JUDGEMENT

          Complainant Smt. Sanjukta Das by filing this complaint has submitted that complainant and her husband Sri Sourav Das, Smt. Pratima Dutta and Saptarshi Das are joint mediclaim policy holders under the op Nos. 1 & 2 Insurance Company and they paid last premium on 22.10.2013 – 2014 for a sum of Rs. 28,921/- by A/C Payee Cheque bearing No. 614306 from the Bank of India, Amherst Street Branch against policy receipt issued by the op no.1 and policy was valid for the period 2013-2014.

          On 07.07.2014 all on a sudden complainant felt pain in her brain and fell on the ground floor of her resident and for which she was admitted with the assistance of the people of contiguous residence at Diagnostics Centre Institute of Neuro Sciences at 185/1, A.J.C. Bose Road, Kolkata – 700017 for her treatment on the same day.  During continuation of the treatment of the complainant in the said Centre, complainant’s husband contracted with the deputed agent of the op no.1 Mr. Ranjit Dey bearing his Code No. ID10770406 for payment of Medi Claim benefits to the said Diagnostics Centre.

          The authority of Institute of Neuro Sciences contracted on 08.07.2014 with the op no.3 for cashless claim of the complainant while she was admitted but the op no.3 rejected the claim benefits of the complainant on the grounds stated therein that mental disorder is not covered by the Medi Claim benefits and thus the complainant is not entitled to get claim benefits.

          It is specifically mentioned by the complainant that complainant is not a patient of mental disorder at all, but she was admitted on 07.07.2014 and discharged on 09.07.2014 from the said Diagnostics Centre and at the time of discharge from the said Centre, the authority of the said Centre handed over a Final Bill to the to the tune of Rs. 37,582/- and Rs. 1,700/- for test of C.T. Scan of Brain i.e. totaling of Rs. 39,372/- to the husband of the complainant and her husband paid the entire amount of bill to the said Centre against proper money receipt, although the complainant is entitled to get benefits of Medi claim as complainant paid the premium up to October – 2014.

          Further case of the complainant is that Mediclaim Policy was made from the op no.1 when complainant was physically and mentally sound lady and after proper scrutiny, Mediclaim policy was issued by the op authority and truth is that any person may suffer from any disease at any time.  Nobody can say when any type of disease can attack to any person.  But in the present case the disease was detected after treatment that it was panic disorder of the complainant for the first time in July-2014 and it was never earlier detected and it was not mental disorder.  But the complainant on several time requested the op no.1 for mediclaim benefits but op did not pay any heed and for which the matter was placed before the Ombudsman Authority.  But they decided that they have no jurisdiction to adjudicate the mediclaim of the complainant and for such sort of negligence and deficient manner of service, arbitrary decision of the op, complainant has suffered much and for which this complaint is filed for redressal.

          On the other hand op nos. 1 & 2 by filing written statement submitted that it was a Mediclaim Policy of 2012 and as per Clause 5.3 Cashless facility is only a mode of claim payment and cannot be demanded claim at any time and if TPA have doubts regarding admissibility of a claim at the final stage which cannot be dedcided without further verification of treatment records, request for Cashless facility may be declined and such decision by TPA or the ops shall be final and denial of Cashless facility would not imply denial of claim and if Cashless facility is denied in that case the claimant may submit the papers on completion of treatment and admissibility of the claim would be subject to the terms, conditions and exceptions of the policy.

          As per Clause 4.4.6.1 Convalescence, general debility, Run down condition or rest cure, obesity treatment and its complications, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, venereal disease, intentional self injury and illness or injury caused by the use of intoxicating drugs/alcohol, no claim would be payable under this policy what are excluded under this policy.

          But fact remains that after denial of Cashless benefit, complainant ought to have submitted the claim form for reimbursement after discharge from the hospital which was not done in this case and complaint does not stand as it is premature in nature and should be dismissed on the ground that no claim was submitted by the complainant.  In the above circumstances, there was no negligence and deficiency on the part of the op for which the present complaint should be dismissed.

                                                      Decision with reasons

          On proper consideration of the complaint and written version and also considering the materials on record, it is found that no doubt the complainant is a mediclaim policy holder and fact remains she was admitted to Hospital of Neuro Science in Kolkata on 07.07.2014 and was discharged on 09.07.2014 and from the discharge certificate, it is found that she had no neuro deficit and her neuroimaging has normal.  But suddenly the panic disorder was detected.  But it is admitted fact that complainant prayed for Cashless benefit and that was rejected on the ground that complainant has been suffering from mental disorder.

          At the same time it is fact that after rejection of Cashless benefit, complainant did not file any final claim for her treatment cost which has been paid by the complainant’s husband to the Institute of Neurosciences Kolkata for the treatment period from 07.07.2014 ton 09.07.2014.

          So, considering that fact, it is clear that for rejection of Cashless benefit, practically no cause of action arose because it was not repudiation of the claim.  Practically final claim was not submitted by the complainant.  So, apparently we find that complainant failed to ventilate her grievance before the op authority for release of her claim and without claim application, complainant cannot file any claim before this Forum.  But in this regard after hearing the Ld. Lawyers of both the parties and after scrutiny of the documents, materials we have gathered that the rejection of Cashless benefit on the ground of mental disorder is completely in arbitrary nature and the lady has not been suffering from any mental disorder because from the discharge certificate, it is found that she had no Neuro deficit and her neuroimaging effect is normal.

          So, considering that fact, we find that the rejection of Cashless benefit by the op may be their decision.  But rejection on the ground of Mental disorder is found completely bad and uncalled for and after thorough study of the said discharge certificate, we are confirmed that the lady has not been suffering from any mental disorder prior to her admission and panic disorder is a problem which is sudden in nature and this lady is aged about 30 years. 

          So, we find that complainant shall have to submit his final claim to the op along with all documents for settlement her claim by the ops and on receipt of the said claim by the ops from the complainant, ops shall decide on proper way but not in any case op shall have not to reject on the ground of mental disorder because we are confirmed that complainant has not been suffering from any mental disorder.

          Accordingly the complaint succeeds in part and we are passing such necessary order to give a chance to the complainant for filing his mediclaim in respect of treatment cost for the period from 07.07.2014 to 09.07.2014 and op on receipt of the same shall have to dispose of the claim of the complainant forthwith and in any case op shall not have to reject on the ground of limitation because we are condoning the limitation in all respect and accordingly this complaint succeeds in part.

          Hence, it is

                                                           ORDERED

          That the complaint be and the same is allowed on contest against the op with a cost of Rs. 500/-.

          Ops are directed to dispose of the mediclaim of the complainant on receipt of the proper claim application form along with all documents as per their requirement and complainant shall have to submit the same a fresh and thereafter op shall have to dispose the claim of the complainant.  But keeping in their mind that the said claim application on the ground barred by limitation or on the ground of so called mental disorder same shall not be repudiated.

          On receipt of the claim application along with required documents, ops shall have to decide the same within 45 days from the date of receipt of the claim application form from the complainant and if it is not decided by the ops, after receipt claim application form along with documents within the stipulated period of time, in that case op shall have to pay a sum of Rs. 35,000/- to the complainant and accordingly this claim of the complainant shall be settled finally and in all cases the payment must be made within 7 days after expiry of the stipulated 45 days as per this order.

          If op fails to comply the order, in that case op shall be imposed penalty and fine etc. for any sort of violation of the Forum’s order.  Complainant is directed to comply the spirit of this order and submit such claim application form at once to the office of the op on proper receipt.