Complainant by filing this complainant has submitted that he is regularly paid premium against Medi-Claim Policy of NIC Ltd. and his previous Policy is No.100301/48/11/8500003484 and present Policy No.100301/48/12/8500003794.  It is his further case that his mother was hospitalized on different dates and on different occasions at Hindusthan Health Point Nursing Home, the listed nursing home of the TPA and as and when the bill was sent by the said hospital, every time op denied cashless facility and refused without showing the reasons for rejection for cashless benefits and his claim is that his first claim for Rs.18,856/- was settled and deposited to his Bank, but actual claim was not settled and subsequently his father was also treated for fracture of pelvic ramie region and in support of that also Nursing Home Authority informed the TPA but said claim was also denied and in fact the op has denied the claim on three occasions though all bills were submitted by him time to time along with necessary papers and he also sent letters to ops for release of the said claim but that was turned down what tantamounts to unfair trade practice of the ops, complainant has prayed for redressal.

          In the present case, practically op no.2 TPA by filing written statement submitted that regarding admission of the patient from 09.06.2012 to 17.06.2012 at Hindusthan Health Point Nursing Home was received by the op on 09.06.2012 and claim was of Rs.28,499/- which was submitted on 10.07.2012 and admissible portion of the claim for Rs.18,856/- as per terms and conditions of the policy was settled and allowed on 14.10.2012.

          Further intimation along with treatment document was received from the policy holder regarding hospitalization dated 16.08.2012 showing the date of admission on 06.07.2012 which was after 45 days from the date of admission and date of discharge from the Hospital and in that case patient was treated for Perianal abscess with bed shore from 06.07.2012 to 18.07.2012 at Hindusthan Health Point and the total treatment cost as per claim bill was Rs.93,111/- which was submitted on 16.08.2012.

          But inspite of that complainant was asked to file cause for delay for submission but complainant did not answer, so the said claim was closed.  Further it is submitted that the TPA considered all the aspect and decided and release portion of the claim but in respect of the subsequent claim, complainant did not file any document as required by the TPA for which the claim was closed.

          But anyhow op Insurance Co. has not appeared in this case and for which the case is heard accordingly.

                                                 Decision with reasons

          Practically in the present complaint, complainant has prayed for relief in respect of his mediclaim policy and also compensation to the extent of Rs.19 lakhs and more.  But after considering the insurance policy it is found that the said policy covers the mediclaim risk of Kaushik Roy (self), Amita Roy (mother), Uma Roy (sister) and Asit Kr. Roy (father) and in each case sum assured is Rs.75,000/- each except in case of Uma Roy Rs.50,000/- along with bonus amount Rs.26,250/- in case of Kaushik Roy and Amita Roy but in case of Uma Roy Rs.17,500/- and in respect of Asit Kr. Roy Rs.18,750/-.  So, it is clear that in respect of claim, complainant is entitled to only Rs.75,000/- for Amita Roy minus bonus amount.  But anyhow it is found that complainant claimed Rs.93,111/- on 16.08.2012 and no doubt that claim was received by the op TPA.  Thereafter that complainant was asked to file some documents in respect of queries but that was not filed and lastly final reminder was sent on 15.11.2012 but that was not answered and after considering the said reminder by Heritage Health Pvt Ltd it is found that complainant failed to give any paper for condo nation of delay with sufficient document and for which the claim was rejected.  But earlier claim was in respect of Rs.28,499/- submitted on 10.07.2012 was settled and a sum of Rs.28,856/- was released and complainant received it.

          No doubt in this case it is to be mentioned that it is the duty of the complainant to give such clarification for delay in filing 2^nd claim but that was not done.  Might be for some reasons otherwise it was not possible to submit the 2^nd claim of Rs.93,111/- within time but that cannot be justified reason to close the said settlement of claim.

          No doubt we are confirmed that complainant did not file any reminder for condolation of delay in submitting the 2^nd claim in time and that is no doubt fault on the part of the complainant.  But question is how such a complainant can make such allegations against the op that op acted illegally.  Because it is a contract in between the two parties and both parties shall be guided by the terms and conditions of the contract (Mediclaim).  So, we are sure that the complainant adopted an arrogant attitude and did not file prayer for condolation of delay which is against for settlement of claim and fact remains op TPA repeatedly sent reminders to the complainant and complainant received it but did not file and that was caused for closing the 2^nd settlement of claim.

          Anyhow we have gathered the sum assured is Rs.75,000/- out of that Rs.18,856/- was paid on 14.12.2012 in respect of the treatment of her mother from 09.06.2012 to 17.06.2012 but actual claim was Rs.28,499/- and policy period from 24.12.2011 to 23.12.2012 and 2^nd claim was for the treatment of her mother for Rs.93,111/- which was submitted on 16.08.2012.  But that claim was closed for non submission of such documents with prayer for condolation of delay of 45 days (discharge from hospital on 18.07.2012 or date of admission on 06.07.2012).

          Anyhow we have gathered after considering the insurance policy being Policy No.100301/48/11/8500003484/100301 that total sum assured was Rs.75,000/- but Rs.18,856/- has already been paid.  Then balance sum assured may be released in favour of the complainant and it is found that balance insured amount of Rs.56,144/- may be released in favour of the complainant in respect of the 2^nd claim of Rs.93,111/- and under any circumstances complainant is not entitled to more than sum assured of Rs.75,000/- within the valid period of the policy (valid period from 28.12.2011 to 23.12.2012) and fact remains that complainant did not at all realize the terms of contract and also the total sum assured and so due to wrong conception of the complainant, complainant wrote a letter at various places being dissatisfied.  But we have gathered that the complainant made special allegations against the ops but truth is that complainant did not comply the terms and conditions of the policy and before bringing any allegations against the ops, complainant must have to show that he has complied the requirement of the ops as per contract and no doubt op TPA repeatedly sent letters and reminders for submitting such document along with prayer for condolation of delay that was not done and such sort of act on the part of the complainant as consumer is not at all appreciated by this Forum.  And we are sure if such reminders of the op would be properly faced by the complainant in that case invariably complainant shall have to get some other benefit but without adopting the said path complainant only for purpose of getting compensation filed this complaint bringing some uncalled for allegations against the ops.

          In the light of the above observation and considering the whole situation, we are directing the op insurance company to release a sum of Rs.60,000/- in favour of the complainant after treating both the claims dated 10.07.2012 and 16.08.2012 by which complainant claimed Rs.28,499/- and Rs.93,111/- are finally settled.

          Accordingly, the complaint succeeds in part.

          Hence, it is

                                                       ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs.2,000/- against op no.1 but same is dismissed against op no.2 but without any cost.

          Op no.1 is hereby directed to pay a sum of Rs.60,000/- positively within the one month from the date of this order treating the claim No. HH111307812 submitted on 10.07.2012 and claim No.HH111305330 submitted on 16.08.2012 as finally settled and closed.

          No compensation further is awarded in view of the fact, negligent and deficient manner of service on the part of the op is not at all proved.

          In the above consequences, op is directed to comply the order within the one month from the date of this order failing which for each day’s delay op shall have to pay a sum of Rs.200/- as punitive damages to the State Consumer Welfare Fund till full satisfaction of the present decree and even if it is found that op no.1 is unwilling to comply the order in that case penal measure shall be taken against them for which they shall be liable.