Complainant by filing this complaint has submitted thatcomplainant purchased a Mediclaim Policy for treatment of diseases and injury as arisen out of accident against policy No. 100600/48/11/8500003467/100600-DO-VI which was issued by the op no.1 on receipt of premium and same was valid for the period 20.07.2011 to midnight of 19.07.2012 and it was renewed year to year and in fact the said Mediclaim Policy was started in the year 1999 and since then the policy is being continued on payment of yearly premium without any claim save and except this particular claim against which this complaint has been filed.
Fact remains during subsistence of the said Mediclaim Policy, complainant’s daughter Miss Aeshita Sinha, I.D. Card No. H HIS. 010871412 became seriously ill with left sided Phenumonia with high grade fever since one week along with chest pain during coughing and lastly the Board of doctors diagnosed the complainant’s daughter that the complainant’s daughter Miss Aeshita Sinha under the joint care of Dr. Tridib Banerjee, Prof. Dr. Apurba Ghosh and Dr. Anirban Moitra and was admitted at Vision Care Hospital on 03.03.2012 where she was treated and discharged on 16.03.2012 from the said hospital on that date. But again she felt ill due to some illness and was under the treatment of the said doctor and was admitted in the said hospital on 28.03.2012 and was discharged on 10.04.2012 and due to her treatment her father spent 2,09,097.35 paisa. Complainant after final release of her daughter submitted a claim form along with for supporting papers and deposited the same in the office of op no.2 on 14.05.2012. But since filing of the claim, no letter was served upon the complainant regarding the statement of the said claim. But on enquiry through TPA, complainant submitted a prayer statement of claim for claim of Rs. 2,09,097.35 paisa. But since then op did not sanction the same on the contrary op did neither settled the same nor rejected the same but lastly on 12.03.2014 complainant through his Ld. Advocate sent a notice to the ops through Speed Post with A/D with a reminder of the claim. But even after receipt of the notice, op did not settle the claim and did not give any satisfactory reply and for which being aggrieved and negligent and deficient manner of service of the op the present complaint is filed for redressal.
On the contrary op no.1 National Insurance Company by filing written statement submitted that op no.2 received the claim form duly acknowledged to the complainant on 14.05.2012 and against that sent a letter dated 01.06.2012 to the complainant asking him that additional queries in connection with patient name and they have reviewed the claim and requested the complainant to provide them some additional documents like Dr’s advice for admission, claim intimation copy duly accepted by the underwriting office (NIC) within 7 days from D.O.A. and original deposit money receipt of Rs. 1,45,000/- from hospital and complainant was directed to send the same and ultimately final reminder dated 20.06.2012 was sent to the complainant for the above required document. But complainant did not send the same for which the matter is ultimately closed.
Moreover it is submitted that complainant took Family Health Insurance Policy vide Policy No. 100600/48/12/8500003872 for the period from 28.07.2012 to midnight of 19.07.2013 against her daughter sum insured was Rs. 1,00,000/- but he claimed medical reimbursement for Rs. 2,09,097.30 paisa which is excessive claim amount than that of the sum insured. Therefore complainant’s claim is not tenable as per terms and conditions of the policy. Further it is submitted that the complaint under reply of the para no.6 the op no.1’s authorized TPA sent another letter dated 22.03.2013 for additional queries in connection with the complainant’s documents. But complainant has failed to compliance the said requirements as per letter dated 22.03.2013 and in fact complainant failed to comply with the requirement and the claim was closed by TPA on 11.07.2012 for non-submission of money receipt for an amount of Rs. 1,45,000/- along with doctor’s advice for admission and other documents. So there was no negligence and deficiency on the part of the op as and when complainant shall have to file all those documents and the matter shall be further reopened for consideration for which the complaint should be dismissed.
Decision with reasons
On proper consideration of the entire materials on record including the written version of the op and the allegation of the complainant as per complaint, it is found that complainant has his one mediclaim policy under the op and op has admitted that fact. But fact remains that in respect of the patient daughter of the complainant as per policy her sum insured is Rs. 1,00,000/-. Truth is that complainant filed claim in respect of Rs. 2,09,097.30 paisa and also fact is that as per mediclaim policy at best the complainant ought to have filed the claim from in respect of sum insured of Rs. 1,00,000/- but that has not been filed.
After proper assessment of the documents as filed by the op and complainant, it is proved that complainant was asked to file certain documents but that had not been filed by the complainant even after repeated reminders and it is no doubt uncalled for on the part of the complainant. Because those documents are required for settlement of his claim. So, apparently there is no negligence or deficiency on the part of the op. But fact remains that complainant was liable to submit those documents as required by the ops. But complainant has failed to prove for what reason those documents were not filed by the complainant for settlement of claim. At the same time complainant ought to have submit such prayer for deletion of the claim amount of Rs. 2,09,097.30 paisa but his prayer for claim ought to have been within the range of Rs. 1,00,000/- out of total expenditure for treatment of his daughter.
Whatever it may be after considering the entire materials on record and further considering the terms and conditions of the policy including the very vital fact and documents, we are convinced to hold that complainant should be instructed to file all those documents as required by the ops and on receipt of the same ops shall have to dispose of the complaint within the terms and conditions of the policy and taking into account the sum insured of Rs. 1,00,000/- and accordingly necessary order is passed directing the complainant and also directing the op to settle the claim as per policy conditions and treating that claim within the ambit of the sum insured of Rs. 1,00,000/- and disposed of the claim application after opening the said claim file by the ops and in this regard op must have to dispose of the said claim of the complainant treating it as claim of the complainant within the ambit of Rs. 1,00,000/- on receipt of the required documents to be filed by the complainant.
Accordingly the complaint is disposed of finally by passing such final order.
Hence, it is
ORDERED
That the complaint be and the same is allowed on contest against the ops without any cost.
Complainant is directed to submit all the documents as required by the ops and to rectify the claim application to the extent of Rs. 1,00,000/- as per the policy and same must be submitted by the complainant to the ops within one month from the date of this order. Similarly on receipt of the said documents and prayer of the complainant, op shall have to open mediclaim case of the complainant and shall have to dispose of the same on merit within one month from the date of receipt of those documents from the complainant and to issue such cheque in respect of the settled amount.
Parties are directed to comply this order within the stipulated period and if complainant fails to comply the order in that case the matter shall be treated as a closed and if complainant complies the order, in that case op shall have to comply the order as per spirit of the order within the stipulated period failing which penal interest at the rate Rs. 200/- per day shall be assessed from the expiry of stipulated time of the order against the ops and till full recovery of the said amount and for disbursement to the complainant and if such penal interest is collected, it shall be deposited to this Forum. Even if it is found that parties are complied the order within the stipulated the period in that case against either of the parties penal proceedings shall be started for which parties should be prosecuted and may be imposed penalty and fine.
