This is an application u/s.12 of the C.P. Act, 1986.
Complainant by filing this complaint has submitted that complainant purchased a mediclaim insurance policy from the OP in the month of March, 2000 and same has been renewed time to time without any gap for any year and every year new fresh policy number was given and document was accordingly handed over to the complainant after due renewal and in the policy the name of the complainant has been duly recorded as the insured person no.1 and name of his wife Chandrabati Sarkar is noted as insured no.2.
Complainant on payment of Rs.7,453/- as premium extended the said policy for the period from 30-03-2008 to midnight of 29-03-2009 which was for hospital benefit policy/mediclaim policy – 2007 and said policy number after renewal was 510500/34/07/11/00005708 from the previous policy number 510500/34/06/20/00001137 valid for the period 2007-2008 and the sum insured was Rs.50,000/- each along with applicable cumulative bonus.
All on a sudden, complainant suffered Retroprexy that is complete prolapsed of the rectum for the first time and he was hospitalized for the period from 14-01-2008 to 27-01-2008 at the Belle Vue Clinic, Kolkata and operation was held on 15-08-2008 by Dr. Sumanta Ghosh and for such treatment total amount of bill of Rs.1,56,863-32 was paid by the complainant because cashless facility was not allowed by the OP.
Thereafter, complainant lodged a claim of total amount of Rs.1,56,863-32 with the Medicare TPA Services Pvt. Ltd. after lapse of 1½ years as he was ailing and his wife was also ailing, for which it was not timely filed. Later on complainant came to know that his claim was rejected for want of documents for which he immediately lodged his claim along with all documents with TPA on 11-02-2011 but the said claim has not yet been entertained or repudiated.
In the meantime, while the said policy was still active and the same was renumbered after renewal as policy no.510500/34/08/11/00005351. For the period 2009-2010 the complainant suddenly fell unconscious for a sudden fall in Sodium and Potassium content in blood below normal limit. He was hospitalized for the period from 28-10-2009 to 08-11-2009 at the Belle Vue Clinic and bill was raised by the hospital was to the tune of Rs.66,747-42 and complainant immediately lodged his claim with TPA in December, 2009 being claim No.1209942 and the membership number of the complainant was 02100238344A but the said claim was unilaterally settled to the tune of Rs.50,939/- by the OP without citing any reason and said amount was paid to the complainant by cheque No.099222 dated 26-12-2009 and that was encashed. Thereafter, complainant raised grievance before the Chief Vigilance Office of the OP vide letter dated 15-02-2010, thereafter, made further representation on 29-03-2010 to The Ombudsman.
Subsequently, TPA issued a letter dated 19-05-2011 stating that claim for hospitalization for the period of October-November, 2009 has been settled at Rs.50,939/- and TPA sought information regarding processing of the complainant’s claim for hospitalization in January, 2008.
Further supporting document has been enclosed along with said letter but till now OPs have not decided the same though they are bound to release such claim and accordingly, lastly complainant through his Lawyer’s letter dated 22-03-2012 asked the OPs to settle the claim of the complainant without any further delay but OP did not pay any heed to that and the two claim has not yet been settled and for which for negligence and deficient manner of service complainant filed this complaint for releasing first claim amount of Rs.1,56,838-32 and Rs.15,808-42 the balance amount of the second claim and for compensation etc.
On the other hand, OP Insurance Company by filing written statement submitted that no doubt complainant has claimed that he was admitted at Belle Vue Clinic on 14-01-2008 and discharged on 27-01-2008 after treatment but subsequently after lapse of three years from the date of discharge, on 15-02-2011 complainant submitted some documents with the TPA and raised a claim of Rs.1,56,863-32 without submitting any claim form. Accordingly, TPA observing inordinate delay of said 3 years of lodging the claim, recommended the claim as ‘no claim’ under the purview of the scope of the Clause 11.0 of the terms and conditions of the policy and TPA settled the claim as -no claim- within the purview of that policy because as per policy condition the claim form along with all documents must be submitted not later than 30 days of the discharge from the hospital but there is no doubt a waiver clause – waiver of period of limitation may be considered in extreme cases of hardship where it is proved to the satisfaction of the company or TPA that under the circumstances in which the insured was placed it was not possible for him or her or any other person to give such notice or file claim within this prescribed time limit. But as per such condition complainant also did not file any such prayer for condonation of delay showing their sufficient cause for lodging the claim at such belated stage and in the above circumstances, the first claim of the complainant is not tenable in the eye of law.
Regarding second claim OP has submitted no doubt complainant submitted a claim that was decided on merit that claim was for Rs.66742-42 but actually OP paid Rs.50,939/- as per policy condition. Moreover, the total sum insured for each insured was Rs.50,000/- and, in fact, there was no deficiency, negligence or deceitful manner or act on the part of the OP and entire allegation is false and only to regularize the first time barred claim the complainant has filed this complaint for getting a relief by misrepresentation for which the complaint should be dismissed.
Decision with Reasons
On proper appreciation of the documents including the claim of the complainant and defence of the OP and also relying upon the arguments as advanced by the Ld. Lawyers of both the parties we have gathered that no doubt in respect of policy bearing No.510500/34/08/11/00005351 was valid from 30-03-2009 to 29-03-2010 and in respect of that policy complainant lodged second claim for hospitalization for the period from 28-10-2009 to 08-11-2009 and raised a total claim of Rs.66,742-42 on 29-11-2009 and admitted fact is that said claim was settled and disbursed settling amount finally a sum of Rs.50,939/- and that was paid to the complainant and complainant has encashed it but anyhow complainant’s claim is that balance amount of Rs.15,808-42 was not released illegally. In this regard we have gone through the clause of the mediclaim policy wherefrom it is found that complainant is entitled to one person of the sum insured without cumulative bonus in respect of room, boarding, nursing expenses as provide by the hospital or nursing home not exceeding 1.0 percent of the sum insured per day or actual whichever is less but in case of Intensive Care Unit/Intensive Cardiac Care Unit expenses not exceeding 2.0 percent of the sum insured per day, or actual, whichever is less and regarding medical pre-hospitalization medical charges up to 30 days period and post-hospitalization medical charges up to 60 days etc. shall be paid 25 percent of sum insured but Surgeon or Medical Consultant, Anaesthesist, Medical Practitioner, Consultants’ fee and other medical expenses related treatment shall be paid at the rate charge as payable in case of room boarding and nursing expenses provided by the hospital or the nursing home. So, considering that clause it is clear that complainant’s claim in respect of second claim shall not exceed the sum insured of Rs.50,000/-. But anyhow, complainant submitted a bill of Rs.66,742-42 and considering that fact it is clear that no doubt complainant used such room, boarding and nursing expenses in the Belle Vue Clinic which is excess than 1 percent of the sum insured for which it was deducted similarly Clause 2.1, 2.2, 2.3, 2.4 were applied and it was rightly deducted. So, the claim of the complainant in respect of the balance amount of second claim is completely uncalled for and without any foundation and deduction as made by the OP in this regard is quite correct and legal and that was done as per policy condition and as per rule the complainant cannot get any amount above the sum assured of Rs.50,000/- but even then OP gave some relaxation and allowed Rs.50,939/- so, we are convinced that in respect of the second claim complainant’s claim is illegal, uncalled for and without any foundation. Now, we shall have to consider the first claim which is in respect of Rs.1,56,863-32 for the policy No.510500/34/06/20/00001137 which was valid for the period 30-03-2007 to 29-03-2008 with sum assured value of Rs.50,000/- along with necessary cumulative bonus amounting to Rs.17,500/- subject to terms and condition of the policy. Truth is that the said claim was closed by the TPA as ‘no claim’ on the ground the said claim was submitted on 15-02-2011 whereas complainant was discharged at the relevant time from Belle Vue Clinic on 27-01-2008 whereas he was admitted on 14-01-2008 that means the complainant submitted his claim after lapse of three years from the date of his discharge for the first time and claim. Anyhow, it is evident that complainant did not file any application along with such application form for claim for condonation of delay along with such document for consideration of condonation of delay as per clause. Truth is that complainant has failed to produce any document before this forum to show that he submitted all these documents praying for condonation of delay etc and even after that OP did not consider it. But anyhow, OP has specifically mentioned that TPA Authority sent the letter for filing such document but that was not submitted for which the matter was closed.
Another factor is that that policy in respect of first claim sum assured was Ra.50,000/0 and cumulative bonus was Ra.17,500/- whereas complainant submitted a claim of Rs.1,56,863-32 but anyhow complainant is not entitled to get any such amount as claimed for first treatment because his sum assured is Rs.50,000/- moreover, other clauses of the mediclaim shall be considered.
In respect of this particular claim of the complainant we have gathered that provision of law i.e. the terms and conditions of the policy and even proper consideration of the same it is found that complainant filed that claim after lapse of three years from the date of discharge and date of discharge in respect of first claim from Belle Vue Clinic is 27-08-2009 but claim was submitted on 15-02-2011 without any proper form of claim application along with proper form of duly condonation of delay etc, and further some documents were not submitted. So, invariably and rightly OP closed that claim and there was no illegality on the part of the OPs.
Anyhow, from the written version of the OP we have gathered that OP has specifically mentioned that if complainant files any such documents showing sufficient reason for such inordinate delay the OP may leave necessary evidence in this regard for which the leave may be granted. Considering that fact we find that complainant may file a fresh application form for claiming his claim in respect of first treatment along with condonation of delay etc. to the OP Authority and must be filed within one month from the date of this order and thereafter, it shall be considered by the OP invariably as per terms and conditions of the policy and if OP is satisfied that delay may be condoned in that case OP shall have to consider his prayer for first claim but invariably it must not exceed the sum insured of Rs.50,000/- and including bonus etc. but noway the Forum is creating any pressure upon the OP to release the amount but everything shall be decided by the OP as per terms and conditions of the policy and about inordinate delay of three years in filing the claim but invariably complainant shall have to file such fresh application form along with supporting documents and also such documents in support of condonation of delay to the OP authority within one month from the date of this order otherwise the previous order of no claim as passed by the OP shall be final.
Hence,
Ordered
That the case be and the same is allowed in part on contest against all the OPs but without any cost.
In respect of the 2nd claim complainant is not entitled to any relief as per findings of the judgment as already ventilated in the body of the judgment.
In respect of the first claim complainant shall have to follow the direction of this Forum within one month and if it is filed OP shall have to consider as per terms and condition and legal aspect to the policy but if it is not filed within one month by the complainant in that case the order of the OP regarding closure of that claim already shall be the final.
