Order No. -33                                                                                                       Dt.-21/07/2015

        Shri Prabin Chettri, Member

        Complainant’s case in short is that he purchased a “LIC Health Plus Plan” from the O.P.no.1 and the date of commencement of the Policy was 29/03/2008 with a premium of Rs.7,500/- and agreed to pay similar amounts on yearly mode till 29/03/2019 as policy will expire on 29/03/2020. On 24/03/2013 complainant fell sick and attended Mitra’s clinic and Nursing Home, Siliguri with complain of respiratory distress, the complianant was admitted for the surgery and the doctor suggested some investigations to the complainant and the same were done at Mitra’s Nursing Home, Siliguri. The complainant was under treatment of Dr.C.P.Sharma for tubercular biletaral pleural effusion with diabetes Mellitus and hypertention at Mitra’s Nursing Home, Siliguri from 24/03/2013 to 05/04/2013. After recovery from his ailment, complainant submitted the bills amounting to Rs.91,603/-(Claim no T1205131166) to the O.P.no.1(LICI) claimimg for settlement or reimbursement the cost of treatment. O.P.1 and 2 forwarded the claim to O.P.3.  On 16/05/2013 O.P.3(TPA) rejected the claim of the complainant and informing through letter to the complainant that claim has been rejected, basing on the various records and documents submitted by the claimant on account of L11 Multiple Hospitalization with more than 12 hours gap.

               On 25/05/2013 LICI(O.P.1) sent a letter to the Medicare TPA(O.P.3) requesting to reopen the claim under policy number 454670755 alongwith the claim file mentioning that the policy holder is not satisfied with the rejection of the claim and the competent Authority (LICI) permitted to reopen the claim, late submission was waived. On the basis of this letter O.P.3 again took the matter but rejected the claim on 05/08/2013 on account of following reason(s).

1. L99- Any other rejections NOT covered under the list supplied,

            On 23/11/2013 complainant files this case before DCDRF, Jalpaiguri.

             On the other hand O.P.1 and 2 contested the case by filing joint Written Version. O.P.3(TPA) didn’t appear before this Forum after service of the notice to contest this case.

             O.P. 1 and 2 have denied and disputing the claim of the petitioner. They have submitted that as per Policy Deed the TPA will serve the Policy and the TPA is involved in servicing Health Policies, is licensed by “IRDA” (“Insurance Regulatory and Developments Authority”) LIC of India have enlisted the services of TPA as per rules to assist LICI in processing Health Insurance Claim in accordance with the guide lines as framed by IRDA). O.P.3 (TPA) rejected the claim firstly on 16/05/2013 and also on 05/08/2013 requesting the claimant that if he (Claimant) is not satisfied with the decision of rejection, he (Claimant) may make an appeal to Senior Subdivisional Manager, LIC of India, Jalpaiguri Divisional Office, Jalpaiguri but the Claimant didn’t make any appeal in this regard. LIC is very much considerate to this claim and therefore has further requested the TPA, vide letter dated 08/05/2014 to REOPEN THE CASE but it is TPA who will ultimately take the decision for admission of the Mediclaim Bill. Since all aspect of LIC’s Health Policy Services are assigned to TPA as per rules framed by the IRDA LIC cannot take any decision for payment of claim of LIC’s Health Plus policy as this policy shall be serviced by TPA and the decision for payment/ rejection of the claim will be taken by TPA for which TPA should have proper infrastructure in line of agreement with the insurer. The O.P.1 and 2 also submit that the case is neither maintainable in law or in facts. LICI prays for dismissal of the case/ petition with cost. As there is no deficiencies on the part of the O.Ps.

POINTS FOR CONSIDERATION

1) Is the complainant a consumer under the Consumer Protection act 1986?

2) Was there any deficiency of service on the part of the O.Ps. as alleged?

3) Is the case/ application maintainable under law?

4) Whether the complainant is liable to get reliefs/ rewards as prayed for?  

DECISION WITH REASONS

                   All four points are taken up together for consideration and decision.

                 Admittedly the complainant purchased a LIC’s Health Plus Plan from the O.P.1 date of commencement of which was 29/03/2008, with a premium of Rs.7,500/- and agreed to pay similar amounts of yearly mode till 29/03/2019 as the policy expired on 29/03/2020. So we have no hesitation on this point that the complainant is a consumer under the C.P.Act 1986.

                 After going through the Written Version and the Written Argument of the parties and all the relevant documents. We find that O.P. 1 and 2 in their Written Version in paragraph no.5 have stated that as per policy condition the policy will be served by TPA (Third Party Administration)  and TPA involved in serving in Health Policies is licensed by “Insurance Regulatory and Development Authority(IRDA). LIC of India have entitled the services of TPA as per rules to assist LICI in processing Health Insurance Claim in accordance with the guidelines as framed by IRDA. The complainant in his Written Argument in paragraph 5 states that he has submitted the claim alongwith a prayer for condonation of delay and “delay was condoned”.On 16/05/2013 TPA(O.P.3) send a claim rejection letter to the complainant stating that they (TPA) have scrutinized the claim papers with regard to his(complainant) eligibility as per the policy terms and conditions and after investigating into the details of hospitalization, nature of ailment for which treatment has been undergone etc. and basing on the various records and documents submitted by him (claimant) and ascertained by them (TPA), they (TPA) are of the opinion and have come to the conclusion that he (complainant) is not eligible for the claim as it doesn't fall under the purview of the policy conditions. The TPA thereafter rejected the claim on account L11-Multiple hospitalization with more than 12hours gap.

                    O.P.3 also mentioned in their claim rejection letter dt.16/05/2013 that in case he  (complainant) is not satisfied with their (TPA, O.P.3) above decision of rejection he (claimant) may make an appeal for a re-look at his (claimant) claim within one month at the following address- Sr.Divisional Manager, LICI, Jalpaiguri Divisional Office , Jalpaiguri.  During the pendency of the  case  the LICI wrote a letter to TPA (O.P.3) dt.08/05/2014 to reopen the claim of the complainant vide policy no.-454670755. The O.P.3(TPA) send a letter dt. 19/06/2014 to the claimant stating that the claim has been processed and referred to LICI of India, Health Insurance Division, Hyderabad for consideration of the policy and rules in vogue , for the following benefit i.e. 10 days [HCB for period spend in non ICU (current policy year) amounts (Rs 12400) and  that he (claimant) will be shortly receiving a communication  on the settlement of his claim and in case he (claimant) does not receive any such communication within 15 days he may write to policy servicing Divisional Office at the given address- Sr. Divisional Manager (HI CLAIMS), LICI, Jalpaiguri Divisional Office Jalpaiguri. After this the complainant received Rs. 12,400/- from the TPA(O.P.3) by cheque and he even encashed that cheque without protest as submitted by his Ld. Lawyer at the time of argument.  Ld. Lawyer for the O.P. submitted that as the complainant has encashed the cheque for Rs.12,400/- send to him by the TPA for LICI without any protest so the claim of the complainant was not repudiated and his claim was fully and finally settled by the O.Ps. and as such this case is not maintainable. Relying upon the decision reported in 2015(2) CPR 592(NC) where Hon’ble National Commission observed that “complainant can accept amount under Insurance Claim under protest or upon reserving his right”, we can safely come to the conclusion that as the complainant has received the cheque for Rs.12,400/- send by O.P.3 during pendency of this case and even encashed that cheque without any protest, so we have no doubt that the complainant had received that amount from O.Ps. towards full and final settlement of his claim. Therefore we find there is no deficiency in service on the part of the O.Ps. as alleged. So the case is not maintainable and accordingly the  complainant is not entitled to any reliefs in this case.

            All points are disposed of accordingly.

            In the result the case/ application fails.

            Hence, it is

O R D E R E D

   that the case/ application is u/s 12 of the Consumer Protection Act 1986 stands dismissed on contest against the O.P.1 and 2 and Ex-parte against O.P.3 being not maintainable and in the circumstances we make no order as to cost.

           Let a plain copy of this order be supplied to the parties free of cost forthwith as per sec 5(10) of West Bengal Consumer Protection Rules,1987.