Consumer Complaint No.53 of 2016

Date of filing:31.03.2016                                                                   Date of disposal:20.02.2017

Complainant: Mrinal Kanti Kesh, S/o. Lt. Ajit Kumar Kesh,  18 No., Ramkrishna Road, Santi

                           Apartment, Flat No.D/3, P.O., P.S & Dist.-Burdwan, Pin-713101.

-VERSUS-

Opposite Party: 1.Oriental Insurance Company Ltd., B.C.A. Building, Court Compound, P.O.,

                                  P.S. & dist.-Burdwan, Pin-713101, represented by its Branch Manager.

                              2. Oriental Insurance Company Ltd., Registered Office at A-25/27, Asaf Ali

                                   Road, New Delhi, 110002, Represented by its Chairman.

                              3. M/s. Heritage Health Services Pvt. Ltd., Nicco House, 5^th floor, 2, Hare

                                   Street, Kolkata, Pin-700 001, represented by its Manager.

Present :    Hon’ble Member :  Smt. Silpi Majumder

                  Hon’ble Member :  Sri Pankaj Kr. Sinha

Appeared for the Complainant:     Ld. Advocate, Subrata Ghgosh.

Appeared for the Opposite Party No.1:  Ld. Advocate, Ahibhushan De.

Appeared for the Opposite Party No.2 & 3: Exparte.

JUDGEMENT

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 decide and settle his legitimate insurance claim till filing of this complaint.

The brief fact of the case of the Complainant is that he along with his wife, one daughter and one minor son were insured under ‘Happy Family Floater Policy’ issued by the OP-1 and 2, which was valid for the period from 23.08.2011 to 22.08.2012 and the sum assured was for the each insured was for Rs.2,00,000/-. Thereafter the said policy was renewed for the period from 23.08.2012 to 22.08.2013, 23.08.2013 to 22.08.2014 & 23.08.2014 to 22.08.2015. All of a sudden the son of the Complainant became seriously ill during validity of the said policy on 18.01.2015 and the patient was admitted at Diplomat Nursing Home, Burdwan on 18.01.2015 where he was treated by the doctors namely Dr. N. Roy and Dr. Anirban Mitra. After medical checkup the said doctors prescribed certain clinical tests and after compliance with the same the Complainant submitted all the reports before the concerned doctors. The Complainant incurred the entire expenses for such clinical tests out of his own pocket. Upon perusal of the test reports the doctors referred the patient at the higher centre for further and better management at Super Speciality Wings Hospital (Anamoy). So the patient was discharged on 19.01.2015 from the said Nursing Home. After getting discharge from the Nursing Home the Complainant intimated the said fact to the OP-1 by issuing letter dated 19.01.2015 for their kind information. The OP-1 received the said letter on that day i.e. 19.01.2015. The OP-3 was also intimated the fact by the Complainant on 19.01.2015. The son of the Complainant was taken to the Super Speciality Wing Hospital (Anamoy) on 19.01.2015 and he consulted with the Neurology Department. The doctor of the said department treated the patient and after examination certain tests was prescribed by the treating doctor like MRI, EEG, ECG, USG of whole abdomen and several blood tests. After completion of all the reports the concerned doctor examined the same but was unable to come to the conclusion as to whether the patient was suffering from Epilepsy or not and as such the doctor was reluctant to prescribe proper medicine to the patient. Thereafter without wasting any time the Complainant decided to go to the National Institute of Mental Health & Neuro Sciences, Bangalore (NIMHANS) for better treatment, wherein the doctor treated the son of the Complainant and diagnosed that the patient was suffering from one type of epilepsy and prescribed certain medicines and advised the Complainant to take medicines i.e. Valporate & Folic Acid twice a day and also advised the Complainant to come after three months along with the patient for checkup. Inspite of taking such medicines the patient could not be free from such disease, but the gravity became low and for this reason the Complainant took his son to the Neurology Department, R.G.Kar Medical College & Hospital, Kolkata  on 19.05.2015 for medical checkup for seizer disorder. After examining the patient the concerned doctor told the Complainant that if there will be further occurrence of such disease, the existing medicines should be started and side by side another medicaines should be given. After returning home the Complainant lodged medi-claim before the OPs on 26.05.2015 after observing all the formalities and submitted all the medical documents along with medical bills before the OPs and requested the OPs to settle the claim amounting to Rs.25,476/- which the Complainant had to incur from his own pocket towards the treatment of his son. Inspite of receipt of the claim form along with the relevant documents, the OPs did not settle the claim of the Complainant. The Complainant visited the office of the OP-1 on several occasions requesting to settle the claim, but the OP-1 did not pay any heed to his request. The OP-3 by sending an e-mail to the Complainant sought for certain queries for processing of the claim. Upon receipt of the same the Complainant replied through e-mail whereby request was made by the Complainant for settlement of the claim as early as possible, but till filing of this complaint his insurance claim had not been settled by the OP-1, which according to the Complainant is an example of unfair trade practice on the part of the OP-1. 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.25,476/- to him towards the insurance claim, Rs.50,000 as compensation due to mental pain, agony and harassment and litigation cost of Rs.15,000/- to him.

The petition of complaint has been contested by the OP-1 by filing written version contending that this OP had issued a Happay Family Floater Policy in the anme of the Complainant, his wife, daughter and son for the period from 23.08.2014 to 22.08.2015 for sum assured of Rs.2,00,000/- for each insured and the OP-3 is the TPA. At the time of the issuance of the policy the terms, conditions, clauses and warranties were also issued and attached with the policy. As per the policy condition the OP-1 shall pay for hospitalization expenses for medical/surgical treatment at any nursing home/hospital in India as an in-patient as defined in the policy. It is also stated in the policy that the information of hospitalization should be reported within 48 hours of admission, but before discharge and claim documents should be submitted within 07 days from the date of discharge. The TPA shall reimburse to the hospital only if treatment is taken at Network Hospitals with prior written approval of TPA. Be it mentioned that the expenses for hospitalization are admissible only if hospitalization is for minimum period of 24 hours. The OP-1 has further submitted that the claim of the Complainant was duly processed by the TPA and the TPA settled the claim to the tune of Rs.8,664/-, but the said amount could not be transferred to the insured’s account due to non-availability of bank details of the Complainant. The Complainant was asked by the TPA to submit his Bank details, but he did not submit the same inspite of several reminders.  There have been made some deductions against the bill submitted by the Complainant which are as follows-

1. Rs.202/- as inadmissible item,
2. Rs.400/- as initial management charge not payable,
3. Rs.60/- glucometer chart not available,
4. Rs.6052.47/- train fare dated 09.02.2015, being not payable as per the terms and conditions of the policy,
5. Rs.6052.47/- train fare dated 18.02.2015, being not payable as per the terms and conditions of the policy,
6. Rs.963/- co-deducted from admissible amount as per the terms and conditions of the policy,
7.  Rs.1,134/- being the bill dated 26.05.2016, bill after 60 days is not payable as per the terms and conditions of the policy.

The TPA had duly settled the claim from their end and requested the Complainant to provide bank details along with cancelled cheque leaf for ECS payment, but due to non-availability of the bank details the settled amount of Rs.8,664/- could not disbursed. Therefore the prayers as made out in this complaint and the allegation as mentioned against this OP are all misconceived, false and untenable. As the OP-1 had discharged its liability within due period, but due non co-operation of the Complainant the settled amount could not be disbursed, hence there is no deficiency in service as well as unfair trade practice against this OP-1, so the Complainant is not entitled to get relief as sought for. According to the OP-1 this complaint should be dismissed with cost of Rs.10,000/- being frivolous and vexatious one.

The Complainant has adduced evidence on affidavit along with some documents in support of his contention. On 25.10.2016 the OP-1 by filing a petition had prayed for treating its written version as its evidence on affidavit. As the written version of the OP-1 was filed on affidavit, hence this Ld. Forum was pleased to accept the same as the evidence on affidavit of the OP-1. The OP-1 has filed several documents by way of firisty. The OP-1 has filed written notes of argument with a copy to the other side.

From the record it is revealed that the OP-2 and 3 inspite of receipt of notices did not turn up to contest the complaint either orally or by filing written version. Hence this Ld. Forum was pleased to hold that the complaint will run exparte against the OP-2 and 3.

We have carefully perused the record; documents filed by the contesting parties and heard argument at length advanced by the Ld. Counsel for the parties. It is seen by us that there are some admitted facts in the case in hand i.e. the Complainant obtained Happy Family Floater Policy for himself, his spouse, daughter and son from the OP-1 on 23.08.2011, the said policy was renewed year after year by the Complainant subject to making payment of due premium, lastly for the period from 23.08.2014 to 22.08.2015 the policy was renewed against payment of due premium, sum assured was of Rs.2,00,000/- for each of the insured, during validity of the policy the son of the Complainant became seriously ill on 18.01.2015, he was brought at the Diplomat Nursing Home  on 18.01.2015, got admission, doctors advised for certain medical tests, after perusing the same the treating doctors referred the patient at Anamoy on 19.01.2015 for better treatment and management,  on 19.01.2015 intimation was given by the Complainant to the OP-3 about the illness of his insured son, the patient was taken at Anamoy after getting discharge from the earlier Nursing Home, doctor of the Department of Neurology, Anamoy treated the patient, after examining the doctor prescribed for certain tests, tests were done, after perusing the test reports the treating doctor could not come to the conclusion as to whether the patient was suffering from epilepsy or not, without making any delay the Complainant went to the NIMHANS at Bengaluru for treatment of his son, it was diagnosed that the patient was suffering from one type of epilepsy, prescribed medicines, advice was given to come after three months for further checkup, inspite of following the advice of the doctor though the gravity of his illness became low, but the patient was not fully cured, the patient was taken at the Neurology Department of the R.G. Kar Hospital, Kolkata for medical checkup, the Complainant was told by the doctor of the said hospital that in case of any occurrence of the said disease the existing medicines should be started along with others, the Complainant lodged the medi-claim before the OP-3 on 26.05.2015 along with all the relevant treatment related papers and documents of the concerned patient claiming for Rs.25,476/-, some information sought for by the OP-3, the same was accordingly provided by the Complainant. The allegation of the Complainant is that till filing of this complaint his legitimate insurance claim had not been settled by the Insurance Company and though several requests was made by him, no fruitful result yielded. By filing this complaint the Complainant has prayed for certain reliefs. The case of the OP-1 is that the claim of the Complainant was duly processed by the OP-3 who settled the claim for Rs. 8,664/-, but the said amount could not be disbursed in the bank account of the Complainant as the Complainant did not provide the same inspite of several requests to provide the bank details to the OPs. According to the OP-1 as there is no deficiency in service on its part, hence the Complainant is not entitled to any relief as sought for and prays for dismissal of the complaint.

During advancing argument the Ld. Counsel for the Complainant as well as the Complainant who was personally present submitted that it is within his knowledge that the OP-1 has settled his insurance claim for Rs.8,664/-, but the amount being too meager, hence this complaint is initiated. It is argued by the Ld. Counsel for the OP-1 that after processing the claim of the Complainant it was settled for Rs.8,664/- and intimating the same the OP-3 issued a letter seeking the bank details of the Complainant for transfer the settled amount through ECS mode. The OP-1 has further argued that as the Complainant did not provide his band details to the OP-3, the same could not be disbursed. The Complainant has admitted the same and stated that as the amount was too low he did not bother to provide the required information as he is not at all satisfied with the said settled amount.  It is stated by the Ld. Counsel for the OP-1 that the Complainant is not entitled to get Rs.6052.47/-x 2 = Rs.12,104.94/-  as claimed by the Complainant towards train fare because in view of the terms and the conditions of the policy the insured is not entitled to get the said amount. During argument the Complainant has admitted the argument of the OP-1, and moreover upon careful perusal of the terms and conditions of the questioned policy we did not find that there is any clause by which force the insured is entitled to get any transportation cost as per the insurance policy. So in our view the said amount of Rs.12,104.94/- should be deducted from the claimed amount of Rs.25,476/-.  The OP-1 has deducted the amount of Rs.202/- as inadmissible claim and Rs.400/- as initial Management charge from the claim amount. In support of such deduction the Complainant has raised vehement objection, but the Ld. Counsel for the OP-1 has attracted our notice at the documents no-21 &22 filed by the Complainant at the time of filing the complaint. From the document no-21 it is evident that the costs of Cotton 200 gm, Aqua Sure 2L Drinking Water and Chest Lid for Rs.70/-, Rs.30/- & Rs.102/- were deducted respectively from the claim due to inadmissible item. From the policy copy it is revealed that the Insurance Company shall not pay any amount towards inadmissible item/s. Hence deduction of Rs.202/- cannot be termed as deficiency in service. From the next document (22) it is transpired that Dr. N. Roy charged for Rs.400/- as initial management. According to the OP-1 as by charging the said amount there was no active line of treatment, hence in view of the policy the Complainant is not entitled to get the said amount. In our view such deduction was made by the OP-1 in accordance with the policy, does not create any deficiency. The OP-1 has deducted Rs.60/- as Glucometer chart was not available. In this respect we are to say that admittedly Glucometer was used and though the chart is not available, the OP-1 cannot deduct the said amount as for such non-availability of the same there was no role of the Complainant. Moreover as there is no bar to pay the said amount as per the policy condition, hence in our opinion the Complainant is entitled to get Rs.60/- as Glucometer charge.

The OP-1 has deducted an amount of Rs.1,134/- being the bill dated 26.05.2016  from the claim of the Complainant on the ground that after 60 days the claim is not payable as per the terms and conditions of the policy. In this respect the Ld. Counsel for the OP-1 has attracted our notice to the terms no-3.7 of the policy document from where it is evident that ‘reasonable and necessary medical expenses incurred for the treatment of disease/injury for a period up to 60 days from discharge from the date of discharge from hospital shall be considered as part of claim mentioned under item 1.2. It is seen by us that the OP-1 has rightly rejected the claim for Rs.1,134/- as claimed by the Complainant due to non-submission of the same within the due date of 60 days from the date of discharge. During argument the Ld. Counsel for the Complainant has admitted the same. In respect of the deduction of Rs.963/- towards co-deducted from admissible amount, as per the terms and conditions of the policy, the Ld. Counsel for the OP-1 has relied on the clause no-4.23 of the terms and conditions of the policy, wherein it is mentioned that ‘under Silver Plan the insured has to bear 10% of the claim amount in each and every claim’. In our view the OP-1 has deducted the said amount as per the terms of the policy. Such action hence cannot be termed as deficient service on behalf of the OPs.             

The record shows that the OPs are agreed to pay a sum of Rs.8,664/- to the Complainant towards his insurance claim. Now we are inclined to add a sum of Rs.60/- with the aforementioned amount as in our opinion the Complainant is entitled to get Glucometer charge in respect of the subject policy. Hence the amount will come for Rs.8724/-, which the OP-1 is bound to pay to the Complainant towards the medical expenditure incurred by him for the medical treatment of his insured son. Be it mentioned that the Complainant shall provide his bank details either to the OP-1 or the OP-3 for disbursement of the said amount through ECS mode. In our opinion as there was no deficiency in service on behalf of the OPs, the Complainant is not entitled to get any amount as compensation as sought for because without providing the bank details to the OP-3, the Complainant has approached before this Ld. Forum by filing this complaint praying for certain reliefs. Hence the Complainant is also not entitled to get litigation cost from the OPs as prayed for.

Going by the foregoing discussion hence, it is

Ordered

 that the complaint is allowed in part on contest without any cost against the OP-1 and allowed exparte against the OP-2 and 3 without any cost. The OPs are directed either jointly or severally to pay a sum of Rs.8724/- to the Complainant towards his insurance claim within 45 days from the date of passing of this judgment, in default, the abovementioned amount shall carry interest @8% p.a. for the default period.                       

             Dictated and corrected by me.                                                                 

                      (Silpi Majumder)

                           Member

                   D.C.D.R.F., Burdwan

             (Silpi Majumder)                                                               (Sri Pankaj Kr. Sinha)

                    Member                                                                            Member    

            D.C.D.R.F., Burdwan                                                          D.C.D.R.F., Burdwan