Orissa

Cuttak

CC/19/2019

Smt Arati Manjari Mohanty - Complainant(s)

Versus

Heritage Health Insurance TPA Pvt Ltd - Opp.Party(s)

N Behuria

21 Jan 2020

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL FORUM,CUTTACK.

                                                                                    C.C No.19/2019

Smt. Arati Manjari Mohanty,

W/O:Late Nimai Charan Mohanty,

At:Plot No.C/23,Sector-8,C.D.A,PO/PS:Markatnagar,

Cuttack-14,Odisha.                                                                                          … Complainant.

 

                Vrs.

                                                

 

1.         Heritage Health Insurance TPA Pvt. Ltd.,

NICCO House,5^th Floor,2 Hare Street,

Kolkata-7000001,West Bengal.

 

2.        Manager,O.S.L.I.C of India, Divisional Office,,

Jevan Prakash,Nuapatna,P.No.36,

Cuttack-753001,Odisha.                                                                       … Opp. Parties.

                

Present:               Sri Dhruba Charan Barik,LL.B. President.

Smt. Sarmistha Nath, Member (W).

 

Date of filing:    06.02.2019

Date of Order:  21.01.2020

 

For the complainant.  :   Mr. N.Behuria,Adv. & Associates.

 For the O.P. No.1       :    A/R.

For the O.P No.2         :     Mr. S.Swain,Adv. & Associates.           

 

Smt. Sarmistha Nath,Member(W).

 

The complainant has filed this complaint before this Forum against the O.Ps for Redressal of his grievances Under Section-12 of the Consumer Protection Act,1986(Act in short) in terms of his prayer made in the complaint petition  alleging deficiency in service provided and unfair trade practice adopted by the O.Ps.

1. The case of the complainant in brief is that the complainant’s husband was an officer of L.I.C of India and had made medi-claim policy for himself and for the complainant bearing policy no.120700-34160-400000005.  The O.Ps were the guarantor and provider of said policy.  The husband of the complainant retired from service in the year 1995 as officer of L.I.C.  A copy of the  medi- claim policy is attached as Annexure-1.  The late husband of the petitioner at the age of 84-85, suffered from various ailments and was admitted to Ashwini Nursing Home,Cuttack on 17.2.2018 and went into coma.  He was going through various treatments and consumed various medicines as prescribed by the concerned doctors.  He remained in the hospital from 17.2.18 to 7.3.18 and was discharged on 8.3.18.  In the said discharge certificate it was advised to the patient for check up within 15 days.  Copy of the discharge summary issued by Ashwini hospital in respect of the petitioner’s late husband is attached as Annexure-2.  In pursuance to such advice, the patient who is the late husband of the petitioner went to the hospital on 20.3.18 for check up.  After necessary check up, as the condition of the patient was not good, the said Ashwini Hospital on 20.3.18 advised the patient for review by medicine specialist.  Copy of such visit dt.20.3.18 is attached as Annexure-3.  According to the advice by the Ashwini Hospital, the patient was treated by one medicine specialist, i.e. Dr. Kusa Kumar Jajodia,M.D on 20.3.18 and he treated the patient and prescribed various medicines and further advised to consult with chest physician Prof. Jyoti Pattnaik,M.D.  Copy of such prescription dt.20.3.18 by Dr. K.K.Jajodia is attached as Annexure-4.  The patient was being treated under Prof. (Dr.) Jyoti Pattnaik on 20.3.18 and 25.3.18.  After thorough diagnosis, Dr. Jyoti Pattnaik prescribed certain medicines and also advised for certain pathological tests.  Copy of the prescriptions dt.20/3/18 and 25.3.18 of Dr. Jyoti Pattnaik is attached as Annexure-5 series.  The husband of the petitioner submitted his claim form on 28.3.18 before L.I.C of India,Nuapatna with all original documents such as money receipts, medicine bills signed by Prof. (Dr.) Jyoti Pattnaik, all prescriptions duly attested by Class-I officer, L.I.C and all original pathological reports and bills.  Copy of claim form dt.28.3.18 is attached as Aannexure-6.  After receiving the claim form of the late husband of the petitioner on 30.3.18, submitted all the above required documents before O.P.1.  Copy of the letter of L.I.C of Heritage health insurance is attached as Annexure-7.  Instead of settling the claim, the O.P.1 issued a letter on 9.6.187 to LIC of India stating therein that after examination of documents submitted by the complainant it is found that additional information/documents are required for processing of the claim and instructed to produce the advice of medicine purchased on 20.3.18 of Rs.61,950/- in original or certified by Class-I officer.  All the original bills signed by Prof. (Dr.) Jyoti Pattnaik,M.D and all the prescriptions have been duly attested by Class-I officer of LIC.  Therefore asking for the selfsame documents as per their letter dt.9.6.18 is meaningless.  Copy of the letter dt.9.6.18 issued by Heritage Health Insurance is attached as Annexure-8.  The husband of the complainant again complied the requirement as per letter dt.9.6.18 through LIC of India who submitted the same before O.P.1.  After getting the document as per the query in his letter dt.9.6.18 instead of settling the claim again on 25.9.18 O.P.1 wroe a letter to LIC of India to comply further queries 1 to 3.  Copy of such letter of O.P.1 to O.P.2 dt.25.9.18 is attached as Annexure-9.  The complainant also is covered under medi-claim policy bearing No. 120700-34160-400000005. Due to her eye problem she was operated at Paradeep Port Hospital at the cost of Rs.11,769/-.  2^nd surgery was held due to further problems in her eyes at the cost of Rs.14,402/-.  The total expenses in both the surgery comes to Rs.26,171/-.  The complainant submitted all the required documents but O.Ps did not settle the claim and harassed the complainant due to which the complainant and his husband suffered mentally, p[physically and financially.  Due to the non-payment of claimed amount of Rs.1,12,532/- the husband of the petitioner was deprived of getting further treatment and ultimately died on 4.8.2018.  The complainant gave an advocate’s notice on 16.8.18 with a request to settle the claim of her husband of Rs.1,12,532/- and the claim of Rs.26,171/- of herself.  The O.P. gave a reply to the advocate’s notice on 27.8.2018 with self queries made earlier.  Copy of such advocate’s notice dt.16.8.18 and letter dt.27.8.18 given by O.P.1 to the advocate are attached as Annexure-10 & 11 respectively.

Again on 22.9.18 the advocate on behalf of the complainant gave a notice to the O.P.1 along with all documents as per his query and further requested to settle the claim without making delay.Copy of such advocate’s notice dt.22.9.18 is attached as Annexure-12.After getting all the documents, the O.P.1 released a sum of Rs.11,769/- the expenses incurred during 1^st eye operation of the complainant and made further query in respect of Rs.14,402/- which was spent during 2^nd eye operation at Rotary Eye Hospital and again asked for the selfsame document which was submitted earlier in his letter dt.27.10.18.Copy of the said letter dt.27.10.18 is attached as Annexure-13.The O.P.1 in their letter dt.27.10.18 has made query No.(E) to provide the tax invoice of lens in original, which is clearly unfounded and purely non-application of mind because no lens has been installed in the eyes of the complainant and the same is clear from the vouchers submitted by JPM Rotary Eye Hospital on 4.7.18.Copy of such voucher dt.4.7.18 is attached as Annexure-14.Due to negligence and deficiency in service on the part of the O.P.1, the claimant died due to want of further and better treatment due to paucity of funds.Complainant is now suffering mentally, physically and financially.Therefore the complainant prays before the Hon’ble Forum to allow the case and direct the O.Ps to settle both the claims of complainant’s late husband of Rs.1,12,532/- and complainant’s claim of Rs.14,402/- along with accrued interest @ 12% per annum and impose heavy cost and damage of Rs.2,00,000/- for deficiency in service ,harassment, torture and loss of life.

2. The O.P No.1 filed written version in form of a letter stating therein that they have reviewed the cases thoroughly and found the claims are pending for non-submission of valid documents which were asked by them several times.  The O.P.1 has asked to provide the referred letter from Dr. Sampat Dash for consultation with Dr. Jyoti Pattnaik and Dr. Kusha Jajodia, provide the proper cash memo from Om Sai Medicals mentioning batch number and expiry date in original and provide the prescription of above said doctors mentioning the nature and complications of treatment.  The further plea of O.P.1 is that they further communicated for compliance by providing the discharge certificate from hospital in original.
3. The O.P NO.2 appeared through advocate and filed its written version.  According to O.P.2, the consumer complaint filed by the complainant is liable to be dismissed for mis-joinder of party and non-joinder of necessary party and is barred by limitation and is liable to be dismissed.  The O.P.2 took the plea of limitation.  According to the O.P,.2, the complainant has no cause of action to file the consumer complaint.  The complainant has no locus standi to file the present consumer complaint.  The O.P.2  stated that as per LIC of India Central Office circular dt.5.4.2017 the Group Mediclaim policy covering in-service employees and retired employees and their dependants were renewed for the year 2017-18  with New India Assurance Co. Ltd.,   LIC has entered into a renewal agreement with NIA that all claim papers will be submitted to TPA(Third Party Administrator) for settlement.  LIC only submits the claim to NIA through TPA for settlement of claim.  The decision/repudiation of claim settlement rests with TPA & NIA.  The claim forms of complainant were received by the officer Service Department of LIC on 13.4.2018 and the same was duly submitted to TPA on 25.4.18.  The 1^st query letter from TPA was received by LIC on 9.6.18 and the same was intimated to claimant.  The claim of complainant was received on 2.5.18 and was forwarded to TPA on 3.5.18 and the O.P NO.2 has no role in settlement of claim.
4. We have heard from advocates of the parties, went through the pleadings of the parties and perused the documents.  Admittedly the deceased husband of the complainant made medi-claim policy for himself and his wife.  During course of hearing the counsel for the complainant submitted that the husband of the complainant suffered from various ailments and underwent treatment in Ashwini Nursing Home.  He submitted his claim form along with all documents before the LIC on 28.3.18 and after receiving the documents, the LIC submitted all documents before the Third Party Administrators as admitted by O.P No.2 in their written version but the O.P No.1 is not settling the claim on some plea or the other on the other hand the counsel for the O.P.1 submitted that the complainant has not submitted some original documents for which the claim is pending.  After hearing rival submission, we are of considered view that in para-7 and 8, the complainant has categorically stated that the claim form along with original documents was submitted before the O.P.2 and the O.P.2 submitted the same before the O.P.1.  The said fact is admitted by the O.P NO.2 and it is not categorically disputed by O.P NO.1.  So the O.P No.1 is liable for deficiency in service by not settling the claim of the complainant and her deceased husband on the plea of non-submission of original documents.

ORDER

Under the facts and circumstances, the complainant succeeds and the O.P No.1 is directed to pay Rs.1,12,532/-Rupees one lakh twelve thousand and five hundred thirty-two) towards the claim amount of complainant’s husband, Rs.14,402/-(Rupees fourteen thousand and four hundred two) towards claim amount of the complainant and Rs.50,000/-(Rupees fifty thousand) only as compensation to the complainant within a period of 45 days from the date of receipt of copy of this order.

                Typed to dictation, corrected and pronounced by the Hon’ble Member in the Open Court on this the 21^st   day of January,2020  under the seal and signature of this Forum.

 

  ( Smt. Sarmistha Nath )

                      Member (W)                                                                                                                                                                                                                                                                                                                                      (Sri D.C.Barik)

                                                                                                           President.