Order No.                 .

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

          Complainant by filing this complaint has submitted that the complainant purchased one Mediclaim Insurnce Policy from OP1 under cashless scheme since 12-09-2003 and regularly paying premium per year being policy No.108301/48/8500002461 for the period from 12-09-2011 to 11-09-2012.  Complainant suffered from end-stage Renal failure since April, 2011 and was hospitalized on 06-04-2011 with Fortis Hospital, Kolkata and doctor advised immediate Haemodialysis and the entire expenses related to the same were duly reimbursed by the OPs but ultimately the consulting physician Dr. Lalit Kumar Agarwal, Nephrologist advised Kidney Transplantation as the definite treatment for the complainant but due to some infections the Kidney Transplantation could not be done, so the complainant was advised by his doctor to remain quarantined in his room to avoid infection and the complainant was finally hospitalized on 19-03-2012 and was underwent Kidney Transplantation on 21-03-2012 at Woodlands Hospital.  After said treatment complainant was in his room at least for 6 to 8 months in quarantined room and stent was removed on 16-05-2012 and then complainant through his agent submitted the bill of his claim amounting to Rs.43,225/- being 50% of Bed and Nursing charges and doctor’s fees on 21-05-2012 when the policy was valid for the period 12-09-2011 to 11-09-2012.  Subsequently the complainant received a letter from TPA on 31-07-2012 and submitted all required documents on 13-08-2012 but ultimately the claim was repudiated on 31-08-2012 and after receipt of the same complainant being a Chartered Accountant and working as a Professor in Government aided college in West Bengal so, he was astonished that repudiation was made without any legal cause and justifications and thereafter, complainant being shocked and considering the ground for repudiation prayed for condition of delay in submitting the intimation letter dated 17-09-2012 and also prayed for release of the same and complainant followed up the matter but no result was received so, he has been suffering from mental pain and agony and getting no result complainant filed this complaint praying for releasing Rs.43,225/-, the mediclaim amount and interest and also compensation etc.

          OP1, National Insurance Company has submitted that prior to filing of the present complaint petition they duly instructed to the OP2 to satisfy the complainant to pay Rs.43,225/- though they did not pay such amount and                                             when the OP2 did not do the same for that there is no deficiency on the part of the OP1 and further present allegation is completely baseless and without any foundation and they have already issued a cheque of Rs.43,225/- to the complainant. Anyhow, OP1 further submitted that practically matter was in the process in between the complainant and the OP2 TPA.  The fact remains complainant submitted his claim after expiry of limitation period for which the claim of the complainant was repudiated by the TPA OP2 on 31-08-2012 and in that repudiation letter that complaint was asked to file prayer for condition of delay.  Thereafter, complainant submitted condonation of delay in submitting the claim and OP1 considering the seriousness of the decease suffering by the complainant the condonation of the delay to claim of the complainant was immediately condoned  but in respect of that OP2 by another letter dated 27-02-2013 again requested the OP1 to condone the delay was done in writing which was received by the OP2 on 12-03-2013.  Thereafter by E-mail on 25-03-2013 and OP1 was intimated by the OP2 that claim of the complainant shall be duly paid by early April, 2013 which would be received by them in April, 2013 which is called float in insurance industry in respect of that but OP2 did not pay the claim of the complainant without any knowledge of the OP1 so, there was no fault on the part of the OP1 and for which the claim should be treated as finally settled when the cheque has already been submitted.  Anyhow, OP2 did not turn up to contest accordingly the case is heard finally.

Decision with Reasons

Fact remains that case is heard finally but truth is that vide a cheque No.100158 dated 29-05-2014 OP1 already issued the sum in favour of Jayanta Kumar Ghosh in support of payment of total mediclaim of Rs.43,225/- and it has been received by the Advocate of the complainant on 04-08-2014.

          Fact remains complainant himself admitted in his complaint that his kidney transplantation was done by 21-03-2012 in Woodland Hospital.  Stent of the complainant was removed on 16-05-2012 and he submitted bill of his claim amounting to Rs.43,225/- and that was submitted on 21-05-2012 that is long after two months and practically along with claim application certain documents were not submitted.  So, TPA asked the complainant on 31-07-2012 for submitting some documents and, thereafter, complainant submitted this vital documents which are not submitted along with the claim application ultimately submitted on 02-08-2012 which was received by the TPA on 13-08-2013.  Truth is that TPA informed that it is time barred so, condonation of delay petition is required.  Accordingly complainant submitted a petition praying for condonation of delay for filing the said claim after time barred period and that was filed on 17-09-2012.  Thereafter, that condonation application was allowed by the OP1 and that was reported to OP2 by OP1 on 27-02-2013 and also on 12-03-2013 and OP2 received the same in both the cases.  But OP2 reported to them that the complainant will be paid the said amount during April, 2013 as per their receipt of float in insurance industries.  But most interesting factor is that the complaint was filed on 04-04-2013.

          For the sake of the argument if it is accepted that OP2 reported that by April 2013 the amount will be paid by the OP2 to the complainant no reason is shown by the TPA, OP2 why that has not been paid by the OP2,TPA by April, 2013 and, in fact, OP1 ultimately, issued the cheque of Rs.43,225/- dated 29-05-2014 that is after lapse of one year and no doubt there is no explanation for delay in payment over the said cheque for last one year.  In this regard TPA is no doubt at fault and practically it is the negligent and deficient manner of duty on the part of the TPA and practically TPA is authorized administrative agent of OP1 and for his fault OP1 failed to clear up the said amount though it is clear that OP1 directed the OP2 for release of the same, OP2 assured that it shall be released within early April, 2013 and that was not also released so, as agent of the OP1 OP2 is responsible and for which we find that OP2 shall have to pay the litigation cost of Rs.5,000/- and also compensation of Rs.8,000/- to the complainant because complainant has been harassed further for one year.

          But we are not unmindful to the fact that repudiation was made by the OP initially because there was no document filed along with the application and it was submitted after expiry of the stipulated period for filing the claim.  Thereafter, complainant as per their requirement submitted condonation of delay and that was subsequently allowed by the OP1 and OP2 was directed to release.  So, initially there was some fault on the part of the complainant so, first repudiation was justified but from the letter of the TPA dated 25-03-2013 it is clear that TPA reported that the said amount shall be cleared in the early April, 2013 but that was also not cleared so, TPA is legally bound to pay that compensation and litigation cost.

In the result, the case succeeds.

Hence,

Ordered

That the case be and the same is allowed on contest without any cost against OP1 and same is allowed ex parte against OP2 with a cost of Rs.5,000/-.

          OP2 is directed to pay compensation of Rs.8,000/- to the complainant for harassing the complainant in such a manner for one year even after assuring the complainant to pay the sum by April, 2013 and Rs.8,000/- shall be paid by the TPA within 15 days from the date of this order along with the litigation cost and if TPA fails to pay it that case it shall be paid by OP1 the insurance company because the TPA is appointed and regulated by the OP1.

          If OP2 fails to comply the order within the stipulated period in that case proceeding shall be started against OP2 for non-compliance of the Forum’s order and OP2 shall have to pay penal interest @Rs.100/- per day till full satisfaction of the decree which shall be paid to this Forum. 

          At the same time OP1 is also equally responsible but OP1’s term will come if it would not be possible to satisfy the decree against OP2

          OPs1 and 2 are hereby directed to follow the order very strictly.