Date of filing: 22.08.2016 Date of disposal: 08.12.2017.
Complainant: Tulsi Ray, W/o. Pulak Ray, resident of Nivedita Pally, Police Line (West), P.O.-
Sripally, Town, P.S. & Dist.-Burdwan, Pin-713103.
-VERSUS-
Opposite Party: 1. Good Health TPA Services Ltd., represented by its Director, having its Head
Office at Plot No.49, Nagarjuna Hills, Hyderabad, 500 082.
2. United India Insurance Company Ltd., Burdwan Division, represented by
its Divisional Manager, having its office at RUDCO, Floor No.3, G.T. Road,
Palika Bazar, Burdwan, Pin-713101.
3. Andhra Bank, Burdwan Branch, represented by its Branch Manager,
having its office at Parbirhata, P.G. Complex, 1st Floor, G.T.Road, P.O.-
Sripally, Dist.-Burdwan, Pin-713103.
Present: Hon’ble President: Smt.Jayanti Maitra(Ray).
Hon’ble Member: Miss Nivedita Ghosh.
Appeared for the Complainant :Ld. Advocate, Suvro Chakraborty
Appeared for the Opposite Party No.1: None.
Appeared for the Opposite Party No.2 : Ld. Advocate, Shyamal Kr. Ganguli.
Appeared for the Opposite Party No.3 : Ld. Advocate, Soumalya Ganguli.
JUDGEMENT
This is a case U/s. 12 of the C.P. Act for an award directing the O.Ps. to pay Rs.25,968/- towards the treatment expenses of the complainant, to pay Rs.50,000/- towards compensation for mental pain, agony and harassment and to pay litigation cost of Rs.10,000/-, to pay interest @ 12% from 27.4.2015ill realization to the complainant.
The complainant’s short case in hand is that she is the account holder of the O.P. No.3 Bank vide Bank A/c. No.126210011000299. The O.P. No.3 bank proposed the complainant for a mediclaim policy and after knowing the facility of the policy the complainant agreed to incept the same. As such a mediclaim insurance policy was issued in favour of the complainant where the insurer was the O.P. No.2 and the 3rd party administrator was the O.P. No.1.
After payment of premium amount to the O.P. No.2 through O.P. No.3 the O.P. No.2 issued a policy of insurance vide policy No.0504002814P101905064 and the said policy was valid from 11.7.2014 to 08.06.2015. The O.P. No.2 issued an identity card in favour of the complainant. It is pertinent to mention here that the original policy is in the custody of the O.Ps. During continuation of the policy period the complainant began to suffer from some gynological problem. For this problem she consulted with Dr.Asim Kumar Das at Shusrusha Nursing Home, at Kolkata. As per advice of the doctor the complainant took admission at the said hospital on 17.4.2015 and undergone an operation. After operation the complainant was discharged from the said nursing home on 18.4.2015. An amount of Rs.25,968/- was incurred by the complainant towards her treatment expenses. The complainant intimated the O.P. No.3 about the operation ten days before her admission at the nursing home. After taking discharge from the nursing home the complainant intimated the fact to O.Ps. and the O.P. No.1 also issued claim form. After filling up the claim form the complainant submitted the same before the O.P. No.3 on 27.4.2015 along with the relevant documents. The O.P. No.3 received the same and made endorsement by putting their seal and signature. After submitting the claim form the complainant several times requested the O.Ps. to settle the claim of the complainant but no result has been occurred. On 15.7.2015 the complainant received a letter from the O.P. No.1 asking some documents, though the complainant had been submitted all the documents at the time of submitting the claim form before the O.P. No.3. Inspite of that the complainant again sent those documents to the O.P. No.1 through O.P. No.3 along with her letter dated 17.7.2015. But till date the O.ps. did not settle the claim nor have given any reply to the complainant. Hence, the complainant filed this case before this Ld. Forum for relief as stated above.
The O.P. No.2 contested this case denying all the material allegations stating inter-alia that complainant Tulsi Roy was enjoying one Group Health Policy held with United India Insurance Company Ltd. having policy No.0504002814P101905064 for the policy period from 9.6.2014 to midnight of 8.6.2015 although in the para-2 of the complaint it has been mentioned 11.7.2014 to date of its cessation on 8.6.2015. As per the terms of the policy the total sum insured was Rs.2,00,000/- and premium was Rs.2,472/- and on receipt of which one receipt was issued and subsequently one identity card was issued by O.P. No.2 in favour of the complainant. In the said policy the details of terms and condition have been clear stated the name of TPA M/s. Good Health TPA service Ltd., having their office at Hyderabad as per clause No.1 & 2 under tailor-made. It was agreed by all the parties that any claim becoming admissible under the scheme the company will pay through TPA to the hospital/nursing home or to insured persons the amount of such expenses as would fall under different heads which are reasonable and necessarily incurred. Thus it is clearly stated that TPA’s recommendation is necessary for disbursement of any treatment expenses.
Immediately receipt of the claim form the O.P. No.3 forwarded the same to Good Health TPA Services, Hyderabad who after detail verification sent one query letter dated 15.7.2015 where it was requested to provide the details as “Please provides duration of complains a letter from treating doctor and all previous consultation papers and discharge summary and also provide original investigation report including USG abdomen and HPE report for supporting diagnosis. It has been further stated that due to non-receipt of required documents as sought for, the claim could not be processed. It was once again requested to furnish the details for proceeding the same immediately. O.P. No.1 sent several reminders on 23.5.2015, 8.6.2015, 15.6.2015, 29.6.2015, 15.7.2015 and pm 31.7.2015 to the complainant O.P. No.3 to submit some documents and reply to their queries but the complainant did not submit the proper documents and also not provided proper answer to the queries in connection to the above mentioned letter.
That in terms and condition of policy of O.P. No.2 on clause 7.3 it has been mentioned that ‘upon the happening of any event which may give rise to a claim under this policy notice with full particulars shall be sent to TPA in the schedule immediately and in case of emergency hospitalization within 24 hours from time of hospitalization’. But the complainant has not done show and for that reason the complainant has violated the above mentioned clause from which it is clear that the complainant has not come to this Ld. Forum in clean hands. The O.P. No.2 have all time were sincere and persuaded with O.P. No.1 and O.P. No.3 for speedy settlement of the claim but due to non-submission of essential documents related to the treatment made by earlier doctors and non-availability of investigation report including USG abdomen SPE report and also for not getting any proper reply to certain relevant quires as made by O.P. No.1, the O.P. No.1 have not been able to process the claim. Hence, this case.
The O.P. No.3also contested this case stating the fact that complainant Tulsi Roy was enjoying one Group Health Policy held with United India Insurance Company Ltd. having policy No.0504002814P101905064 for the policy period from 9.6.2014 to midnight of 8.6.2015 although in the para-2 of the complaint it has been mentioned 11.7.2014 to date of its cessation on 8.6.2015. As per the terms of the policy the total sum insured was Rs.2,00,000/- and premium was Rs.2,472/- and on receipt of which one receipt was issued and subsequently one identity card was issued by O.P. No.2 in favour of the complainant.
In the said policy the details of terms and condition have been clearly stated the name of the i.e. TPA M/s. Good Health TPA service Ltd., having their office at Hydrabad as per clause No.1 & 2 under tailor-made. It was agreed by all the parties that any claim becoming admissible under the scheme the company will pay through TPA to the hospital/nursing home or to insured persons the amount of such expenses as would fall under different heads which are reasonable and necessarily incurred. Thus it is clearly stated that TPA’s recommendation is necessary for disbursement of any treatment expenses. It has been stated that complainant immediately intimated the O.P. No.3 about the operation schedule to be undertaken at Susrusha Nursing Home Pvt. Ltd. 10 days before admission at the nursing home.
Immediately receipt of the claim form the O.P. No.3 forwarded the same to Good Health TPA Services, Hyderabad who after detail verification sent one query letter dated 15.7.2015 wherein it was requested in their letter dated 28.6.2015 to provide the details as stated below “Please provides duration of complains a letter from treating doctor and all previous consultation papers and discharge summary and also provide original investigation report including USG abdomen and HPE report for supporting diagnosis. It has been further stated that due to non-receipt of required documents as sought for, the claim could not be processed. It was once again requested to furnish the details for proceeding the same immediately. On 17.7.2015 the complainant sent one letter to Good Health TPA Services through Andhra Bank that they have forwarded all necessary papers along with claim form dated 27.4.2015. On 2.4.2016 the Branch Manager of this bank dispatched the original documents which was submitted by the complainant to the TPA on 2.2.2016 through courier service reference No.3449. Again on 2.4.2016 the O.P. No.3 requested O.P. No.1 that the complain of Tulsi Ray is pending at Consumer Forum for not settling Mediclaim although all the papers as sought for have already sent with for settlement of claim. On 20.7.2015 the O.P. No.3 forwarded scan copy of declaration by customer to the effect that he had already forwarded all documents with O.P. No.1 and requested to do the needful at earliest.
The O.P. No.1 vide mail to the O.P. No.3 stated that they have not received the documents which was raised by their doctor viz. letter from treating doctor and all previous consultation paper and discharge summary before admission in the nursing home, to provide all original reports including USG of abdomen and HPE report for supporting diagnosis. On receiving the above documents the TPA will get approval from insurance company for reopen and then only able to claim further. That vide mail dated 5.10.2015 the O.P. No.3 requested O.P. No.2 for immediate settlement of claim.
The O.P. No.3 have all time were sincere and persuaded with O.P. No.1 and O.P. No.2 for speedy settlement of the claim but due to non-submission of some of essential documents related to the treatment made by earlier doctors and non-availability of investigation report including USG abdomen SPE report the TPA have not been able to process the case. More over the O.P. No.1 have neither repudiated the claim till nor settle the claim till date. The O.P. No.3 was only agent and persuaded with customer for enjoyment of health policy scheme and they were not having administrative authority for settlement of any claim which in fact vested with the insurer being O.P. No.2 and also for assessment of eligibility of claim by the TPA, Good Health. Hence, this case.
DECISION WITH REASON
To prove the case the complainant has filed her evidence with affidavit. O.P. No.2 & 3, who contested this case also filed their written version as their evidence which is also supported by affidavit and on their prayer accepted as their evidence. Be it mentioned that O.P. No.1 is not contested this case inspite of receiving notice and the case is heard exparte against the O.P. No.1. The complainant filed questionnaires on the evidence of O.P. No.2 & 3 and O.P. No.2 & 3 gave reply to the questionnaires. Thereafter, both the parties i.e. complainant and O.P. No.2 & 3 tabled elaborate argument in support of their case. From the case record as well as documents filed by the parties it is clear to this Forum that the complainant purchased the insurance policy mentioned above and the validity period was from 11.7.2014 to 8.6.2015. The policy papers filed by the complainant. During subsistance of the policy she was admitted in the Shusrusha Nursing Home, at Kolkata. Before that she was undergoing some ailment and consulted with Dr.Asim Kumar Das at Calcutta since month of February, 2015. The treatment papers of month of February and March, 2015 like prescriptions of the doctor (photocopies) are filed. Thereafter, following the advice of Dr. Das as per his reference she was admitted Shusrusha Nursing Home, at Kolkata on 17.4.2015 and discharged on 18.4.2015. Summary of treatment is D & C operation was done under General Anesthesia. In the discharge certificate some medicines are prescribed by the doctor. The complainant also filed series of papers showing bills to the tune of Rs.25,968/-, vouchers etc. for the treatment at the Shusrusha Nursing Home and also prescriptions of the doctors for treatment since February, 2015. In her evidence the complainant has stated that she submitted claim form along with all requisites, medical papers and other relevant documents before operation. She also informed the O.Ps. about her admission in the nursing home. She submitted the claim form before the O.P. No.3, Bank on 27.4.2015 and the bank received the same with seal and signature on 15.7.2015. The complainant received letter from O.P. No.1, TPA asking some documents though she had already submitted all the documents in original along with her claim form through O.P. No.3 bank. O.P. No.3, Bank forwarded the same to the O.P. No.1 and requested to settle the matter.
O.P. No.2 argues that they were sincere and persuaded O.P. No.1 & 3 for speedy settlement of the claim but non-availability of the investigation report of USG and not getting reply from the complainant on queries they were not able to settle the claim. From the letter of complainant dated 17.7.2015 it is clear that she has submitted all consultation papers, discharge summary, investigation reports in respect of her policy for early settlement of the claim. This fact has also been corroborated by O.P. No.3 bank in its written submission and during hearing argument of this case. We cannot disbelief the complainant in this regard.
In the said policy, details of terms and conditions have been clearly stated with the name of TPA and it is agreed by all the parties that claim will be paid through TPA. The complainant immediately intimated that she is to be admitted in the nursing home for operation. After operation she collected all the documents, medical papers, report etc. and was diligent in furnishing the claim form. On 2.4.2016 O.P. No.3 Bank even dispatched the original documents submitted by the complainant to the TPA on 2.2.2016. Again on 2.4.2016 the O.P. No.3 requested the O.P. No.1 to settle the claim as early as possible. O.P. No.3 again on 20.7.2015 forwarded the scan copy of the declaration of the complainant by customer to the effect that he had already forwarded documents for settlement of the claim by the Insurance Company. Therefore, the O.P. No.3 is always sincere and persuaded o the TPA for speedy settlement of the claim. But the Insurance Company and TPA have not been able to process the case for a considerable period of time, neither repudiated the claim nor settle the claim of the complainant till date. This is nothing but deficiency in service on the part of the O.P. No.1 & 2. The complainant therefore able to prove her case and she is entitled to get relief as sought for. The complainant unnecessarily had under gone mental pain and harassment. Therefore, she is entitled to realize compensation. The complainant also compelled to come before this Forum and for this reason she is also entitled to get litigation cost. Thus complaint case succeeds. C.F. paid is correct. Hence, it is
Ordered
that the C.C. No.147/2016 is allowed on contest against the O.P. No.2, exparte against the O.P. No.1 and dismissed against the O.P. No.3.
The O.P. No.1 & 2 are directed to pay a sum of Rs.25,968/- towards medical expenses to the complainant.
The O.P. No.1 & 2 are also directed to pay Rs.5000/- as compensation towards mental pain, agony and harassment to the complainant.
The O.P. No.1 & 2 are further directed to pay Rs.3000/- as litigation cost to the complainant.
The above directions will be complied with within 45 days from this date of order, failing which the complainant is at liberty to execute this order in accordance with law.
Let the copies of this order be supplied to the parties free of cost.
Jayanti Maitra (Ray)
Dictated and corrected by me. President
D.C.D.R.F., Burdwan
Jayanti Maitra (Ray)
President,
D.C.D.R.F., Burdwan
(Nivedita Ghosh)
Member
D.C.D.R.F., Burdwan
