Order-8.

Date-17/08/2016.

The complaint petition is filed by the complainant u/s 12 of C.P Act, 1986.

In brief the case of the complainant is that the complainant and his wife Mrs. Ratna Bose have joint Mediclaim policy being No. 103000/48/14/8500004952, Branch No. XIV, Council House Street, Kolkata-700001. Mrs. Ratna Bose wife of the complainant was admitted on 24/09/2015 as indoor patient at AMRI Hospital, Dhakuria and discharged on 27/09/2015.

As per the status of said Mediclaim policy the policy holder is entitled to get the cashless treatment along with pre and post hospitalization period and also cost of medicine up to 60 days is payable.Insurance Co had already paid the entire bill of cashless treatment to the Hospital authority.

After discharging from hospital his wife, the complainant submitted claim form to the insurance co. but as per instruction of Insurance Co. the complainant placed the demand with required documents to the op who is the claim settlement authority as per IRDA guide line.

The op was assured the complainant for seedy settlement but not settled the claim rather harassed the complainant. As such the complainant appeared before this Forum for getting redressal with some prayer.

Op did not appear and contest the case after duly receiving the notice of this Forum. So, the case is heard exparte against the op.

Point for decision

Is the complainant entitled to relief as prayed for?

Decision with Reasons

On in depth study of complaint petition, documents, evidence and argument advanced by the complainant we find that complainant and his wife had joint medicaim policy with the National Insurance Co. and as per IRDA rules op is the service provider of Insurance Co. Mrs. Ratna Bose wife of the complainant got admission on 24/09/2015 as indoor patient at AMRI Hospital, Dhakuria and was discharged on 27/09/2015 thereafter she has to purchase medicine by the advice of doctor as out-patient and as per policy documents in clause 7 pre and post Hospitalization expenses, it is specifically mentioned that upto 60 (sixty) days  after discharge the mediclaim policy allows reimbursementof relevant Medical expenses.

The complainant has submitted claim form to the Insurance Co but they advised complainant to submit the same to the TPA i.e. of Op who will settle the claim as per IRDA rules and accordingly the complainant submitted the original bill and other required documents to the op and op by sending theirletter dt. 20.01.2016, 06/02/2016 and 15.03.2016 asking the complainant to submit cash receipt of Hospital dt. 27/09/2015 of Rs.2022/- and copy of Medi Card. But regarding cash receipt is specifically mentioned left hand side ofthe in-patient bill cum receipt cash dt. 27/09/2015 of AMRI Hospital and for asking copy ofMedicard is the issuing authority of Insurance Co. in whose claim op can verify and settled the same. So TPA has no problem to collect the Medicard from Insurance Co. but their letters op assured the complainant that your claim be settled within 7 days after verification of documents but till date op did nothing regarding settlement of claim. Such act of op is clearly proves that op was negligent and deficient of service and harassed the complainant. Where as of right as per terms of policy complaint is entitled to reimbursement of the amount of medicine bills up to 60 days pre and post of hospitalization, in such a case op harassed the complainant day by day and now a days people at large are afraid of taking the Mediclaim policy for unnecessary harassment by the authority even after submission of required documents and many complains lodged in various Forums against mediclaim policy.

In view of the discussions here in above we think that op was not rendering proper service rather deficient in service and also harassed the complainant who being a senior citizen as such the complainant is entitled to relief as prayed for.

Complaint case succeeds.

Hence, it is

Ordered

That the complaint case is allowed ex-parte against O.P. with cost of Rs.2,000/-.

O.P. is directed to pay Rs.17,666/- as reimbursement of medical bills along with litigation cost to the complainant.

O.P. is further directed to pay the said amount to the complainant within one month from the date of this order failing which complainant will be at liberty to put this order into execution as per provision of law.

The complainant is also directed to supply the copy of Smartcard to the O.P. within ten days if available from the date of this order.