Order No.                 .

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

          Complainant and her husband Arun Kumar Agarwalla both purchased hospitalization benefit policy No.110800/48/10/8500000538 from the OP1 on payment of requisite insurance premium but Arun Kumar Agarwalla died on 04-12-2010 at Belle Vue Clinic being admitted on 23-10-2010 and for his treatment complainant received a sum of Rs.1,75,000/- and Rs.96,975/- from OP2 as full and final settlement of the claim against the Policy No.510300/34/10/11/00005529 issued by New India Assurance Company Ltd.

          But the complainant could not submit those documents for payment for medical expenditure to the OP1 in time as entire papers were submitted to the New India Assurance Co. Ltd. and for settlement of their claim and documents were in the custody of the New India Assurance Company and when the same was returned by the New India Assurance Company it was submitted to the National Insurance Company Ltd. on 01-06-2011.

          Complainant’s husband Arun Kumar Agarwalla intimated to the OP vide letter dated 05-04-2010 during his life time that payment against the New India Assurance Co. Ltd. for cashless benefit was received and the request was made to the OP1 to issue claim form and subsequently he sent all payments, voucher and documents along with discharge certificate with a letter dated 04-03-2011 to the OP1 who were received the on 31-03-2011 and complainant also sent photocopy of the policy of New India Assurance Company and claim settlement letter of the New India Assurance Company as desired by the OP and OP2 vide his letter dated 02-09-2011 asked the complainant to give valid reasons for 10 months delay in submission of all those papers.  So, complainant by another reminder letter dated 12-10-2011 and 08-11-2011 replied about the cause of delay in submission of the documents and by that letter complainant informed that all papers were submitted to the OP as on 04-03-2011 for a claim amount of Rs.1,34,805/- when claim of the complainant has not been settled by the OP2 and OP2 is totally silent without giving any consideration to the clarification given by the complainant for delay in submission to the OP2.

          It is further submitted by the complainant that as because the papers were first submitted to the New India Assurance Company for another policy and after settlement made against that policy, the same were submitted to the OP1, National Insurance Co. Ltd.  Another reason is that the Insured, Arun Kumar Agarwalla expired and the complainant alone handled this matter as she has no son and daughter stay outside Kolkata but knowing this reason, and even after knowing the position of the complainant the OPs in collusion with each other denied settlement vide their letter dated 30-11-2011 although the complainant’s claim against the policy of the New India Assurance Co. Ltd. was settled and paid by the OP on behalf of the New India Assurance Co. Ltd.  and this very fact is known to other OPs but they have adopted unfair trade practice and rejected the claim of the complainant though complainant prayed reimbursement of medical bills and for causing mental agony etc. she has claimed a total sum of Rs.1,34,805/- with interest etc. for causing harassment caused by the OP1.

          On the other hand, Insurance Company by filing written statement submitted that complainant already got mediclaim against mediclaim policy issued by New India Assurance Co. Ltd. and on the basis of said documents of Arun Kumar Agarwalla on 04-12-2010 complainant received a sum of Rs.1,75,000/- and Rs.96,975/- from New India Assurance Co. Ltd. as full and final settlement of Mediclaim but no claim was made to OP1 till 10-06-2011.

          It is further submitted on scrutiny of their document it was found that ‘cashless’ and pre and post hospitalization claim were settled by TPA Heritage Health TPA (P) Ltd. under individual Mediclaim Policy for the period 27-10-2009 to 26-10-2010 issued by New India Assurance Co. Ltd. and in the said letter complainant stated that complainant had submitted copy of claim settlement and further it was also informed to the complainant that complainant did not claim any amount to the claim form and for non-submission of the above document it was not entertained vide letter dated 01-06-2011 which was reported to the complainant.

          It is further submitted that complainant in her objection already admitted that she got all settlement amount from New India Assurnce Company Ltd. and after receiving the document from the New India Assurance Company he submitted all the documents to the OP on 01-06-2011 so the allegation of the complainant is nothing but distortion of fact and only to convince the Forum brought invented allegations against OP1. 

          OP1 further submitted that Arun Kumar Agarwalla since died on 04-12-2010 but the said information was given only on 05-11-2010 to the OP with a request to issue the claim form and not on 04-03-2011 as alleged.  Moreover, she had stated in the claim that only after settlement of claim of New India Assurance Company he submitted present claim on 01-06-2011 in reply to the OP’s letter dated 11-05-2011, so, the entire allegation of the complainant is false.  It is further submitted that in the claim form complainant cannot claim any amount vide her letter dated 11-05-2011 and it is also admitted fact that complainant failed to produce other documents i.e. policy of New India Assurance Co. Ltd., Claim settlement of New India Assurance Co. Ltd., Death Certificate of A.K. Agarwalla, the original bills of Money Receipt of Belle Vue Clinic, Discharge Certificate of Belle Vue Clinic, Kolkata, the post Hospitalization expenses bill for settlement of claim in time.  And in fact, for the reasons for non-submission of the document mentioned in Para 4 complainant claim was decided as ‘no claim’ and further OP submitted that there was no fault on the part of the OP and further the complainant’s claim has already been decided by the National Insurance Company.  In the result OP prays for dismissal of this case.

Decision with Reasons

In the present case after hearing argument of the Ld. Lawyer of both the parties and also considering the material documents it is found that it is undisputed fact that complainant and her husband Arun Kumar Agarwalla purchased one Hospitalization Benefit Policy, National Insurance Company having valid period from 06-07-2010 to midnight of 05-07-2011 and fact remains on 05-11-2011 OP sent a letter to the complainant stating that the complainant has already enjoyed cashless pre and post hospitalization claim settled by TPA Heritage Health Pvt. Ltd. under individual Mediclaim Policy No.510300/34/09/11/00005529 for the period from 27-10-2009 to 26-10-2010 issued by New India Assurance Company Ltd. and it was also submitted that the complainant also submitted the policy of the New India Assurance Company and copy of the settlement sheet and intimation letter but complainant did not claim any amount in the claim form.  And, so, the OP reported to the complainant for non-submission of the above documents they are not in a position to entertain her claim. 

          From the letter of the complainant after receipt of the letter of the OP dated 05-11-2011 complainants submitted Xerox copy of the policy of New India Assurance Company Ltd. of 2010-2011, 2009-2010 and settlement letter of New India Assurance Company and that letter was despatched on 01-06-2011.

          Further it is proved from letter dated 05-11-2010 issued by the complainant in favour of the National Insurance Company that complainant for the first time prayed for necessary claim form.

          By a letter dated 04-03-2011 complainant reported to National Insurance Company as because her husband has another policy with New India Assurance Company Ltd. and the original bills and money receipt of Belle Vue Clinic had already been submitted to the New India Assurance Company Ltd. and that claim has been settled already so requested to place her claim as soon as possible and by that letter he submitted a copy of the death certificate of her husband.  Subsequently, on 02-09-2011 Medi Assist India TPA Pvt. Ltd., informed that on scrutiny of the document the complainant more information required for processing balance claim and on receipt of the matter would be taken into account for consideration and by that letter complainants were asked to submit the valid reasons for late submission of all those papers etc.

          On 16-11-2011 complainant informed the OP2 that he received final payment from New India Assurance Company Ltd. and then she deposited all documents on 31-03-2011 and that was deposited as per letter of the OP.  Fact remains that the Medi Assist India TPA Pvt. Ltd. reported to the complainant vide their letter submitted that in that case the claim matter shall be closed as ‘no claim’ and no further correspondence made in this connection in future. And that was on 30-11-2011 thereafter the complainant sent a letter to the OP2 on 26-12-2011 that she has no son and her daughter was out of Kolkata and after collecting documents on 31-03-2011, she submitted it. 

          Practically, in this case it is proved that complainant deposited all the documents ultimately but most of them are Xerox copies to the OP2 on 31-03-2010 as per statement of the OP but OP2 reported on 30-11-2011 required information and documents were not supplied and it is also proved that in their claim application complainant did not mentioned the amount what she has prayed for and claim application is found blank.  Another factor is that all documents – discharge certificate, medical bils etc. which were submitted to the TPA Heritage Health TPA Pvt. Ltd. for settlement of claim under individual mediclaim policy No.510300/34/09/11/00005529 for the period 27-10-2009 to 26-10-2010 issued by New India Assurance Company Ltd. and truth is that in respect of that treatment and in respect of those medical papers claim was settled by the New India Assurance Company Ltd. both cashless and pre and post hospitalization claim and truth is that complainant already received Rs.1,75,000/- and Rs.96,975 that means complainant has no allegation against settlement of claim made by New Inda Assurnce Company Ltd. and another factor is that regarding the treatment of the husband of the complainant, complainant submitted all the documents to the said Insurance Company for settlement and Insurance Company settled that claim on the basis of the documents.

          It is settled principle of law that in respect of selfsame treatment period policy holder cannot get double benefit if it is once settled by any Insurance Company when it is found that in respect of said insured that there is another claim policy of any type of different insurance organization.  But in this particular case complainant submitted all medical papers of Belle Vue Clinic in respect of the treatment of her husband and Belle Vue Nursing Home settled her claim in respect of her treatment pre and post hospitalization and thereafter handed over two cheques of Rs.1,75,000/- and Rs.96,975/- and so, those medical papers cannot be placed before another insurance company for further claim by using the same document which has been considered by the Insurance Company who already released claim amount and in the present case there is no allegation against the National Insurance Comp-any that they did not consider the medical papers properly and they released less amount than that of their claimed amount.

          Further fact is that for one treatment or for a particular period of treatment if any claim of a mediclaim policy holder is settled by the one Insurance Company further claim cannot be entertained by another Insurance Company in respect of which the said insured has another mediclaim policy (of any nature) further fact is that complainant has not filed the copy of the policy of New India Assurance Company and has also failed the entire claim settlement order and further the prayer for claim made by the complainant to the New India Assurance Company Ltd. in this case.

          Not only that from the complaint it is found that complainant’s husband was admitted to hospital on 23-10-2010 and expired on 04-12-2010 and complainant submitted document all medical documents, pre and post hospitalization and other medical treatment papers for that period before the New India Assurance Company Ltd. and New India Assurance Company Ltd. granted Rs.1,75,000/- and Rs.96,975/-.  Then, complainant’s entire claim has been satisfied by the New India Assurance Company Ltd. then how can complainant claim further medical benefit for same treatment and pre and post hospitalization treatment cost.

          It is settled principle of law in respect of one period of treatment if mediclaim is entertained by any insurance company and same is realized by using those medical treatment documents further claim cannot be made before any other Insurance Company but in this case same thing has happened.  Most interesting factor is that present disputed policy 1008000/48/10/85/0000538 was valid from 06-07-2010 to midnight of 05-07-2011 and sum insured is Rs.1 lakh and in both the cases complainant is guided by some terms and condition of the Insurance Company because both the National Insurance Company and New India Assurance Company are Government Undertaking Company.

          Two or three policies are purchased by insured only for to get such benefit if one after another treatment is required by any person that means if sum is insured is Rs.1 lakh against one policy and another is Rs.2 lakhs and another is Rs.3 lakhs in that case against any policy if claim is submitted along with medical papers for particular period of treatment and if it is settled and realized such an amount and against such payment insured as no objection in that case said insured cannot produce the same medical documents for further realization of mediclaim policy against another policy of another insurance organization but two or three policies are purchased for getting relief for each and separate treatment.  But it must be separate documents for separate period in respect of which no claim has been decided by any other Insurance Company.  Considering the above fact we are convinced that complainant claim in respect of the treatment and pre and post hospitalization and other matter had been decided by the National Insurance Company and National Insurance Company already paid Rs.1,75,000/- and also Rs.96,975/- that means total Rs.2,71,975/- but complainant has not produced any document to show what was the sum insured by the said policy by New India Assurance Company Ltd.

          Further considering all the documents it is found that complainant submitted all the papers most of the Xerox copies and other papers on 01-06-2011 whereas her husband died on 04-12-2010 i.e. long after 6 months.  But for the sake of the argument if it is expected that delay was for submitting those medical papers before the New India Assurance Company then it is clear that New India Assurance Company considered that medical papers and released on two occasions a total sum of Rs.2,71,975/- then how this documents can be placed to another company for further consideration but document for any fresh period of treatment, related to her husband other than documents already filed for any claim, in that case only same may be considered by the insurance company.

          Moreover, complainant has not expressed before this Forum either in the complaint or in the evidence actually what was his total claim of mediclaim before New India Assurance Company and out of which complainant got Rs.2,71,975/- so without considering those papers some other legal aspect cannot be decided by this Forum.

          Moreover, in the claim form there was no mention of any amount or any list of respect treatment cost etc. and considering that fact in respect of the complainant present claim which was placed with inbuilt bio-datas was not considered and so OPs failed to decide the same and ultimately informed that it is impossible for them to decide on such materials.

          In view of the above facts and circumstances and also considering the terms and condition as laid down in the policy we hold that in respect of the treatment of same period complainant cannot get relief from two insurance policies in respect of treatment cost of the same period and fact remains another insurance company already released Rs.1,75,000/- and Rs.96,975/- i.e. total Rs.2,71,975/- but till now, it is impossible to ascertain actually what was the actual claim of the complainant before New India Assurance Company and out of that what part of amount has not been considered by the New India Assurance Company and peculiar factor is that complainant is silent about that what was complainant’s claim for reimbursement of medical treatment cost to New India Assurance Company and why complainant did not file any objection against payment of only Rs.2,71,975/- out of total claim and when complainant has not made any complaint against such release of amount of Rs.2,71,975/- by New India Assurance Company then in respect of rejected part of claim complainant cannot raise any further claim for that balance amount to other Insurance Company but as per principle of law for particular period i.e. from 27-10-2009 to 26-10-2010 complainant submitted mediclaim for reimbursement from New India Assurance Company and in the present case also complainant submitted reimbursement of treatment cost of the deceased for the period from 27-10-2009 to 26-10-2010 but in the eye of law it is not tenable so under any circumstances, this Forum is not able to give any relief without considering all the papers which are in the custody of the New India Assurance Company Ltd. for determining the complainant’s present claim.

          In the light of the above observation and also considering the entire materials on record we are disposing of this matter by giving this complainant a chance to produce all such papers and assessment as made by the New India Assurance Company to the present OP Company for further reconsideration and to that effect the order is being passed and present OP Company shall reconsider the same if complainant is able to produce all the papers related to mediclaim submitted to New India Assurance Company i.e. claim form, assessment sheet of the New India Assurance Company in respect of releasing Rs.2,71,975/- and all other papers.

          Accordingly, the complaint is disposed of finally.

Hence,

Ordered

That the complaint be and the same is allowed in part but without any cost against the OP.

          OP National Insurance Company is directed to reconsider the claim of the complainant if complainant is able to produce all the papers particularly copy of claim application form, assessment of mediclaim by the National Insurance Company and report related to release of Rs.2,71,975/- and also to determine entire file of the present complainant as maintained by National Insurance Company for settling the claim of the complainant in respect of her claim before the National Insurance Company and in this regard OPs are also directed to verify the file by the complainant in respect of release of claim of Rs.2,71,975/- and to determine whether further amount can be released by the OP or not and invariably OP shall decide the same after considering all those documents and if result is found negative in that case the complainant shall have no right to file any further claim before any forum.

          Accordingly, this complaint is disposed of and question of giving any compensation and litigation cost and relief do not arise in view of the fact.  Apparently, we have failed to search out the genuinity of the claim as per terms and condition for the policy and for suppressing many material documents.