FINAL ORDER/JUDGMENT   

SMT. SUKLA SENGUPTA, PRESIDENT

The fact of the case in brief is that the complainant has filed this petition of complaint  U/s 35 of the CP Act,   2019.

            The fact of the case in brief is that one mediclaim policy being No. 100800501910000966 was purchased by the complainant from the OP National Insurance Company Ltd.  for the period on and from  14.07.2019 till 19.07.2020. The sum assured was amounting to Rs. 5,00,000/- and  customer Id No. 9512600695.

The complainant further stated that she was admitted at Colombia Asia Hospital one B 193,  Sector -III,  Salt Lake City, Kolkata-7000106 on  14.11.2019 for recurrent episode of post-menopausal bleeding. She was diagnosed for hysterectomy and was operated for both tube and ovaries and closant saction evaluation and lymthademecpomy and ompantectomy on  15.11.2019. Other steps based on frozen section biopsy. Thereafter, the complainant was discharged from aforementioned hospital on  20.11.2019 and total cost for the said operation including other expenses  as raised by the Colombia Asia Hospital as was of Rs. 2,97,461/- only and the complainant paid the entire amount.

The complainant further stated that he prior to take admission in the hospital and operation as mentioned above. She intimated the matter to the OP insurance company over telephone and vide letter dated  13.11.2019.

Thereafter, the complainant submitted her claim along with all medical papers and bills issued by the Colombia Asia Hospital to the office of the OP situated at 32A, Chittranajan Avenue, Janabazar, Taltala, Kolkata-700072.

 It is further stated by the complainant in her petition of complaint that on  14.01.2020 the OP-1 the Deputy General Manager, has allowed Rs.,  85,000/- vide email out of the total claim amounting to Rs. 2,97,458/-. The rest amount is Rs. 2,12,458/- of the hospital expenses mentioned in the Schedule B of the petition of complaint was disallowed by the OP insurance company on the alleged ground of  “reasonable and customaries”.

 It is further alleged by the complainant that she had tried to explain that the mentioned expenses does not fall within “reasonable and customarily expenses” as alleged by the OP and those expenses are under the coverage of  the insurance for reimbursement in terms of the clause 2.1.1 as well as 2.1.1.1. The complainant sent a letter explaining the entire matter addressing the Deputy General Manger of the OP-1, who did not reply the said letter thereafter, the complainant  sent email to the OP-2 and requested to pay the remaining medical expenses amounting to Rs. 2,12,458/-  but the OP-2 sent an email in reply with sterio type version.

The complainant tried to make understand the OP on several occasion but in vain which compelled the complainant to file this case against the OPs 1 and 2 with a prayer to give direction to the OP-1 and 2 to reimburse  the remaining  medical expense of Rs. 2,12,458/- to the complainant as paid by her as mentioned  in the schedule B of the petition of complainant.

The complainant  further prayed for giving  to  giving  direction to pay compensation of Rs.  1,00,000/- to her for deficiency   in service ,  negligence and  mental pain and agony along  with litigation cost of Rs. 50,000/- along with interest @12 % p.a. on the amounting to Rs.  1,88,158/-.

The OP-1 has filed the WV by denying all the material allegation leveled against it.

The OP-2 did not appear in this case in spite of getting the notice, hence, the case do run ex parte against the OP-2 vide order dated 15.02.2022.

The OP-1 in its WV has alleged that the petition of complaint as filed by the complainant harassing, malafide and baseless one. The Petition U/S 35 of the CP Act, 2019 as filed by the complainant is entirely misleading and suppression of material facts.  The complainant has filed the petition of complaint with ulterior motive.

Admittedly the complainant took a National Mediclaim Policy being No. 100800501910000966 for the period from 00.00 hrs. of 14.07.2019 up to midnight of 13.07.2020 for the sum assured Rs.5,00,000/- only for which total amount of premium paid of Rs.25,936/- as per collected receipt dated 09.07.2019 and terms and conditions of the National Insurance Plus policy and medical reimbursement paid to the complainant / insured as definition of Reasonable and Customized Charges and Preferred Provider Network (PPN) of the National Medicalim Policy (Annexure-A).

It is also admitted fact that the complainant was filed a claim intimation on 21.11.2019 to the Authorized ‘TPA’ wherein facts revels that the complainant admitted at Colombia Asia Hospital, Kolkata on 14.11.2019 for “Post-Menopausal Bleeding” under consultant Dr. Manas Chakraborty and was discharged on 20.11.2019. Thereafter on a close scrutiny of the medical bills submitted by the complainant it is the found  that the claim of the complainant has been calculated by the TPA dated 23.12.2019 amounting to Rs.85,000/- only as per PPN rate and sent a letter for claim settlement-cum-discharge Voucher (D.V) to the complainant on 01.03.2020 wherein amount paid of Rs.85,000/- against policy No. 100800/50/191/190000966 and it is the further mentioned in the said letter that “Please quote your CID/SMS/ID number mentioned above for any future correspondence” (Annexure-B).

The OP further stated that the complainant has no cause of action to file this case against the OPs as there was no deficiency in service on the part so the complainant is not entitled to get any compensation from the OPs rather. Thus the petition of complaint is liable to be dismissed.

In view of the above stated facts and circumstances, the points of consideration are as follows:-

1. Is the case maintainable within the ambit of law?

2. Is complainant a consumer within the ambit of CP Act, 2019?

3. Has the complainant any cause of action to file this case?

4. Is there any deficiency in service on the part of the OPs?

5. Is the complainant entitled to get relief as prayed for?

Decision with reasons

All the points of considerations are taken up together for convenience of discussions and to avoid unnecessary repetition.

From the facts and circumstances of this case as well as from the position of law, it is revealed that the case is well maintainable in the eye of law.

From the admitted position as stated  by the contesting OP-1 National Insurance Company  Ltd.  in its WV that the complainant has purchased the questioned national mediclaim policy being No. 100800501910000966 for the period on and from  14.07.2019 up  to the midnight of 13.07.2020 for the sum assured of Rs. 5,00,000/- on payment of  required premium amounting to Rs. 25,936/- as per collection receipt dated 09.07.2019 on  the basis of terms and conditions of (National Insurance + Policy ) and mediclaim reimbursement to the complainant /insured as it is available in annexure-A.

From which,  it is palpably clear that the complainant has been continuing the mediclaim policy in question since  1999 as purchased from  of the OP-1 on payment of premium,  it was renewed from time to time till 13.07.2013. From which  it is held by this commission that a  complainant is a consumer and the OPs  are the service providers  within the ambit of CP Act 2019.

Now Let us see whether,  there is /was any sort of deficiency  in service on the part of the OPs.

 In this regard,  the respective case of the complainant is that she was prescribed  and advised for recurrent episode of post menopausal bleeding and she was admitted at Colombia Asia Hospital, Kolkata at Saltlake, Kolkata on  14.11.2019 as per advise of the attending doctor. where  she was diagnosed and operated  on  15.11.2019 for hysterectomy  and removal of both tubes and ovaries and frogent section evaluation and lynthademectomy and omentectomy and other steps based on frogent section biopsy. This matter of her admission in Colombia Asia hospital was intimated to the OP Insurance Company over telephone as well as vide letter dated 13.11.2019.

It is also evident from the evidence on record that the complainant was discharged from the hospital on 20.11.2019 and the total hospital charge including cost of operation was of Rs.2,97,461/- only and the husband of the complainant has paid the entire amount.

Thereafter, the complainant placed the claim to the OP Insurance Company along with  all the required  medical papers on 14.01.2020 amounting to Rs.2,97,458/- as paid by her/her  husband for reimbursement. But it is alleged that the OP insurance co. only allowed Rs.85,000/- out of the total amount of Rs.2,97,458/- on the “reasonable and customary” ground. In this regard, I have carefully gone through the terms and conditions of the policy and found that as per Policy condition 2.1.1 the entire amount of hospital expenses as placed by the complainant of Rs.2,97,461/- is payable to the complainant by the OP Insurance Co. because the entire hospital charge is / was under the policy in question but the OP insurance Co. deliberately deducted the amount of Rs.2,12,458/- out of Rs.2,97,458/- the total claim and only allowed Rs.85,000/- which they cannot. It is well settled principal of law that both the parties are bound by the terms and condition of the insurance policy. In the instant case both the complainant and the OP National Insurance Co. Ltd. are bound by the terms and condition of the policy in question and as per clause 2.1 and 2.1.1 of the policy in question it is reflected that the complainant is entitled to get the entire claim amount of Rs.297,458/- out of which the OP insurance Co. only paid Rs.85,000/- to the complainant but as per terms and condition of the policy in question the OPs are  bound to pay the rest amount of the claim amounting to Rs.2,12,458/- to the complainant as described in the schedule-B of the petition of complaint.

In view of the discussions made above, it is crystal clear that the complainant being a consumer could be able to prove his case beyond all reasonable doubts against the OP service providers. But the OP service providers on getting the prayer of claim of Rs.2,97,458/- deliberately deducted a sum of Rs.2,12,458/- from the claim of Rs.2,97,458/- and paid a sum of Rs.85,000/- only.  The complainant on several occasion requested the OP Insurance Co to reconsider the matter and to consider the same favourably to the complainant by paying the rest amount of medical expenses in question but the OPs/service provider did not lent their ear to the appeal of the complainant and neglected her prayer which caused harassment mental pain and agony to the complainant. Such conduct of the OP service provider proved that there was deficiency in service on the part of the OPs as service provider and they are bound to pay compensation  to the complainant for their deficiency.

On the basis of above made thread bare discussion, it is held by this Commission that the complainant has / had sufficient cause of action to file this case and the complainant a being consumer could be able to prove her case against the OPs beyond  all reasonable doubt. The OPs have refused the claim of the complainant and compelled her to come before this Commission for getting relief which is also tantamount to deficiency in service on the part of the OPs.

Thus, the complainant is entitled to get the relief as prayed for. 

All the points of consideration are considered and decided in favour of the complainant.

The case is properly stamped.

Hence,

Ordered

that the case be and the same is decreed on contest against the OP-1 National Insurance Co. Ltd. and ex parte against the OP-2 with cost of Rs. 5,000/-.

The complainant do get the decree as prayed for.

The OPs-1 and 2 are directed to pay the balance amount of the claim amounting to Rs.2,12,458/- to the complainant as mentioned in the Schedule-B of  the petition of complaint either jointly or severally within 45 days from this date of order.

The OPs are further directed to pay compensation to the complainant of a sum of Rs. 30,000/- for harassment, mental pain and agony along with litigation cost of Rs.15,000/- within 45 days from this date of order either  jointly or severally, i/d the complainant will be at liberty to execute the decree as per law.  

Copy of the judgment be uploaded forthwith on the website of the Commission for perusal.