Date of filing: 05.02.2013 Date of Disposal: 03/11/2017
Complainant: Mamata Roy, W/o. Late Dilip Kumar Roy, resident of Radhanagarpara, B. L. Hati Road, Burdwan, PIN – 713 101.
Opposite Party: 1. Medi Assist India TPA Pvt. Ltd., represented through its General Manager, having its office at 47/1, Sri Krishna Arcade, 1st Main, 9th Cross, Sarakki Industrial Layout, J.P. Nagar, 3rd Phase, Bangalore, 560 078. (Expunged vide Order No. 12, dt. 01.8.2016)
2. Medi Assist India TPA Pvt. Ltd., represented through its Regional Manager, having its office at # 4, “Premier Court”, 4th Floor, Chandni Chowk Street, Kolkata – 700 072.
3. The oriental Insurance Co. ltd., represented by its Branch Manager, having its office at Contractor’s Association building, Court Compound, PS. & Dist: Burdwan, PIN – 713 101.
Present : Hon’ble President: Smt. Jayanti Maitra (Ray).
Hon’ble Member : Sri Pankaj Kumar Sinha.
Hon’ble Member : Smt. Nivedita Ghosh.
Appeared for the Complainant: Ld. Advocate, Kailash Dutta..
Appeared for the Opposite Party No. 2: None (ex parte).
Appeared for the Opposite Party No. 3: Ld. Advocate, Sourav Dey.
J U D G E M E N T
This complaint is filed by the complainant u/S. 12 of the C.P. Act, alleging deficiency in service and unfair trade practice against the Ops as the Ops have not settled his mediclaim till filing of this complaint.
The fact of the case is that the complainant’s husband, since deceased, incepted a mediclaim insurance policy from the OP-3 in the year 2013. After payment of premium amount of Rs. 1,749=00 and filing up proposal form, the OP-3 issued a policy of insurance being No. 313101/48/2014/1537 which was valid from 05.9.2013 to 04.9.2014. It is pertinent to mention here that the OP-1 and the OP-2 are the marketing agent of the OP-3 and as per MoU between them the OP-1&2 proceed with the claim of the policy holders of their nominees. The complainant further submits that due to ill-luck of the complainant her husband felt ill in the first week of May, 2014 and as per advice of the treating doctor he was admitted in Max Super Speciality Hospital, at Delhi on 25.5.2014. The treatment of the husband of the complainant was continued till 14.6.2014 and a sum of Rs. 4,39,124=90 was incurred for treatment expenses and a sum of Rs. 3,60,000=00 was paid by the complainant and remaining amount of Rs. 79,124=00 was also paid by the complainant. The husband of the complainant expired on 17.6.2014. The complainant further submits that after the death of the husband of the complainant, with the help of her neighbours and near relatives, intimated the Ops regarding the matter of treatment and death of her husband at their toll free numbers. She also requested them for issuing claim form in favour of her. The Ops instead of issuing claim form sent one after another letter by asking the complainant for submitting documents. As such the complainant compelled to submit all the necessary documents. Inspite of that as per requirement of the Ops the complainant also submitted the Succession Certificate and identity proof on 08.01.2014 and the OP-3 duly received the same. Inspite of that the OP-1&2 vide their letter dated 02.4.2015 and 13.4.2015 asked the complainant for submitting documents relating to past treatment prescriptions and treatment details and other documents for processing the claim. The complainant further states that the Ops only for dragging the matter and harassing the complainant instead of issuing claim form sent one after another letter to the complainant. Being so aggrieved the complainant sent a legal notice through her Advocate on 30.4.2015 to the Ops. After getting such notice the OP-1&2 issued the claim form in favour of the complainant and sent the same at the email address of the son of the complainant. But very surprisingly, after going through the claim form, the complainant came to learn that the OP-1&2 issued a claim form in the name of one Liji Kunnath and not in favour of the complainant. Being so surprised the complainant requested the OP-3 for issuing appropriate claim form in favour of her. The Ops inspite of getting all the relevant documents, dragging the mater for unlimited period. Moreover, the Ops knowing fully well, only for harassing the complainant issued wrong claim form. They have not issued correct claim form in favour of the complainant till date of filing of this complaint. These acts of the Ops are deficiency in service and unfair trade practice and they are liable to compensate the complainant. In this way they have neither sent correct claim form nor have they settled the claim till filing of this complaint. The complainant has prayed for directing the Ops to pay Rs. 4, 39,124.90 in favour of the complainant by holding them liable for their acts of deficiency in service and unfair trade practice, to pay Rs. 30,000=00 towards mental pain and agony for delay in issuing claim form and harassment and to pay a sum of Rs. 20,000=00 as litigation cost.
After admitting the case notices were issued against all the Ops. Thereafter complainant filed an application for expunging the name of the OP-1 from the cause title of the complaint. The said application was registered as M.A. Case being No. 113/2016. As the said M.A. was allowed, therefore the name of the OP-1 was expunged vide order No. 12, dated 01.8.2016. In respect of OP-2, though the OP-2 received the notice but did not appear to contest the case either orally or by filing written version. So the case was heard ex parte against the OP-2.
This complaint is only contested by the OP-3 by filing written version denying all the material allegations made by the complainant in his petition of complaint. The case of the OP-3 is that the husband of the complainant, since deceased, took a policy from this OP for the period from 05.9.2013 to 04.9.2014 for the sum assured of Rs. 1, 00,000=00. The OP-3 has already taken up the matter with the T.P.A. It is learnt from the said Customer Service Department of Medi Assist India Private Limited (T.P.A.) that they have issued two letter dated 02.4.2015 & 13.4.2015 for submission of the documents i.e., provide all past prescriptions, Treatment Details related to Present Diagnosis ckd Diabetes, Hypertension etc. disease. Provide the h/o ckd, diabetes, Hypertension, Colonic, Ulcers, Gammopaghy (since when) certified by treating Doctor. The TPA also assured in their letters dated 02.4.2015 & 13.4.2015 that on receipt of the above stated information/documents their claim shall be processed expeditiously. The TPA also said in their letters that if he requires any clarifications do call on their Customer Service Help Line. Be it mentioned that all the above listed documents are required to process the claim are to be furnished within ten days from the date of said letter dated 02.4.2015 and also within seven days from the date of said subsequent letter dated 13.4.2015. It was also stated in the said letter that it shall be the sole responsibility of the insured to submit the required claim documents. But inspite of the said letters dated 02.4.2015 & 13.4.2015 the insured or their family members did not submit till date the said required documents and as such the said TPA could not process the claim till date and as such the present claim filed by the complainant, is highly premature one. Thus the claim file is pending for settlement of the claim for non-receiving/non-submission of the said relevant documents/information, as required and thus under the aforesaid facts and circumstances, the complainant is not entitled to get any relief as prayed for in the instant complaint. This Op further begs to submit that there has not been any deficiency in service or negligence on the part of the OP-3. The OP-3 prays for dismissal of the complaint with cost.
Decision with reasons:
Heard the argument at length. Perused all the documents submitted by the complainant and OP-3.
The main defence taken by the OP-3 is that the complainant has not fulfilled the requirement as demanded by the OP-3 for settling the claim of the complainant.
The contention of the complainant is that she has already complied by supplying the documents as required by the OP-3.
It is seen from the documents that Medi Assist India Private Limited (T.P.A.) of this policy have sent two letter dated 02.4.2015 & 13.4.2015 (reminder of the first letter) requesting to furnish
- All past prescriptions, Treatment Details related to Present Diagnosis ckd Diabetes, Hypertension etc. disease.
- Provide the h/o ckd, diabetes, Hypertension, Colonic Ulcers, Gammopaghy (since when) certified by treating Doctor.
OP-3 informed the ld. Advocate of the complainant by giving a letter that claim under Policy No. 313101/48/2014/1537 was under process, but till date OP-3 has not yet settled the claim.
OP-3, in the course of making argument and in their written argument, submitted that they have not been able to settle the claim as the complainant has failed to furnish the documents as demanded by the Medi Assist India Private Limited (T.P.A.) on two occasions, namely, on 02.4.2015 & 13.4.2015. And without getting the green signal from the Medi Assist India Private Limited (T.P.A.), the OP-3 is not able to disburse the claim.
As a good gesture, the OP-3 argued that the claim is still open and they are ready to pay the sum assured of Rs. 1, 00,000=00 which the complainant claims Rs. 4, 39,124.90 if the complainant complies with the requirement as demanded by the Medi Assist India Private Limited (T.P.A.).
The complainant when prayed for claim form from OP-3, received a claim form from the OP-3 in favour of Liji Kunnath, not in favour of the complainant. This is highly irregular on the part of the OP-3.
The OP-3 admitted this irregularity, on their part and promised to send the claim form in favour of the complainant at the earliest.
Whatever may be, the complainant should comply supplying with the documents as required by OP-1&2 vide their letters dated 02.4.2015 & 13.4.2015.
Hence, it is
O r d e r e d
that the Consumer Complaint being No. 11/2016 be and the same is allowed on contest against the OP-3 and allowed ex parte against the OP-2 with a direction to the OP-3 to supply the claim form in favour of the complainant within 15 days from the date of passing of this order and after receiving the claim form by the complainant, the complainant is directed to submit the filled up claim form along with required documents to the OP-3, as required by the OP-1&2 (TPA) vide their letters dated 02.4.2015 & 13.4.2015, within 15 days from the date of receipt of the claim form in his favour. The OP-3 is further directed to settle the claim within 30 days after receiving the documents as per their requirement (vide letters dated 02.4.2015 & 13.4.2015 of OP-1&2) along with the filled up claim form submitted by the complainant, in default, the complainant is at liberty to put the order in execution as per provisions of law.
Let plain copies of this order be supplied to the parties free of cost as per provisions of law.
Dictated & Corrected by me: (Jayanti Maitra (Ray)
President
(Pankaj Kumar Sinha) DCDRF, Burdwan
Member
DCDRF, Burdwan
(Pankaj Kumar Sinha) (Nivedita Ghosh)
Member Member DCDRF, Burdwan DCDRF, Burdwan
