1. This complaint case has been filed against the O.Ps u/s 12 of Consumer Protection Act against the O.P. for repudiating the Mediclaim of the complainant’s wife illegally and arbitrarily and thereby committed deficiency in services.
2. The complainant’s case in brief is that the O.P. No. 1 Oriental Insurance Company Ltd. is a body corporate constituted under company act to carry out General Insurance business as well as Individual Mediclaim Family Floater Insurance business whole over India through its so many subordinates offices including one at Ranchi and other at Dumka, i.e; O.P. No. 2 and 3 respectively.
3. It is further submitted that the complainant being the account holder of Oriental Bank Medi Claim policy with family floater and accordingly for the first time on payment of premium amount worth of Rs 6,830, The Oriental Bank Medi Claim Policy with family floater bearing policy no. 331100/48/2013/768 was issued by Patna Office of Oriental Insurance Co. Ltd. in favor of the complainant covering his wife Sima Basaiwala and kids and accordingly the policy was subsequently been renewed on payment of premium amount and accordingly the policy no. 331100/48/2014/825 was issued by Patna Office. 
4. Similarly in the same sequence the Oriental Bank Medi claim with family floater bearing policy no. 332200/48/2015/1194, 332200/48/2016/1453,332200/48/2017/1730, 332200/48/2018/1563 has been issued by Ranchi Office of Oriental Insurance Co.  Ltd. in favor of the complainant covering his wife Sima Basaiwala and kids. It is no doubt that the said policy was made to pay hospitalization expenses for medical/ surgical treatment at any Nursing home/ hospital in India as an in – patient.
5. And during the validity of the policy no. 332200/48/2016/1453 valid from 08.02.16 to 07.02.17, the wife of the complainant Smt. Sima Basaiwala has been treated at Disha Eye Hospital Pvt. Ltd. Barrackpore WB where she was operated for cataract surgery on 05.07.16 as in – patient and discharged on 05.07.16. It is further submitted that on the day of admission in hospital, i.e; 05.07.16 the complainant informed the authorized authority of the insurer namely the Medi Assist India TPA Pvt. Ltd., Premier Court 4^th Floor, Chandani Chowk Street, Kolkata 700072 and lodged the claim on mobile before it which was numbered as 10366937 dt. 05.07.16 and also submitted all the requisites papers including the medical treatment bill as required by the Insurance Co. and the same has been delivered to Medi Assist TPA Pvt. Ltd. on 26.07.16.
6. The Medi Assist TPA Pvt. Ltd. lodged the claim under reference no. 13020666 and made some query vide its letter dt. 02.08.16 which was received on 08.08.16 and accordingly the complainant replied it and furnished all the details with the documents replied it and furnished all the details with documents vide speed post dt. 13.08.16. And again the complainant vide letter dt. 16.01.17 which was delivered to Medi Assist on 21.01.17 requested to settle the claim but after the lapse of a considerable period the Insurance Co. did not take a pain to reply or settle the claim.
7. Thereafter the complainant vide e-mail dt. 05.09.17, 10.09.17, 03.10.17, again requested the Medi Assist TPA for settlement of claim but in each count the Medi Assist only asserted that the matter has been referred to processing team but never settled the claim of the complainant. On 16.09.18 the complainant again requested the Medi Asist to settle the claim and for the first time the Medi Assist vide e-mail dt. 17.09.18 replied that the claim has been denied by writing as follows : -

“On perusal of documents forwarded it is being observed that patient Sima Basaiwala was admitted on 05.07.16 and discharged in 05.07.16. Patient admitted for cataract Lt eye and Phaco done. As per policy condition cataract covered after 2 years of policy complete. Policy since 08.02.15 and its 2^nd year running policy… hence the claim is denied as per policy exclusion 4.2(vii) hence we regret our inability to admit this policy under the present policy conditions.”

8. After a series of correspondence and after the lapse of more than 2 years the Insurance Company wrongly and illegally repudiated the claim of the complainant on the basis of the baseless, concocted, false and frivolous observations which was neither disclosed to the complainant at the time of policy nor was mentioned in the certificate of policy itself by the Insurance Company. And the Insurance Co. wrongly and illegally observed that it was 2^nd year running policy in which the claim was raised rather the fact is that it was the 4^th year running policy in which the claim was raised.
9. And this act of the O.Ps is nothing but a patent and glaring deficiency in services rendered by the O.Ps and it is a patent negligent act of the O.Ps for which the complainant has suffered mental tension, agony, harassment to the tune of Rs 1,00,000/-. And due to the wilful act of deficiency and negligency of the O.Ps the complainant has been deprived off from availing the amount worth Rs 19,401.60 and the O.Ps has enjoyed the said amount and is also enjoying the same causing loss of interest to the complainant.
10. Further, the complainant has hired the services of the O.Ps by paying the Insurance Premium amount as consideration of the services and as such the complainant comes under the purview of the consumer as defined in Consumer Protection Act. The present case is within the territorial and pecuniary jurisdiction of this Commission also.
11. The complainant has claimed the following reliefs : -

1. To issue and order directing the O.Ps to pay Rs 19,401.60 on account of incurred medical expenses.
2. To issue and order directing the O.Ps to pay Rs 1,00,000 as compensation on account of mental tension, agony, harassment caused to the complainant due to the deficiency and the negligent act of the O.Ps.
3. To issue and order directing the O.Ps to pay the interest @ 12% from 05.07.16 till payment to the complainant.
4.  And to issue an order directing the O.Ps to pay cost of litigation of Rs 10,000.

12. After filing the case complainant has submitted and filed the requisites for summoning the O.P and thereafter on 18.12.19 the Penal Lawyer of the Oriental Insurance Company, Shree C.N.Mishra, advocate appeared and filed his hazri. And thereafter, the O.P. has been given opportunity to file the show cause since 18.12.19 till 21.11.22 no show cause / WS has been filed on behalf of the O.Ps and as such vide order dt. 21.11.22 the O.P were debarred to file the WS/ Show cause.
13. And after that the case was fixed for evidence of the complainant and the complainant filed oral and documentary evidence both. The O.P. was also given time to file the evidence in support of his case but he failed to adduce any evidence in this case. As such, in presence of both the Learned Lawyer the argument was heard and case was proceeded for judgment. Apparently no WS/ Show cause has been filed on behalf of the complainant in this case and case was heard exparte against the O.Ps.
14. The main point for the determination in this case is whether the complainant is entitled to get any relief or reliefs as claimed!

                                                                          Findings

The complainant in support of his case has filed affidavit of Rajendra Prasad Basaiwala as a complainant witness no. 1 and also filed the following documentary evidence which are as follows : -

Exhibit 1 – is the medical policy schedule issued by Oriental Insurance Company with policy no. 332200/48/2016/1453 effective from 08.02.16 to 07.02.17. In this policy the previous policy is also mentioned which is 332200/48/2015/1194. Total 2 sheets.

Exhibit 2 – is the medical policy schedule issued by Oriental Insurance Co. bearing policy no. 332200/48/2015/1194 effective from 08.02.15 to 07.02.16. previous policy mentioned as policy no. 331100/48/2013/768 effective from 08.02.14 to 07.02.15.

Exhibit 3 – is the e-mail dt. 20.07.16 sent by Rajendra Prasad Basaiwala ro Medi Assist India TPA Pvt. Ltd. along with reimbursement of claim form.  

Exhibit 4 – is the letter by Medi Assist India Pvt. Ltd. to Sima Basaiwala dt. 02.08.16.

Exhibit 5 – is the e-mail by Rajendra Prasad Basaiwala to Medi Assist India TPA Pvt. Ltd. dt. 13.08.16

Exhibit 6 – is also the letter dt. 16.01.17 by the complainant to Medi Assist India TPA Pvt. Ltd.

Exhibit 7 – is the Gmail sent by Medi Assist India TPA Pvt. Ltd. to Rajendra Prasad Basaiwala dt. 17.09.18 in which regarding reputation of claim has been denied.

15. As already mentioned that the O.Ps although appeared in this case and participated in the proceedings of the case but has not filed their show cause or any documents in support of his case. He simply denied the claim of the complainant and submitted that the Medi Assist India TPA Pvt. Ltd. has rightly rejected and repudiated the claim of the complainant. He simply shown note of argument in this case on behalf of the Insurance Company.
16. Heard the Learned Counsel of both the parties and also perused the case record, evidences oral and documents adduced on behalf of both the parties. The Learned Lawyer of the O.P has argued that the Medi Assist India TPA Pvt. Ltd. has rightly repudiated the claim of the complainant as the policy running in second year and for the cataract treatment and claim more than 2 years continued policy is required. He also draw the attention of this Commission towards Exhibit – 7 in which Medi Assist India TPA Pvt. Ltd. has observed, “On perusal of documents forwarded it is being observed that patient Sima Basaiwala was admitted on 05.07.16 and discharged on 05.07.16. Patient admitted for Cataract Lt. eye and Phaco done. As per policy condition cataract covered after 2 years of policy complete. Policy since 08.02.15 and it is 2^nd year running policy period. Hence the claim is denied as per policy exclusion 4.2(vii). Hence we regret our inability to admit this liability under the present policy conditions.
17. On the other hand the complainant vehemently denied the allegations of the O.Ps that his policy was not second year running policy and the decision of the Medi Assist India TPA Pvt. Ltd. is totally wrong and misunderstood.
18. Exhibit 1 is Medi claim policy no. 332200/48/2016/1453 valid from 08.02.16 to 07.02.17. Exhibit 2 is the Mediclaim policy no. 332200/48/2015/1194 effective from 08.02.15 to 07.02.16. And another policy no. 331100/48/2014/825 which was effective from 08.02.14 to 07.02.15. In this policy the previous policy is also mentioned 331100/48/2013/768 effective from 08.02.14 to 07.02.15. Apparently first policy was effective from 08.02.13 to 07.02.14, second was effective from 08.02.14 to 07.02.15 and third policy was effective from 08.02.15 to 07.02.16 and fourth policy was effective from 08.02.16 to 07.02.17.
19. The complainant’s wife Sima Basaiwala admitted on 05.07.16 for cataract operation and on the same day she was discharged. Apparently this period comes within the Mediclaim policy which is Exhibit 1.
20. From carefully going through the Mediclaim policies issued by the O.P. to the complainant which was for the period of 2013-2014, 2014-2015, 2015-2016, 2016-2017. And there is no breakage in the policy as the premium amount has already been deposited prior to the date of the renewal. As it appears from the policy schedule. It is very surprising how the Medi Assist India TPA Pvt. Ltd. has come on the conclusion that the policy was second year policy. It is very surprising that the Medi Assist India TPA Pvt. Ltd. has wrongly calculated that the policy was second year running policy because prior to that the complainant has already taken the policy from the year 2013 which was continued by the complainant subsequently without fail up to 2018 as mentioned in the complaint petition on page 3(iii).
21. It is also argued that on behalf of the Learned Lawyer for the O.P. that as per condition no. 5.9 under the head of repudiation the insured person shall have the right to appeal/ approach the Grievance Redressal cell of the company and its policy running office/ concerned divisional office concerned Regional office or the grievance or the Grievance Cell of the Head Office but the complainant has not taken the recourse of the above Redressal cell and allowed the claim before this commission. But I find no force in the argument of the O.P. as no one can restrict his legal right by saying that he has not followed the proper procedure before filing the case before this commission.
22. From the above discussion we come to the conclusion that the O.P. has wrongly, intentionally and arbitrarily rejected/ repudiated the claim of the complainant merely on the basis of baseless, concocted, false, frivolous observations as the policy of the complainant was 4^th year running policy and the O.P are negligent and in great deficiency in providing the services to the complainant for which the complainant has suffered not only the economical loss but also suffered mental tension, agony and harassment for which the complainant has claimed in his complaint petition. It is therefore, we

                                                                        Ordered

                  That the O.P. No. 1, 2 and 3 are hereby directed jointly and severally to pay Rs 19401.60/- to the complainant on account of incurred medical expenses. The O.P. No. 1, 2 and 3 are hereby directed jointly and severally to pay Rs 1,00,000/-as compensation to the complainant on account of mental tension, agony and harassment due to negligent and deficient act. The O.P. No. 1,2 and 3 are hereby directed jointly and severally to pay interest @ 12% from 05.07.16 till payment to the complainant and the O.P. No.1, 2 and 3 are also hereby directed jointly and severally to pay cost of litigation of Rs 10,000/- to the complainant.

                 All the above payments should be made within 45 days from this order failing which the complainant is entitled to realise above amount through process of court.

                                          Let a copy of this order be served to both the parties free of cost. Let this document be deposited in the record room and to be shown on the website of the commission.