Consumer Complaint No. 188 of 2016
Date of filing: 24.10.20167 Date of disposal: 21.4.2017
Complainant: Smt. Mithu Mukherjee, W/o. Champak Mukherjee, resident of Bardhaman Housing, Flat No. G+3D, Muchipara, G. T. Road (Beside Petrol Pump), PO: Sripally, PS. & District: Burdwan, PIN – 713 103.
-V E R S U S-
Opposite Party: 1. New India Assurance Co. Ltd., represented by its Branch Manager, having its office at R. G. Bhavan, 1st Floor, Parbirhata, G. T. Road, PO: Sripally, PS. & District: Burdwan, PIN – 713 103.
2. Medicare TPA Services (I) Pvt. Ltd., represented by its Manager, having its office at 6B, Bishop Lefroy Road, Kolkata – 700 020.
Present: Hon’ble President: Sri Asoke Kumar Mandal.
Hon’ble Member: Smt. Silpi Majumder.
Hon’ble Member: Sri Pankaj Kumar Sinha.
Appeared for the Complainant: Ld. Advocate, Suvro Chakraborty.
Appeared for the Opposite Party No. 1: Ld. Advocate, Shyamal kumar Ganguli.
Appeared for the Opposite Party No. 2: None
J U D G E M E N T
This complaint is filed by the Complainant u/S. 12 of the Consumer Protection Act, 1986 alleging deficiency in service as well as unfair trade practice against the OPs as the OPs did not pay the entire amount towards insurance claim as they have settled the claim in part and repudiate the balance amount of the claim arbitrarily, illegally and whimsically.
The brief fact of the case of the Complainant is that she along with her husband obtained one medi-claim insurance policy from the OP-1 in the year 2014 by covering the risk of the health of herself, her husband and their only son. The policy was valid for the period from 13.06.2014 to 12.06.2015. The premium of the said policy was for Rs.9, 253=00 and the due amount towards premium was paid on 12.06.2014 and accordingly one receipt was issued. During continuation and validity of the policy the Complainant got admission at the ILS Hospital and underwent Fistula operation on 04.06.2015. After the operation the Complainant got discharge from the hospital on 06.06.2015. An amount of Rs.62, 665=00 was incurred by the Complainant towards her treatment expenses. After returning at home the Complainant submitted the claim form before the OP-1 on 22.06.2015 along with a letter, all original documents, prescriptions, doctor’s certificate etc. and completed with all formalities for getting reimbursement of the claim. After filing of the claim form the Complainant on several occasions verbally requested the OP-1 for reimbursement through her husband. All on a sudden the Complainant received a letter dated 07.07.2015 from the OP-2 being the TPA of the OP-1, through which the OP-2 asked for some documents from the Complainant. Though all those documents were submitted before the OP-1 at the time of submitting the claim form, inspite of this the husband of the Complainant by issuing a letter dated 14.07.2015 again sends all the documents as per requirement of the OP-2. In the letter dated 14.07.2015 the husband of the Complainant clarified about the original money receipt also. Again the OP-2 sought for same documents from the Complainant by issuing letter dated 06.08.2015, which the OP-2 asked earlier. In reply the husband of the Complainant again send a letter to the OPs on 14.08.2015 along with the money receipts, but the OP-2 by crossing the limit adopted unfair trade practice and deficiency in service again send a letter dated 19.08.2015 to the Complainant by asking the same document. The Complainant sends another letter dated 17.09.2015 to the OPs requesting them to settle the claim urgently by making payment of the remaining amount of Rs.35, 665=00. It is submitted by the Complainant that the OP-2 without giving any intimation either to the Complainant or her husband had credited a sum of Rs.27, 436=00 in the bank account of the husband of the Complainant on 28.08.2015, but the OPs have neither replied nor intimated to the Complainant anything about such deduction. The husband of the Complainant again on 09.10.2015 and 04.04.2016 send written representations to the OPs, but the OPs inspite of receipt of the same kept themselves silent. As the dispute of the Complainant have not been redressed by the OPs, having no alternative the Complainant has approached before this Ld. Forum by filing this complaint praying for direction upon the OPs to pay a sum of Rs.35, 329=00 to her towards the balance amount of the insurance claim, to pay Rs.40, 000=00 as compensation due to mental pain, agony and harassment and litigation cost of Rs.10, 000=00 to her. The complainant has prayed for interest @12% p.a. on the amount of Rs.35, 329=00 from 22.06.2015 till realization.
The petition of complaint has been contested by the OP-1 by filing written version contending that the Complainant enjoyed one mediclaim policy covering of three persons and total sum assured was of Rs.3, 00,000=00 for the period from 13.06.2014 to 12.06.2015. The OP-1 received net premium of Rs.9, 253=00 and policy was issued accordingly subject to the terms and conditions of the policy mentioned therein. On 22.06.2015 the husband of the Complainant submitted the claim form before the OP-1 along with a letter regarding admission on 03.06.2015 and she underwent Fistula operation at the ILS Hospital, Kolkata on 04.06.2015 under Dr. Om Tantia and she got release on 06.06.2015 from the said Hospital. The claim was provided by the OP-2 and the Complainant submitted for a sum of Rs.62, 665=00. The Complainant was requested to submit several documents in original for processing the claim. Correspondences were made by and between the husband of the Complainant and the OP-2.Thereafter a sum of Rs.27, 436=00 was credited in the bank account of the husband of the Complainant by the OP-2 against the claim amount of Rs.62, 665=00. On 17.09.2015 the husband of the Complainant submitted a letter requesting to send detailed break up of payment/non-payment against submitted bill of Rs.62, 665=00. As no response was given, then the husband of the Complainant submitted another two letters dated 09.10.2015 and 04.04.2016 requesting to re-open the claim and to pay the entire reimbursement of the claim without any further delay. In reference of the letter dated 04.04.2016 submitted by the husband of the Complainant, the OP-2 issuing a letter dated 23.04.2016 clarified the reason/reasons for deduction in details. The OP-2 vide letter dated 09.05.2015 forwarded the claim file along with the containing note of claim settlement of Rs.27, 436=00. In the note sheet it is clearly stated that the hospitalization charges claimed for 03 days @Rs.2000=00 X 3 = Rs.6,000=00, but the admissible amount was Rs.3,000=00 only as per the policy guidelines maximum payable 1% of sum insured, likewise physician charges as claimed Rs.23,400=00 and admissible amount was Rs.11,700=00, for medicine etc claim was made for Rs.4,536=00 and the admissible amount was for Rs.4,536=00, medicine from shop was claimed as Rs.407=00 and the same was the admissible amount, OT charges claimed as Rs.9,000=00 while the admissible claim was Rs.4,500=00, Rs.7,974=00 was claimed towards Miscellaneous charges, but Rs.300=00 was the admissible amount. In this manner the total amount became admissible for Rs.25, 018=00 against claim amount of Rs.52, 467=50, while the total inadmissible claim amount is for Rs.27, 449=50. The Complainant was admitted at the higher category accommodation, but she is eligible as per policy condition 1% of the sum insured i.e. Rs.1, 000=00 X 1%=Rs.1, 000=00 per day, but she got admission at higher category room for Rs.2, 000=00per day. Thus as per policy condition no-2.0 higher category rather than her eligible category and all the cases doctor fees and test was also deducted proportionately of room rent. Therefore it is abundantly clear that an amount of Rs.27, 436=00 was admissible as per the terms and conditions of the policy and the same was duly credited in the bank joint account of the Complainant and her husband on 28.08.2015 by the OP-2 as full and final settlement of hospitalization claim made by the Complainant and the amount of Rs.45, 776=00 was disallowed. According to the OP-1 as there is no deficiency in service as well as unfair trade practice on its part, hence the Complainant is not entitled to get any amount/relief as sought for. Prayer is made by the OP-1 for dismissal of the complaint.
After admission of the complaint notices were issued upon the OPs, but the OP-2 inspite of receipt of the notice on 07.11.2016 chose not to appear before this Ld. Forum. As the OP-2 did not contest the complaint hence the Ld. Forum was pleased to fix hearing ex parte against the OP-2.
The Complainant has adduced evidence supported by affidavit along with several papers and documents on support of her contention. The Op-1 has filed some documents in support of its contention.
We have carefully perused the petition of complaint; papers and documents and heard argument at length advanced by the Ld. Counsel for the Complainant and the OP-1. It is seen by us that the Complainant, her husband and their son were covered under a medi-claim policy covering the risks of their health, policy was obtained from the OP-1 by making due premium, the policy was valid for the period from 13.06.2014 to 12.06.2015, during validity of the said policy the Complainant was operated upon for Fistula at ILS on 04.06.2015, treatment cost was incurred for Rs.62,665=00, after getting discharge from the Hospital insurance claim was lodged along with the treatment related papers, several requests was made by the husband of the Complainant for settlement of the claim, by issuing some letters the TPA of the OP-1 asked for some documents, the same was accordingly provided to the OP-2, an amount was credited to the tune of Rs.27,436=00 in the joint bank account of the Complainant and her husband on 28.08.2015. The allegation of the Complainant is that though the insurance claim was lodged for Rs.62, 665=00 but at the time of reimbursement of the claim the OP-1 has paid only a sum of Rs.27, 436=00. Further allegation of the Complainant is that without giving her prior intimation about the credited amount, the OP-1 has arbitrarily, illegally and on whimsical basis settled the claim at a very lower amount and no cause has been assigned as to why such deduction was made. By filing this complaint the Complainant has sought for the remaining amount towards reimbursement along with cost and compensation. The rebuttal case of the OP-1 is that as per the terms and the conditions of the questioned policy the claim of the Complainant has been settled in a proper manner and no amount has been deducted arbitrarily. It is further submitted that as per requirement of the Complainant the detailed break up towards credit and deduction has been forwarded to her. According to the OP-1 as there is no deficiency in service on its part, prayer is made for dismissal of the complaint.
From the policy document it is revealed that the Complainant was covered under the risk of her health to the tune of Rs.1, 00,000=00, but she got admission in the room cost of Rs.2, 000=00 per day at the ILS Hospital, where she is entitled to get Rs.1, 000=00 per day as per the policy condition i.e. maximum payable 1% of sum insured. In such manner though physician, surgeon & Anesthetist/Assistant was incurred for Rs.23, 400=00, but the admissible claim is for Rs.11, 700=00 in view of the clause 3.1 of the policy condition. We have carefully gone through the Annexure-K1 submitted by the OP-1 along with its written version and from there it is evident that as per the policy condition deduction was made proportionately, but the claims for medicine, injection from stock and medicine from shop were paid entirely and no deduction was made on the two accounts. From the said document we have noticed that claimed amount was for Rs.52,467=50, out of which admissible amount was Rs.25, 018=00 and inadmissible for Rs.27,449=50. From the reverse page of the annexure-K1 it is noticed by us that total claim was made by the Complainant for pre-hospitalization period of Rs.16,885=00, out of which admissible claim was for Rs.700=00 & inadmissible Rs.16,185=00 and total claim of post hospitalization was claimed for Rs.3,859=00, out of which admissible and inadmissible claim was for Rs.1,718=00 & Rs.2,141=00. The OP-1 has also provided the inadmissible break up, investigation and doctor fees break up in details. From the said annexure we do not find any anomaly which proves that deduction was made by the OP-1 in an improper manner, illegally and on whimsical basis. As the OP-1 has settled the amount as per the policy terms and conditions, which the Complainant had also adopted at the time of taking out the policy, hence such deduction cannot be termed as deficiency in service or/and unfair trade practice on the part of the Insurance Company. Not only that without making any delay the OP-1 has credited the settled amount in the joint bank account of the Complainant and her husband. In our opinion as the insurance claim was settled based on the terms and conditions of the policy by the OP-1, hence the Complainant is not entitled to get the balance amount as sought for and as the action of the OP-1 does not suffer from any deficiency in service, we are of the view that the Complainant is also not entitled to get any amount as compensation and litigation cost.
Going by the foregoing discussion, hence it is
O r d e r e d
that as the Complainant has failed to prove her case, the complaint is dismissed on contest against the OP-1 without any cost and dismissed ex parte against the OP-2 without any cost.
Let plain copies of this order be supplied to the parties free of cost as per provisions of Consumer protection Regulations, 2005.
(Asoke Kumar Mandal)
Dictated and corrected by me. President
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
(Pankaj Kumar Sinha) (Silpi Majumder)
Member Member
DCDRF, Burdwan DCDRF, Burdwan
