Hon’ble Mrs. Rumpa Mandal, Member.
The pith and substance of the case is that the Complainant Sriraj Ghosh was medically treated at Dr. P.K. Saha Hospital Pvt. Ltd., Proforma O.P. No.5 on 18th August, 2022 at noon 12.30 P.M. with acute health issues and after treatment he was discharged on 20th August, 2022 at about 2.44 P.M. and advised him to take rest (Annexure-C). The Complainant purchased a Family Health Optima Insurance Plan from O.P. No.1 i.e. Managing Director Star Health and Allied Insurance Company Ltd through O.P. No.2 & 3 on 31.03.2017 and renewed the said plan by vide policy No. P/191131/01/2022/009121 on 09.03.2022 valid up to 30.03.23 (Annexure- B & B1). After getting little well Complainant raised a claim bearing No. CIR/2023/191131/0767153 for reimbursement of the medical expenses caused during his treatment and medication to the tune of Rs.41,979/- (Nursing Home bill Rs.31,000/- and Medicine bill Rs.8,800/-+ Rs.2,179/-) before O.P. No.1 through O.P. No.2, 3 & 4 (Annexure-D to D6). Though the Complainant raised the claim even after submitting all the necessary original documents to O.P. No.1 through O.P. No.4. But O.P. No.1 informed the Complainant with a letter dated 16th October, 2022 containing that the claim of medical insurance stands rejected with very lame excuses. Thereafter, several requests and raising queries for the said claim, the O.P. No.1 did not pay any heed towards the reimbursement of the claim and still today O.P. No.1 did not pay a single penny of the insured medical expenses incurred by this humble complaint and for which Complainant has huge financial loss as well as mental harassment by these O.Ps. The cause of action of the present case arose on 31.03.2017 and on 09.03.2022 when this complaint respectively bought and renewed the health insurance plan and lastly on 18th August, 2022 when this Complainant got admitted to the hospital and it is still continuing. The Complainant therefore prayed for an award from the O.Ps for a sum of Rs.41,979/- the health insured claim money and pay sum of Rs.1.5 Lakhs for deficiency in service and pay a sum of Rs.1.25 for unfair trade practice and Rs.32,000/- for cost of proceeding in favour of him.
As per Order No.3 dated 22.05.23 the case is decided to be heard ex-parte against O.P. No.1, 2, 3 & 5. They did not turn up before this Commission. The O.P. No.4 contested the case by filing written version denying all the allegations against them. The positive defence case is that the Complainant did not informed to the O.P. No.4 i.e. Branch Manager Star Health and Allied Insurance Company Ltd of his getting admission in the P.K. Saha Hospital within stipulated time as per clause 4(2) (D) of the policy. The Complainant did not send them all documents. The Complainant never approached to the grievance Department of Insurer Company for reconsideration of his claim. The alleged cause of action is vague and not proper. Non compliance of the same simply makes the claim subject of repudiation. The Complainant was never harassed by the O.Ps and he had never to face any mental harassment or pain and agony for fault of these O.Ps. So, the Complainant has intentionally made assertions claiming compensation on the ground of mental pain and agony.
As the claimant did not comply with the order terms and conditions of the policy, so the claim remained unsettled. So, the O.P. No.4 Star Health Allied Insurance Co. Ltd acted proactively in the whole matter so the question of deficiency in service or unfair trade practice on the part of the O.P. No.4 does not arise. Accordingly, the instant case is liable to be dismissed in favour of the O.P. No.4.
Perused the case record and documents filed by both the parties. Heard, the arguments advanced by the Ld. Advocates of both parties at length. The following points need to be discussed for adjudicating the case.
Points for Determination
- Is the case maintainable in its present form and prayer?
- Is there any deficiency in service on the part of the O.Ps?
- Is Complainant is entitled to get any relief?
Decision with reason
Point No.1.
The pleading of the parties disclosed that the Complainant purchased mediclaim insurance from the O.P. No.1 through O.P. No.2, 3 & 4 on 31.03.17 and renewed the said plan by vide policy No. P/191131/01/2022/009121 on 09.03.2022 and it was valid up to 30.03.2023. Accordingly, the Complainant is a consumer under the C.P. Act, 2019.
It is also important to consider that the O.P. No.4 never filed any petition for challenging the maintainability of the case. The O.Ps has just evasively denied the case of the Complainant. Thus it is clear from the above facts that there is a consumer service provider relation among the parties. Thus, having perused the pleadings and the evidence on record this Commission is of the view that the case is maintainable in its present form and prayer under the C.P. Act.
Point No. 1 is accordingly answered in favour of the Complainant.
Point Nos.2 & 3.
Both the points are taken up together for brevity and convenience of discussion. It is the admitted fact that the Complainant purchased mediclaim insurance under the O.Ps having policy No. P/191131/01/2022/009121.
From the documents and evidence, it is crystal clear that the Complainant paid premium. This is established through his supported documents and O.P. No.4 admitted in their written version and evidence in chief.
The Complainant in order to substantiate the case proved the following documents.
- Policy papers – Annexure B and B1.
- Discharge Summery- Annexure-C.
- Money Receipt- Annexure-D.
- Claim Form-Annexure-E.
- Rejection Letter- Annexure-F.
The Complainant duly proved the intimation letter in the form of an application about the admission to the Hospital within two days of this admission to the O.Ps.
It is the defence plea that there is a delay in informing the claim to the O.Ps. So, the claim has been repudiated. The O.Ps further claimed that any incident of hospitalization should be informed within 24 hours.
Ld. Advocate for the Complainant argued that there is delay of only two days which is duly explained.
Perused the documents and the case record.
The defence plea of instantaneous is not acceptable on the ground that in a case when the patient is seriously ill, the friends and relatives are too arrange for his treatment and remain busy until and unless the immediate danger is recovered. Even sometimes the patient has to admit in the ICU or ICCU. So at least one/two days is usually taken. So two days delay in giving the intimation cannot be considered as inordinate delay.
The O.Ps also denied the claim on the ground that they did not get the letter. It appears that the Complainant sent the letter through P.K. Saha Hospital. There is also a stamp the P.K. Saha Hospital in the said form/ letter.
It is further found of the case record that the O.Ps for the first time stated in the repudiation letter that the Complainant did not send the documents. But the Complainant claimed that despite sending all the documents the O.Ps repudiated the claim.
It is further defence case that the Complainant never raised the claim before the grievance cell.
This is not essential that before lodging claim it should be intimated to the grievance cell. The O.PS could not prove any document to establish that the claim is liable to be rejected if it is not intimated to the grievance cell.
Except a reasonable delay of two days the Complainant duly proved all steps or entitlement of the claim.
It is further found from the case record that the O.Ps has not cross-examined the Complainant challenging the said letter. Thus having assessed the entire evidence and observation made herein above the Commission comes to the findings that the Complainant is duly proved the case against the O.Ps.
Accordingly, Point Nos.2 & 3 are decided in favour of the Complainant.
In the result the instant case succeeds on contest.
Hence, it is
Ordered
That the complaint case No. CC/14/2023 be and the same is allowed on contest with cost.
So, the O.P. No.1, 2, 3 & 4 are directed to pay the Health Insured claim amounting to Rs.41,979/- to the Complainant jointly and /or severally. Due to deficiency in service he suffered mental pain and agony. They are also directed to pay Rs.20,000/- as compensation for deficiency in service and mental pain and agony and Rs.5,000/- towards cost of proceeding to the Complainant jointly and/or severally within 30 (Thirty) days from the date of this Order failing which the total sum of Rs.66,979/- (Rupees Sixty Six Thousand Nine Hundred Seventy Nine only) will carry an interest @ 6% per annum till its realization.
D.A. to note in the trial Register.
Let a plain copy of this Order be supplied to the concerned party by hand/by Registered Post with A/D forthwith, free of cost, for information & necessary action as per rule.
The copy of the Final Order is also available on www.confonet.nic.in.
Dictated and corrected by me.
