PER SHRI. S.B.DHUMAL - HON’BLE PRESIDENT :

1) In brief consumer dispute is as under –

That the Complainant has obtained Medical Insurance Cover from the Opposite Party – The Oriental Insurance Co. Ltd. through Shriee Amrut Dhurandhar Jain Yuvak Mandal vide Master Policy No.121200/48/2008/11272 for the period 01/03/2009 to 29/03/2009 for himself and his family members. The Complainant has produced Certificate of Insurance in which sum insured is Rs.2,00,000/-. The said policy was renewed for the further period from 30/03/09 to 29/03/2010. The Complainant has produced copy of said Certificate of Insurance alongwith complaint at page No.13.

2) It is case of the Complainant Mr. Kirit Mehta that he was fallen down at home on 01/04/2009 & thereby sustained injury in his abdomen. He was vomiting through that day. As per the advice of Dr. R.M. Pokar, the Complainant was admitted in Thane Health Care Hospital on 03/04/2009. In the said hospital the Complainant was operated by Dr. Pokar and then he was discharged on 11/04/2009. According to the Complainant, on his own accord he took discharge from Thane Health Care Hospital on 11/04/2009 due to the heavy hospital charges and then immediately admitted in Hira-Mongi Navneet Hospital, on the same day i.e. on 11/04/2009. At Hira-Mongi Navneet Hospital, he took post operative treatment up to 24/04/2009 and took discharge form the said hospital. Thereafter, on 25/06/09, he lodged claim for reimbursement of medical treatment to Opposite Party. The Opposite Party No.2 is a TPA of Opposite Party No.1. Inspite of continuous follow up with Opposite Party No.2, there was no settlement of claim. So on 16/11/2009, the Complainant wrote a letter to Opposite Party No.2 and requested for early settlement of his claim, but there was no response from the Opposite Party No.2. The Complainant approached to Opposite Party No.1 and wrote a letter dtd.26/11/2009. The Complainant complied with the queries of Opposite Party No.2 and submitted details of incident history & MLC/FIR copy. Subsequently, it was informed by Opposite Party No.2 to the Complainant that his claim file was closed. The Complainant again made inquiry and wrote letter to the Opposite Parties. Opposite Party No.2 asked to submit FIR copy. The Complainant submitted FIR copy which was lodged to Thane Police Station. But there was no response from the Opposite Parties. The Complainant might have made inquiry with the Opposite Party on 60 to 65 times but Opposite Parties have not taken decision regarding his claim, so the Complainant has filed this complaint.

3) The Complainant has requested to direct Opposite Parties to reimburse to the Complainant an amount of Rs.1,96,000/- alongwith interest @ 18% p.a. from 25/06/2009 till realization. The Complainant has claimed Rs.50,000/- towards compensation and expenses incurred from the Opposite Party. Further, he has requested to direct Opposite Parties to pay to the Complainant an amount of Rs.75,000/- towards compensation for mental agony and hardship.

4) In support of complaint the Complainant has filed his own affidavit and copies of the documents at page no.9 to 56.

5) Opposite Party No.1 has filed written statement and thereby resisted claim of the Complainant contending interalia that complaint is false, frivolous and bad in law and therefore, complaint deserves to be dismissed with cost. It is alleged that the Complainant has suppressed material facts from this Forum. There are discrepancy and inconsistency in the pleading of the complaint.

6) According to the Opposite Party, there is no deficiency in service on their part. The Complainant never supplied necessary documents to the Opposite Party for settlement of the claim inspite of several demands.

7) The Opposite Party No.1 has admitted that the Complainant and his family members were covered under the mediclaim policy which is valid from 30/03/09 to 29/03/2010. The Complainant was assured for a sum of Rs.2 Lacs. The Complainant due to alleged injury to the abdomen was admitted in Thane Health Care Hospital and thereafter in Hira-Mongi Navneet Hospital, Mulund. It is admitted that after discharge form the hospital the Complainant had submitted claim to Opposite Party No.2 and after scrutiny of papers vide letter dtd.11/01/2010, Opposite Party No.2 asked the Complainant to provide necessary documents like the letter from treating Doctor stating details history, copy of MLC/FIR, etc. The Complainant failed and neglected to supply necessary documents therefore, on 10/03/2010, Opposite Party No.2 have closed file of the Complainant. It is submitted that Complainant has given letter of Dr. Pokar’s Hospital stating that Complainant admitted in the Thane Health Care Hospital. It is contended that Dr. Pokar has no concern with Thane Healthcare Hospital and therefore, he has no right to issue such letter/certificate. It is alleged that the Complainant has deliberately avoided to give necessary papers and certificate of Thane Healthcare, inspite of several reminders.

8) Opposite Party has denied allegations made in the complaint and submitted that Complainant is not a ‘Consumer’ as defined under Sec.2(1)(d) of the Consumer Protection Act, 1986. Opposite Party has denied allegations of the Complainant that the Complainant supplied all the documents demanded by the Opposite Party. It is submitted that there is no cause of action for the complaint and Complainant not entitled for relief prayed and therefore, complaint deserves to be dismissed with compensatory cost. In support of the written statement Mr. Vijay Gaurkahede of Opposite Party No.1 has filed affidavit.

9) Opposite Party No.2 was duly served with the notice of this complaint but he has not appeared before this Forum. Therefore, ex-parte order was passed against Opposite Party No.2. The Complainant has filed affidavit of evidence and written argument. The Opposite Party No.1 has also filed written argument. We heard oral submissions of Complainant and his representative Mr. Vinay Magia and Ld.Advocate Mr. Nitin Patil for Opposite Party No.1.

10) Following points arises for our consideration and our findings thereon are as under -

      Point No.1 : Whether the Complainant has proved deficiency in service on the part of Opposite Parties ?

      Findings :    Yes.

      Point No.2 : Whether the Complainant is entitled for reliefs as prayed for ?

         Findings :    As per final order.

Reasons :-

Point No.1 :- Following facts are undisputed facts that Opposite Party No.2 is a TPA of Opposite Party No.1- Oriental Insurance Co. Ltd. According to the Complainant, he had obtained Mediclaim Policy for himself and his family members. He has produced copy of Insurance Certificate for the period 01/03/2009 to 29/03/2009 and Insurance Certificate of Group Mediclaim Policy for the period from 30/03/2009 to 29/03/2010. It is Group Mediclaim Master Policy No.121200/48/09/19541. Family Floater sum insured is Rs.2,00,000/-. It is not disputed that on 01/04/09, the Complainant sustained injury to his abdomen due to fall at home. According the Complainant as per advice of Dr. R.M. Pokar, he was admitted in Thane Health Care Hospital at Thane on 03/04/2009. This fact is not disputed by the Opposite Parties.

                 According to the Complainant, at Thane Health Care Hospital, he was operated by Dr. Pokar and then he was discharged on 11/04/09. It is submitted on behalf of the Complainant that due to the heavy charges of Thane Healthcare Hospital on 11/04/09, he got discharge from the said hospital and then he immediately admitted in Hira-Mongi Navneet Hospital, on the same day and took post operative treatment. Thereafter, he took discharge from the said hospital on 24/04/09. After discharge from the said hospital the Complainant submitted his claim for reimbursement of medical expenses of Rs.1,96,144/- to the Opposite Party. The Complainant has produced copy of mediclaim submitted to Opposite Party on 23/06/09. According to the Complainant, from time to time, Opposite Party No.2 TPA of Opposite Party No.1 asked for documents. The Complainant has submitted all the necessary documents alongwith claim form he had submitted necessary case papers and documents. Inspite of his continuous follow up the Opposite Parties have not taken decision regarding his claim so he has filed this complaint. According to the Opposite Parties, after receipt of claim form from the Complainant the Opposite Party No.2 scrutinized documents and vide letter dtd.11/01/2010, asked the Complainant to provide necessary documents like the letter from treating Doctor stating details history, copy of MLC/FIR, if done. etc. The Complainant failed to supply aforesaid documents to the Opposite Party. Therefore, the Complainant was informed that his claim file was closed. The Complainant submitted letter from Dr. Pokar’s Hospital in which Dr. Pokar has stated that the Complainant was admitted in Thane Healthcare Hospital. According to the Opposite Party No.1 Dr. Pokar has no concern with Thane Healthcare Hospital and therefore he has no right to give such certificate.

                 According to the Complainant on 01/04/09, as he was fallen down at home and thereby he sustained injury in his abdomen so he was vomiting full day. Thereafter, as per advice of Dr. R.M. Pokar, the Complainant was hospitalized at Thane Healthcare Hospital on 03/04/09. At Thane Healthcare Hospital, he was treated and operated by Dr. Pokar and then he himself took discharge from Thane Healthcare Hospital due to heavy charges of the said hospital. The Complainant has produced copies of correspondence took place between Opposite Party No.2, discharge card certificate of Thane Healthcare Hospital. It appears from discharge card that on 03/04/09, the Complainant was admitted in Thane Healthcare Hospital. Exploratory laparotomy was done on 04/04/09 by Dr. Pokar. Mr. Kirit Mehta was referred by Dr. Pokar to Thane Healthcare Hospital. Particulars of treatment given to the Complainant are stated in the discharge card. It is stated in the discharge card of the Thane Healthcare Hospital that the patient was transferred to ESIS Hospital. Dr. R.M. Pokar, Consulting Surgeon has issued receipt of payment of Rs.29,500/- for operation of Purporative Peritonitis performed on the Complainant. The Complainant has produced photo copy of bill/invoice of Rs.65,675/- given by Thane Healthcare Hospital and other receipts issued by Thane Healthcare Hospital. From Thane Healthcare Hospital the Complainant was admitted in Hira-Mongi Navneet Hospital. The Complainant has produced copy of discharge card of Hira-Mongi Navneet Hospital. It appears that on 11/04/09, the Complainant was admitted in the aforesaid hospital and was discharged on 24/04/09. In the case summery it was recorded that patient was admitted by Dr. R.M. Pokar and the Complainant was transferred from Thane Healthcare Hospital. The Complainant has also produced certificate of Dr. Pokar. Dr. Pokar has certified that Mr. Kirit Mehta had sustained Purporative Peritenities after alleged accident fall at home. He was admitted on 03/04/09 at Thane Healthcare Hospital at Thane and was operated for the same.

           It appears from the copy of the medical form that alongwith claim form the Complainant had submitted necessary discharge certificates of the hospitals surgeons’ certificate, bills receipts, etc. In the said claim form the Complainant had claimed reimbursement of an amount of Rs.1,96,144/-. Thereafter, as per the directions of Opposite Party No.2 the Complainant submitted necessary certificates. However, vide letter dtd.10/03/2010, Opposite Party No.2 has closed claim file of the Complainant. Copy of the aforesaid letter is produced by the Complainant alongwith complaint at page no.19. In response to the claim submitted by the Complainant Opposite Party No.2 made query vide letter dtd.10/03/2003. It appears from the contents of the letter dtd.10/03/03, Opposite Party No.2 had asked to submit a letter of treating doctor stating detailed incident history, etc. In the letter it is stated as follows –

“1) Final Reminder was sent on 10/03/2010.

 2) First Reminder was sent on 04/02/2010.

 3) Second Reminder was sent on 10/03/2010.”

               Further in the said letter dtd.10/03/2010, Opposite Party No.2 has stated that –

              “We are sorry to say that till date no proper reply has been received from your end. Hence, file has been closed and no further correspondence will be entertained.”

               Subject matter of letter dtd.10/03/2010 sent by the Opposite Party No.2 to the Complainant is as “Claim File Closed”. As mentioned above, contents of the letter are inconsistent and contradictory. The Opposite Party No.2 treated aforesaid letter as first reminder, second reminder and in the same letter it is stated that file is closed. Therefore, it is clear from the documentary evidence on record that Opposite Parties without application of mind have closed Complainant’s claim on unjustified ground. From the claim form it is clear that the Complainant had sent necessary case papers and medical details. Besides that he had given certificate of treating doctor- Dr. Pokar. Even then Opposite Parties have wrongly rejected Complainant’s claim. Rejection of claim without application of mind amounts to deficiency in service on the part of Opposite Parties. Therefore, we answer point no.1 in the affirmative.

Point No.2 :- The Complainant has claimed reimbursement of medical expenses of Rs.1,96,144/- from the Opposite Partiesy. It is admitted by the Opposite Parties that during relevant period they had given Mediclaim Insurance Policy to the Complainant and Complainant’s family members and sum insured given under the said policy was Rs.2 Lacs. As discussed above, the Opposite Parties have rejected the Complainant’s claim without application of mind. Alongwith complaint, the Complainant has produced medical bills issued by the Thane Healthcare Hospital, Hira-Mongi Navneet Hospital,, Receipt of Dr. R.M. Pokar who performed the operation, etc. It appears that Thane Healthcare Hospital has given total bill of Rs.65,675/-. The Complainant has spent Rs.9,745/- for blood examination, etc. The Complainant has produced receipts of payment made to Thane Healthcare Hospital. Receipt of Rs.6,500/- paid to Jupiter Scan Centre, Receipt of Rs.29,500/- paid to the treating Dr. R.M. Pokar, Receipt of Rs.24,750/- issued by Hira-Mongi Navneet Hospital, Detailed bill of Hira-Mongi Navneet Hospital, etc. From the documentary evidence produced by the Complainant it appears that the Complainant has spent Rs.65,675/- in Thane Healthcare Hospital + Rs.9,745/- + Rs.6,500/- + Rs.29,500/- + 24,750 = Rs.1,36,170/- for his medical treatment. Under the mediclaim policy the Complainant is entitled to receive aforesaid amount from the Opposite Parties. Hence, we think it just to direct Opposite Parties to pay to the Complainant an amount of Rs.1,36,170/-.

               The Complainant has claimed interest on aforesaid amount @ 18% p.a. The interest claimed by the Complainant is at excessive rate. We think it just to direct the Opposite Parties to pay to the Complainant interest @ 9% p.a. from the date 10/03/2010 till realization of entire amount to the Complainant.

                The Complainant has claimed of Rs.50,000/- towards compensation for mental agony, etc. and Rs.75,000/- towards cost of this proceedings and expenses. We think it just to direct Opposite Parties to pay to the Complainant Rs.10,000/- as a compensation for mental agony and Rs.5,000/- towards cost of this proceedings to the Complainant. Hence, we answer point no.2 accordingly.

                  For the reasons discussed above we partly allowed the complaint and pass the following order -

O R D E R

i.Complaint No.71/2011 is partly allowed.

ii.Opposite Party No.1 & 2 shall jointly and/or severally pay an amount of Rs.1,36,170/- (Rs. One Lac Thirty Six Thousand One Hundred Seventy Only) to the Complainant with interest @ 9% p.a. on aforesaid amount from 10/03/2010 till realization of entire amount to the Complainant.

ii.Opposite Party No.1 & 2 shall jointly and/or severally pay to the Complainant an amount of Rs.10,000/- (Rs. Ten Thousand Only) as compensation for mental agony and Rs.5,000/- (Rs. Five Thousand Only) towards cost of this proceeding.

iv. Certified copies of this order be furnished to the parties.