FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER
This is an application U/s.35 of the C.P. Act, 2019.
The fact of the case in brief is that the Complainant Mr. Biswajit Patra got admitted to the OP 1 Hospital Green View Clinic on 05.08.2020 for treatment of suspected Covid 19 disease. He informed the Hospital about his Mediclaim Policy with the OP5 but the OP 1 Hospital advised him to deposit Rs.30,000/- and the same was deposited on 05.08.2020 and thereafter on 08.08.2020 another amount of Rs.45,000/- was also deposited to the OP 1. The complainant was found positive on 07.08.2020 as per Discharge Summary. He got discharged on 17.08.2020. After discharge the complainant submitted bill to the OP5 but the OP5 vide e mail dated 08.04.2021 asked for some more documents to process the claim. The complainant asked for those documents from the OP1 several times but the OP1 did not hand over the documents. Finding no other way the complainant sent one demand notice to the OPs through Speed Post on 21.04.2021 which was duly received by the OPs on 06.05.2021 asking them to provide the documents as asked for by the OP5 but the OPs sat tight over the issue and did not hand over the papers. The OP5 thereafter sent their e mail dated 22.06.2021 rejecting the impugned claim for non receiving the essential papers. Cause of action arose on 17.08.2020 when the OP1 did not provide the papers and on 22.06.2021 when the OP5 rejected the claim.
Finding no alternatives the complainant has filed the complaint petition before the Commission for justice and relief.
While perusing the order sheets of the Commission we observe that the case has been heard ex parte against OP No. 5 vide order dated 17.06.2022 and thereafter again the case has been heard ex parte against OP No 1 to 4 vide order dated 30.06.2022. As such the OPs have lost their scope to contest the case.
Points for Determination
In the light of the above pleadings, the following points necessarily have come up for determination.
1) Whether the OPs are deficient in rendering proper service to the Complainant?
2) Whether the OPs have indulged in unfair trade practice?
3) Whether the complainant is entitled to get relief or reliefs as prayed for?
Decision with Reasons
The above mentioned points are taken up together for the sake of convenience and brevity of discussion.
Now travelling over the documents filed by the complainant it is observed that the complainant has enclosed two money receipts , one of Rs.30,000/- dated 05.08.2020 and the other of Rs.45,000/- dated nil issued by the OP1 Clinic along with one Patient Bill Summary Report dated 08.08.2020 issued by the OP1, Green view Pharmacy Bill of Rs.1574/- , Invoice Bill of Shristi of Rs.2750/- & Rs.3000/- & Discharge Summary & Certificate of Sanjiban Hospital and copy of one claim form duly filled in by the complainant. There is no whisper of any complaint against the Sanjiban Hospital who is however not a party to the case.
He has also filed the Demand Letter dated 17.04.2021 sent to the OP Nos. 1 to 4 asking them to provide him the papers and documents which were required to be submitted to the OP Insurance Company for settlement of claim.
The complainant has also enclosed the Rejection Letter of the OP5 Insurance Company dated 22.06.2021. From the said letter it appears that the OP5 Insurance Company could not settle the claim for want of documents.
From the facts and circumstances of the case it appears that the complainant was admitted to OP1 Green View Clinic Pvt. Ltd. on 05.08.2020 and appears to be there upto 08.08.2020 on package amount of Rs.75,000/-. The claim was refused by the OP Insurance Company for want of documents which were supposed to be provided by the OP1. Since the complainant have specifically asked for the documents from the OP1 vide his letter dated 17.04.2021 which were needed to be submitted to the OP Insurance company it was the duty of the OP1 Clinic to provide him the same. Non compliance of the same tantamount to deficiency in service and unfair trade practice on the part of OP Nos. 1 to 4. OP Insurance Company cannot be held liable for non settlement of claim for the simple reason of non submission of relevant documents as asked for vide their reminder letter dated 12.04.2021.
In view of the facts and circumstances of the case we are of the view that the complainant has established the case against OP Nos 1 to 4 and has not established the case against OP No.5.
All the points under determination are answered accordingly.
In the result, the Consumer Complaint succeeds in part.
Hence,
Ordered
The Consumer Complaint be and the same is allowed ex parte against OP Nos. 1 to 4 and dismissed ex parte against OP No.5 with the following direction.
- The OP Nos. 1 to 4 are directed to hand over the Medical Papers as asked for by the Insurance Company for settlement of the impugned Claim as per law and payment of fees,if any.
- The OP Nos. 1 to 4 are directed to pay jointly and severally a sum of Rs.5,000/- as litigation costs to the complainant.
The above orders are to be complied within a period of thirty days from the date of the order failing which the complainant will beat liberty to put the order into execution as per prevailing rules of the C.P.Act.
The judgment be uploaded to the website of the Commission forthwith for perusal of the parties. Copy of the Judgement be supplied to the parties free of cost as per C.P.Act.
