JUDGEMENT

          Complainant by filing this complaint has submitted that complainants are senior citizen and complainant no. 1 took a Medi-claim policy in the year 2003-04 and the same was continuing for more than 10 years i.e. till 2012-13 for self and his wife and the said policy was renewed as comprehensive policy titled as Hospitalisation Benefit Policy from National Insurance Company Ltd., the op no.2 for the year 2011-12 being Policy No. 100600/48/11/8500004334 dated 11.08.2011 which was valid till midnight of 10.08.2012 and at the time of purchasing and renewing the said policy, complainant paid Rs.29,095/- on 09.08.2011 covering the risk both the complainants in respect of the said Medi-claim Policy.  Prior to that complainants never made any claim in respect of such Medi-claim policy but one Mr. Sanjoy Kr. Das authorized agent of the op nos. 1 & 2 approached the complainants about four/five years back for renewal or transfer the Medi-claim Policy from New India Assurance Company Ltd. to National Insurance Company Ltd., op no.1.  Pursuant to such request of Mr. S.K. Das, authorized agent of op nos. 1 & 2, the complainants shifted or renewed their Medi-claim policy from New Indian Assurance Co. Ltd. to National Insurance Co. Ltd. the op no.1 as continuation of previous policies being the op no.2.

          During validity of the said insurance policy the complainant no.2 was admitted in a Government Hospital, AIIMS, New Delhi in its Eye Block for Cataract Surgery on 02.03.2012 and it was discharged from the hospital on 06.03.2012 and at the time of admission in the hospital the complainant no.1 paid Rs.6,000/- in cash which was refundable and adjustable at the time of final payment.  Thereafter at the time of discharge of the complainant No.2 the hospital authority gave a final bill for about of Rs. 17,536/- and other expenses incurred by the complainants totaling Rs. 25,000/- and at the time of settling the final bill the receipt of advance amount of Rs.6,000/- was taken back by the hospital authority for payment.  After payment of the final bill the complainant no.2 was discharged.

          Complainant no.1 intimated the agent of op no.1 about such admission and also intimated the Insurance Company.  Complainant Nos. 1 & 2 made a claim for the said amount of Rs.25,000/-, however the insurance company op no.1 sent the bill to their TPA agency, Heritage Health TPA Pvt. Ltd. the op no.3.  Accordingly the said TPA Agency accepted the said claim as Claim No. HH11214096 and the said TPA Agency in the name of settling the claim asked the complainant to file original documents and the bills, money receipt of Rs.6,000/- from the hospital but that cannot be produced as required by the said TPA Agency.  In view of the fact the original money receipt of Rs. 6,000/- was returned to the hospital authorities for settling the final bill as the credit of Rs. 6,000/- was given only on receipt of the original receipt back to the hospital accounts section at the time of settling the final bill that was reported by the complainant.  Even after that matter has not yet been disposed of and ultimately for not settling the complainants’ claim without any cogent reason and for negligent and deficient manner of service, complainant has filed this case and for directing the op to pay Rs.25,000/- against the op.

          On the other hand TPA by filing written statement submitted that no doubt the complainants had their valid insurance policy with sum insured Rs. 3,75,500/- and cumulative bonus for Rs. 56,250/- for himself and his wife each valid from 11.08.2011 to 10.08.2012 and no doubt Mrs Reba Roy Choudhyri had been admitted to Dr. Rajendra Prasad Centre for Ophthalmic Sciences on 02.03.2012 diagnosed with Cataract and after treatment she was discharged and expenses incurred for Rs. 17,914/- on 21.03.2012.  But TPA sent query letters on 21.04.2012 to the insured asking for the original money receipt of Rs. 6,000/- which was no submitted by the insured.  So, the claim was closed at their end due to non-submission of query reply on 02.05.2012 and op no.2 had nothing to do and they have their no defective and complainant ought to have moved to Insurance Company.

          NIC appeared in this case by filing power through their Ld. Lawyer on 07.02.2014 and they submitted a joint written version on 04.03.2014 and in that written statement they have also stated that for non-submission of original bill of Rs.6,000/- TPA held the same and it was closed and they have prayed for that they have their no negligence but for non-submission of the original bill the matter could not be settled and was closed and prayed for dismissal of this case.

                                                           Decision with reasons

          On proper assessment of the complaint and written version including the documents and also the argument as advanced by the Ld. Lawyers of both the parties including the letter dated 20.12.2012 sent by National Insurance Company to the complainant’s lawyer it is found that TPA was authorized to settle the claim and TPA asked the complainant to file the original bill of advance payment of Rs. 6,000/- and no doubt complainant failed to produce it because it is explained by the complainant that original receipt of advance payment of Rs. 6,000/- has been deposited to the hospital authority at the time of final settlement of final bill of the treatment cost.

          But admitted fact is that AIIMS authority issued final bill and no doubt AIIMS is not a private company and from the bill for hospitalization charge issued by Dr. Rajendra Prasad Centre for Ophthalmic Sciences, it is clear that advance payment was received by the hospital authority vide Bill No.2917/RPC/11-12 and that was adjusted by the Hospital Authority that is noted and that original bill was submitted to TPA and TPA received it on 17.03.2012.  Further complainants submitted another bill of Rs.1,400/- only dated 06.03.2012 of Rs.7,400/- dated 06.03.2012 and Rs. 9,387/- dated 03.03.2012 issued by Dr. Rajendra Prasad, Centre for Ophthalmic Sciences and all the original bills were received from the TPA.  But we have failed to understand for what reason the TPA did not satisfy the claim when about advance payment of Rs. 6,000/- is noted by the Hospital Authority in their bill dated 08.03.2012 and received which isnoted there.

          So, considering all the above fact and circumstances, we find that TPA ought to have been disposed of the matter without any doubt and in view of the fact that Hospital Authority itself has mentioned in their final bill about receipt of Rs. 6,000/- vide Receipt No. 78604 dated 02.03.2012 and no doubt the total bill had been provided Rs. 18,187/- is well proved.  But truth is that except those bills some other bills for purchasing medicines etc were also received by the TPA in original and total bill of medicines purchased a bill of Rs. 19,804/- was filed by the complainant and in respect of that practically TPA had no grievance.  Only due to non-submission of original bill in respect of advance payment of Rs. 6,000/-, there was problem and there was claim of the op to file the same no doubt it was not possible to file because it was deposited at the time of final settlement of the bill.  No doubt from the letter of the op no.2 dated 28.05.2012 it is found that claim was submitted by the complainant and it was registered as claim No. HH11214096 against that policy.

          But fact remains only for want of original receipt in respect of advance payment of Rs. 6,000/- the matter could not be decided.  But it is unfortunate to say if actually when complainant failed to produce that receipt in that case after deducting of Rs. 6,000/- balance amount can easily been released by the TPA when the bill was not issued by any private nursing home.  But it is issued by the Eye Department of AIIMS, Delhi, it is the Government institution.  Anyhow TPA is very much guided by their rules and regulations and they are always imposing strict rules in respect of settlement of the claim and if we agree that claim was not settled due to non-receipt of original bill in that case TPA ought to have released the balance amount out of the claim.  But without doing that no doubt TPA has not done any moral or social service in view of the fact that claim is not such a prayer by which the complainants are running any commercial benefit.

          In the light of the above observation and also considering the entire fact , it is found that deficiency and negligence was partly there on the part of the op/Insurance Company because social responsibility on the part of the op no.2 was not observed.  Anyhow after considering the receipt, it is found that complainant tried to  prove by producing their receipt that they have paid Rs. 20,000/- for their treatment and no doubt no other bill is submitted by the complainant.  Further complainant has claimed a sum of Rs.25,000/-.  But considering the material documents it is found that complainant is entitled to Rs. 20,000/- as final settlement of his mediclaim being No. HH11214096 and considering the total act of the TPA, we are annoyed whether TPA is here and there only for the purpose of cancelling the claim of the insured where honest insured is entitled the admissible claim as per law.

          Another question is cropped up in our mind whether TPA is appointed by the insurance company for rejection of the claim.  Is there any moral, social responsibility of TPA in this regard?   Keeping all those matters into our mind we find that TPA should release the amount what are admissible in the eye of law even of total claim of the complainant may not be justified.  In the light of the above observation we are allowing this claim of the complainant with cost and some compensation is awarded in this case and accordingly complaint succeeds considering TPAs uncalled for and immoral attitude not to release the admissible amount of the mediclaim policy holder.

          Hence, it is

                                                              ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs.10,000/- against the ops.

          Op/insurance company is hereby directed to pay a sum of Rs. 20,000/- as final settlement of the medi-claim of the complainant in the particular case in respect of complainants’ medi-claim policy No. HH11214096 and op no.1 is hereby directed to pay the said amount of Rs. 20,000/- along with compensation Rs. 5,000/- i.e. total Rs. 25,000/- within one month along with litigation cost from the date of this order without any further delay and if required op to handover the cheque on proper receipt and if it is found that op/insurance company is reluctant to comply the order of this Forum in that case op no.1 shall be further imposed penalty for violating of Forum’s order.

          For adopting unfair trade practice by the op no.2 TPA, op no.2 is imposed a penalty of Rs. 5,000/- and it is imposed only to check the dogmatic attitude of the TPA in business of mediclaim of the insured in so many cases and that amount shall be deposited to this Forum’s account by the op no.2.

          Op nos. 1 & 2 are hereby directed to comply the order as per spirit of the judgement within one month from the date of this order and for repeated non-compliance of the Forum’s order and for disobeyance of Forum’s order penal interest @ Rs. 100/- per day shall be assessed against each of the ops and even penal proceedings u/s 27 of C.P. Act 1986 shall be started against them.