(Passed on 23/01/2024)

Per Smt. Vaishali R. Gawande, Hon’ble President.

1. The complainant has filed the present complaint under Section 35 and 38 of Consumer Protection Act, 2019, seeking relief as mentioned in the prayer clause of the complaint.
2. The brief facts of the case are as under.
3. That the complainant is the resident of Chandrapur and is working with Vidarbha Kokan Gramin Bank, Chandrapur, District Chandrapur. The employer of the complainant had insured the complainant along with 3 other members of the family under Group Health Insurance Policy issued by OP Nos. 1 and 2. The OP No. 1 is the third party administrator appointed by OP No. 2 for the processing of the claim. OP No. 2 is insurance company, who had insured the complainant and issued the policy to the complainant. The OP No. 3 is the hospital where the complainant took treatment.
4. The complainant along with her family  were insured by OP No. 2 vide policy bearing No. 2302002819P115400348 with member code No. 4102914D. The policy issued for  the sum assured of Rs. 4,00,000/- and the period of insurance is from 29/02/2020 to 28/02/2021.
5. The complainant met with an accident on 03/06/2020 at Nagpur from Mankapur to RBI fly over and was severely injured. The complainant was immediately admitted to Mure Memorial Hospital, Nagpur. The parents of the complainant were residing at Chandrapur and due to effect of Covid-19 at that time, it took sometime to arrange their visit to Nagpur. The parents of the complainant shifted the complainant from Mure Memorial Hospital to Care Hospital, Nagpur for further  and proper treatment. The Care Hospital performed surgery on complainant and the complainant was admitted in both hospitals from 03/06/2020 to 13/06/2020 and even after that was taking treatment as OPD patient. The complainant incurred total expenses of Rs. 715000/- for her entire treatment and filed the claim for the same with the OP Nos. 1 and 2.
6. The OP Nos. 1 and 2 issued additional documents request letter to the  complainant on 6/8/2020 to which the complainant submitted their reply on 13/8/2020. After that till filing of the complaint on 3/10/2022, the OP Nos. 1 and 2 did not intimate the status of the claim to the complainant. The OP Nos. 1 and 2 are in due course deposited an amount of Rs. 36,213/- in the complainant’s account. That is the amount of premium paid by the complainant to the OP Nos. 1 and 2 had been refunded. The complainant had paid the premium and taken the policy for the medical emergency and not for the refund of premium after the claim had been filed. The complainant after and the claim intimation not getting  status of the claim by OP Nos. 1 and 2 and  with no other alternative filed the complaint before this Commission claiming sum assured under the policy with other compensations for mental agony,  harassment and cost of litigation.
7. The OP Nos. 1 to 3 had been served and OP Nos. 1 and 2 failed  to appear before this Commission. Therefore, matter was proceeded exparte against OP Nos. 1 and 2 on 9/2/2023 and without WS against OP No. 3. Later on  10/04/2023, exparte order against OP Nos. 1 and 2 had been set aside and reply of OP Nos. 1 and 2 had been taken on record. The OP No. 3 as well as filed an application for setting aside no WS order. The same had also been allowed on 9/3/2023 and reply of OP No. 3 had been taken on record. The OP Nos. 1 to 3 had denied the allegations made against them in the complaint. The OP Nos. 1 and 2  had categorically said that the original documents for the treatment of complainant had not been provided by the complainant to the OP Nos. 1 and 2 and therefore the OP Nos. 1 and 2 were not able to process the claim of complainant. The OP No. 3 in their reply had submitted that the matter of the complainant being the medico-legal case, the original treatment papers has to be kept in the record of OP No. 3 for further verification and therefore they have issued the certified copy of all the documents required by OP Nos. 1 and 2 and complainant and therefore they prayed for dismissal of the complaint against them.

REASONING

8. We heard counsel for complainant and OP Nos. 1 and 2 at length and it is on record that the original medical bills and other documents of hospitalization were not provided by OP No. 3. The counsel for OP Nos. 1 and 2 during course of the argument had submitted that due to non compliance of original documents by the complainant, the OP Nos. 1 and 2 could not  get an opportunity to verify the documents. The complainant most respectfully submitted that the OP Nos. 1 and 2 were at liberty to visit OP No. 3 and verify original documents if they really wanted to honour the claim of the complainant. The OP Nos. 1 to 3 are just passing the onus on each other for not honouring the legitimate and suffer  severe trauma mentally and physically.
9. After going through  the entire record of the proceeding and arguments made by the parties, the Commission is of the view that the complainant is eligible for the claim as per the policy. The complaint against OP No. 3 is dismissed. The Commission pass the following order.

ORDER

1. The complaint is partly allowed.
2. The OP Nos. 1 and 2 should pay jointly and severally  the complainant an amount of Rs. 4,00,000/-(Sum assured as per the policy) with 9 percent per annum interest from the date of complaint i.e. 03/10/2022 till realization.
3. The OP Nos. 1 and 2 are further directed to pay Rs. 50,000/- to the complainant towards mental agony and harassment  and Rs. 25,000/-towards cost of litigation.
4. The complaint against OP No. 3 is dismissed.
5. Copy of order be supply to both parties, free of cost.