Order-14.
Date-04/04/2018.
Shri Anupam Bhattacharyya, President.
The instant complaint has been filed by the complainant u/s.12 of the C.P. Act, 1986 praying for direction upon the OPs to pay Rs.2,84,318/- along with interest at the rate of12 percent p.a. from 1st June, 2017 till the date of payment and Rs.1,00,000/- for punitive damages.
The case of the complainant, in brief, is that the complainant had taken ‘‘Varistha’ Mediclaim for Senior Citizen Policy’ from National Insurance Co. Ltd. from 31-12-2013 to 30-12-2014 and renewed for further period from 31-12-2014 to 30-12-2015, were covered for Hospitalisation of Rs.1,00,000/- and critical illness of Rs.2,00,000/-. The Complainant admitted at Forties Hospital on 07-11-2014 and discharged on 11-11-2014 and lodged claim Rs.73,802/- with the OP2 on 28-12-2014, OP2 credited Rs.53,194/- on 27-02-2015 in the account of the complainant. Complainant being renal patient was advised to undergo dialysis twice a week. For dialysis from 21-11-2014 to 28-12-2014 he lodged a claim of 26,868/-, for the period between 01-01-2015 and 31-05-2015 he lodged the claim of Rs.92,503/- and for the period between 07-06-2015 to 27-08-2015 lodged claim Rs.62,112/- with the OP2. OP2 on 21-11-2015 credited only Rs.47,700/- in the A/c of Complainant but for balance amount no clarification was given. Against the above circumstances complainant lodged the claim for deficiency of service on the part of OP. Hence the instant complaint.
The written version filed by the OP1, in brief, is that there is no cause of action of the instant complaint and for that the same is liable to be dismissed. The claim of Rs.26,868/- was repudiated due to submission of claim belatedly and Rs.47,200/- out of claim of Rs.92,503/- has been credited in the Bank A/c of Complainanout in full settlement of the claim and with regard to the claim of Rs.62,112/- it was repudiated by the TPA/OP2 due to non-availability of sufficient fund on their credit. OP1 submitted that they settled the claims either favourably or unfavourably strictly in accordance with law and the said application of the complainant is liable to be dismissed in limine.
OP2 has not entered appearance and also not filed any written version on their behalf and the case is taken up for ex parte against them.
Considering the pleadings of complainant and OP1 the following points have been raised for disposal of this case.
Point for Decision
- Whether the case is maintainable in its present form and law?
- Whether there is any cause of action to file the case?
- Whether the case is barred by limitation?
- Whether the complainant is entitled to get the relief as prayed for?
- What other relief/reliefs the complainant is entitled to get?
Decision with Reasons
Point Nos.1 to 5 . All the points are taken up together for the brevity of discussion and convenience.
The instant complaint is for payment of Mediclaim of Rs. 2,84,318/- along with interest at the rate of12 percent p.a. from 1st June,2017 till the date of payment and Rs.1,00,000/- for punitive damages
The complainant’s main case is that complainant took two Mediclaim Policies from OP for hospitalization of Rs.1,00,000/- and for critical issues for Rs.2,00,000/- and under the policy period lodged a claim for hospitalization for Rs.73,802/- with the OP2 but OP2 credited Rs.53,194/- to the complainant’s account as full settlement, after that three claims, one of Rs.26,868/- for 1st policy and Rs.92,503/- and Rs.62,112/- for 2nd policy have been submitted by the complainant but OP only credited Rs.47,200/- against the claim of Rs.92,503/- in complainant’s account and remaining amount repudiated by the OP. Finding no alternative complainant filed this case for deficiency in service against the OPs.
On the other hand, OP1’s main case is that they credited Rs.47,200/- in the Bank A/c of Complainant against the claim of Rs.92,503/- in full settlement of the claim and with regard to the claim of Rs.62,112/- it was repudiated by the TPA/OP2 due to non-availability of sufficient fund on his credit. OP1 submitted that they settled the claims either favourably or unfavourably strictly in accordance with law and the said application of the complainant is liable to be dismissed in limine.
To prove the case both the parties have adduced Evidence on Affidavit and they have filed questionnaires and replies vis-à-vis along with relevant documents in support of their respective case.
The complainant has filed BNA. OP1 has also filed BNA.
Admittedly, the complainant had insurance policy for the period from 31-12-2013 to 30-12-2014 and the same was renewed for the further period from 31-12-2014 to 30-12-2015 where the insurance coverage for hospitalization is Rs.1 lakh and for critical illness for Rs.2 lakhs.
In this case for hospitalization the complainanit filed the complaint for the treatment being admitted in the Fortis Hospital 07-11-2014 and discharged on 11-11-2014 claiming Rs.73,802/- with the OP2 on 28-12-2014 and out of which Rs.53,194/- was credited in the account of the complainanit on 27-02-2015.
For critical illness for dialysis the complainant was admitted in the same hospital for the period from 21-11-2014 to 28-12-2014 and the claim was for Rs.26,868/-, for the period from 01-01-2015 and 31-05-2015 claim was for Rs.92,503/- and again for the period between 07-06-2015 to 27-08-2015 lodged claim of Rs.62,112/-.
In spite of the aforesaid claims for hospitalization benefit and critical illness for dialises Rs.47,700/- was only credited in the account of the complainant in respect of the claim against the claim of Rs.92,503/-.
In this case, the complainant has claimed in total Rs.2,84,318/-. Regarding the expenses towards treatment for critical illness with the detailed break up for reimbursement is for Rs.1,81,483/- and the claim for interest is for Rs.2,835/- and compensation for deficiency in service is Rs.1,00,000/-.
Considering the above claim it is clear that the complainant has not claimed in this case raising allegation as to the claim of Rs.73,802/- where he got with full settlement of Rs.53,194/- which was credited in his account on 27-02-2015 for the claim of Rs.1,81,483/-. It is clear that Rs.47,700/- was credited in the account of the complainant in respect of the claim of Rs.92,503/-.
In the break up for the total claim of Rs.2,84,318/- the complainant has claimed towards expenses for the treatment of Rs.1,81,483/- without adjusting Rs.47,700/- which has been credited in his account against the claim of Rs.92,503/-.
On the other hand, the OP has repudiated the claim in respect of Rs.26,868/- for belated claim and Rs.62,112 for non-availability of the fund in the hand of the OP2.
Regarding the reason for delay in submission of claim the complainant has sent letter datd 08-03-2016 explaining that since discharge from Fortis the complainant was advised by Dr. A.R. Dutta, for dialysis twice a week. Accordingly, the claim have been submitted periodically and it was not possible to submit claim separately for each day dialysis.
Also in the terms of policy as to delay in submission of claim there is exception in some cases including in case of dialysis and, as such, we can safely conclude that the OP cannot repudiate mediclaim of Rs.26,868/- for the delay in submission of claim.
At the same time the ground of repudiation for non-availability of the fund in repudiation of the claim for Rs.62,112/- has not been justified by adducing cogent evidence by the OP and for that the said ground was not acceptable and, as such, the complainant is entitled to get the claim in respect of the unpaid claim of Rs.26,868/- and Rs.62,112/- according to coverage of the particular policy.
Regarding the claim of Rs.92,503/- the OP Insurance Company has paid only Rs.47,700/- but the same has not been established categorically as to the payment in terms of the coverage of the policy.
That being so, the complainant is entitled to get the entire claim of Rs.1,81,483/- adjusting Rs.47,700/- according to coverage of the particular policy along with interest at the rate of 7 percent p.a.
The ground of repudiation for payment of claim of Rs.62,112/- for non-availability of the fund is not at all justified rather it is a serious deficiency in service and also considering the repudiation of the claim for belated filing the claim of a dialysis patient is quite inhuman and for that we are of view that the complainant is entitled to get compensation of Rs.50,000/-.
On the basis of discussion we find that all the points are disposed in favour of the complainant in part and, as such, the complainant is entitled to get the claim along with litigation cost of Rs.5,000/-.
There being no specific claim against OP2, the case against OP2 be allowed ex parte.
Hence,
Ordered
That the instant case be and the same is allowed in part on contest against the OP1 and the same is allowed ex parte against OP2.
The OPs are jointly and severally are liable to pay the awarded amount.
The OPs are directed to settle the entire claim of Rs.1,81,483/- adjusting Rs.47,700/- according to coverage of the particular policies along with interest at the rate of 7 percent p.a. from the date of filing the claim till realization.
OPs are further directed to pay compensation of Rs.50,000/- for deficiency in service along with litigation of Rs.5,000/- to the complainant.
OPs to comply the above order within 30 days from the date of this order, in default, the OPs to pay fine at the rate ofRs.100/- per day delay and the amount so accumulated should be deposited to this Forum.
Failure to comply with the order will entitle the complainant to put the order into execution under appropriate provision in C.P. Act.
