2 jointly they are directed to pay a penalty of Rs.10,000/- each to the State Consumer Welfare Fund for checking their immoral activities to out right reject the meager amount of the claim of the insured and to spend huge money for litigation cost to defend such claim of the insured in different Forums, Tribunal or Court.

          Ops are directed to comply the order very strictly within one month from the date of this order failing which further penalty shall be assessed to the extent of Rs.20,000/- and even penal proceeding for implementation of this order shall be started u/s 27 of C.P. Act 1986 for which they may be sent to jail also.