Order-12.

Date-20/04/2015.

This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that he has a mediclaim policy bearing No.100300/48/13/8500000530 and this policy is being continued for last 10 years and since the year 2011 his father has been suffering from cancer and since then his father has been treating by Calcutta Tata Medical Centre and Mumbai Tata Memorial Hospital and previously complainant submitted insurance claim for the treatment of his father which had been properly entertained and claim was released.

          But on 18-06-2013 complainant submitted a mediclaim for Rs.24,703/- to the OP being claim No.HH11140194 against the above policy number.  Thereafter, the HHTPA authority submitted some queries which has been properly made by the complainant and all documents were duly submitted but on 26-09-2013 again query was made and against that on 30-09-2013 complainant submitted details but the claim has not been settled and on previous occasion in respect other previous claim similar queries were made and same answer was made as made on 30-09-2013 and on previous occasion on the same ground claim was duly released but in respect of the present claim OP did not release the same for which complainant has filed this complaint praying for redressal for deficient manner of service and for illegally refusing the claim of the complainant.

          On the other hand, OP by filing written statement submitted that OP2 by sending three letters dated 04-07-2013, 26-09-2013 and 27-08-2013 to the complainant requested him to submit the discharge certificate as well as the original day care certificate and also the photo identity proof of the patient.  But the complainant did not submit those documents and for which the claim was closed and that was intimated to the complainant on 10-04-2014.  Therefore, there is no deficiency on the part of the OP1 and in fact there is no negligence on the part of the OPs also but it is specifically submitted that complainant tried to convince that he incurred Rs.24,703/- for relevant treatment of his father but the from the documents submitted by himself before this Ld. Forum it is clear that he had to incur Rs.23,873/- only for relevant treatment and for which even if for the sake of argument it is assumed that the complainant is not at all entitled to any claim as prayed for in that case too, the maximum liability of this OP1 can be Rs.23,873/- only and not Rs.24,703/- as claimed to have incurred by the complainant and in the above circumstances, the complaint should be dismissed.

          On the other hand, OP2 by filing written statement submitted that insurer Kalicharan Das had been admitted to Tata Medical Centre on 11-06-2013 for treatment relating to Post Cancer TRURP and subsequently was discharged and Arijit Das thereafter submitted complete treatment documents along with filled up claim form seeking reimbursement of expenses incurred for Rs.24,703/- on 18-06-2013, against that OP2 sent a letter asking the complainant to file original Day Care Certificate but that was not provided for which the claim was not settled for which the complainant should be responsible and so there was no fault on the part of the OP2.

Decision with Reasons

On proper consideration of the complaint and the written version and also considering the material on record it is found that complainant is no doubt a bona fide mediclaim policy holder which is admitted by the OP and fact remains on previous occasion due to cancer treatment of his father mediclaim as made by the complainant has released but in the present case it was not released only for non-submission of the Day Care Certificate but considering the fact that Tata Memorial Centre does not supply any Day Care Certificate regarding treatment and etc. all original papers are kept in the Tata Memorial Centre, only online copy can be downloaded and fact remains on previous occasions in three cases claims were released without Day Care Certificate and those claims are HH111309637, 111311328 and 111402106.  Truth is that complainant submitted all the documents received through online and it is admitted by the OP2 that they received those documents but anyhow complainant failed to produce Day Care Certificate in original because the Day Care Certificate is not issued by Tata Memorial Centre but they only supplied all documents related to treatment and other related papers.  No doubt same are submitted and same are received by the OP2.  Fact remains complainant claimed Rs.24,703/- but OP2 submitted that in fact he is entitled to Rs.23,873/- as per assessment subject to submission of Day Care Certificate.  Fact remains Day Care Certificate cannot be submitted by the complainant in view of the fact that hospital authority does not supply the same but they only supplied all the papers relating to treatment of the patient on the online basis and those documents have been submitted by the complainant which is admitted by the OP2 and truth is that on previous occasions as mentioned above OP released the claim of the complainant.  So, we find that on the ground the present claim as assessed to the instant of Rs.23,873/- should be released by the OP1 without any further delay and OP1 has admitted that maximum liability of the OP1 can be Rs.23,873/- not Rs.24,703/-.  So, we are convinced to hold that OP1 shall have to release a sum of Rs.23,873/- as finally settled medical amount in favour of the complainant without claiming any original Day Care Certificate when it is not issued by the Tata Memorial Centre as per their norms. 

In the result, the case succeeds.

Hence,

Ordered

That the case be and the same is allowed on contest against the OP1 with a cost of Rs.2,000/- and same is dismissed against OP2 without any cost.

          OP1 is hereby directed to pay Rs.23,873/- as finally settlement claim amount of the mediclaim as made by the complainant to the OP within one month from the date of this order  without any further and if OP1 fails to comply the order within the stipulated period in that case OP1 shall have to pay penal interest  at the rateRs.2000/- per month till full satisfaction of the decree and if it is collected it shall be deposited to the Forum’s account and even if it is found that OP1 is reluctant to comply the order in that case prosecution u/s.27 of the C.P. Act shall be started against them for which they shall be further prosecuted and fine may be imposed.