This case has arisen out of an application U/s 12 of the Consumer Protection Act, 1986.
The case of the petitioner is that she purchased mediclaim policy No:4561211 from O.P.No-1 valid from 20.06.2016 to 19.06.2017, sum assured Rs.1,00,000/-, through O.P.No-3/corporate agent of O.P.No-1.
That suddenly on 1st March, 2017 she was admitted to Raiganj District Hospital & being referred admitted to North Bengal Medical College for better treatment & was taken to Peerless Hospitex Hospital and Research Centre Ltd on 06.03.2017 & under treatment of Dr. Ajay Krishna Sarkar, where some pathological testes were done and she was hospitalized for about 01 month and being fit return home.
Thereafter she submits medical reimbursement claim to the O.P office by depositing medical bill, voucher, prescriptions and report. After receipt O.P.No-2/TPA by a letter dated 13.07.2017 asked some papers
and by another letter dated 11.09.2017 stating queries from petitioner where there is no possible to answer the queries & subsequently she sent several reminder to O.P concern for settlement of the claim but no response. On 03.10.2017 O.P.No-2 by a letter repudiated her claim. Then she filed a complaint before AD, CA & FBP for redressal on 01.04.2019 but no action has been taken by O.P concern. Hence, she filed this complaint praying for return of insurance claim Rs.1,00,000/- with interest @10% pa from 01.03.2017, compensation of Rs.50,000/- & litigation cost of Rs.20,000/-.
O.P.No-2 did neither appear nor contest the case.
O.P.No-1 contested the case by filing W.V stating that it issued policy certificate No:-4561211 covering the petitioner for the period 20.06.2016 to 19.06.2017 assuring sum of Rs.1,00,000/-, subject to terms conditions and exclusions mentioned in the Group Health Insurance Policy No:-95000-0000-00.
That upon intimation from the petitioner, O.P.No-1 duly registered claim, through O.P.No-2 sought necessary medical documents required for processing claim on merits vide requirement letters dated 16.06.2017, 23.06.2017, 03.07.2017, 13.07.2017, 16.08.2017 23.08.2017, 02.09.2017 but in vain. The complainant did not furnish required medical documents viz i. Original Pre-printed numbered money receipt is required for the hospital bill amount of Rs.11,86,403/-, ii. The reason for the prolonged hospitalization to be certified by the attending doctor, for processing claim on merits. Lastly O.P.No-1 through O.P.No-2 issued a letter dated 03.10.2017 intimating closure of the claim due to non-submission of documents and no inference could be drawn as to admissibility of the claim within the precincts of the terms, conditions and exclusion of the policy. Thus O.P.No-1 prays for dismissal of the case.
O.P.No-3 also contested the case by filing W.V stating that petitioner is a retired school teacher and she purchased the policy from O.P.No-1 through O.P.No-3 and she herself admitted into Peerless Hospital on 06.03.2017 under Dr. Ajay Krishna Sarkar and after 01 month return home on 07.04.2017 & submits claim for re-imbursement supported by documents but the O.P.No-1 & 2 repudiated her claim whimsically. O.P.No-3 is no way responsible for the same. It also prays for exoneration from this case & dismissal of the case.
Points for consideration is:-
- Whether there was any deficiency in service on the part of the O.Ps which gives rise cause of action to file the complaint and the petitioner is entitled to get the claim?
D e c i s i o n w i t h r e a s o n s
Admittedly, the petitioner is a retired school teacher and she purchased Policy No:-0000000004561211, dated 20.06.2016, from O.P.No-1/Insurance Company, through O.P.No-3/Corporate Agent of O.P.No-1, covering the petitioner for the period 20.06.2016 to 19.06.2017 assuring sum of Rs.1,00,000/-, subject to terms, conditions and exclusions, mentioned in the Group Health Insurance Master Policy No:-95000-0000-00.
The case of the petitioner is that due to sudden illness on 1st March, 2017 she was admitted to Raiganj District Hospital & being referred admitted to North Bengal Medical College & Hospital for better treatment and was taken to Peerless Hospitex Hospital & Research Centre Ltd on 06.03.2017 & under treatment of Dr. Ajay Krishna Sarkar, where some pathological tests were done and she was hospitalized for about 01 month & being fit return home on 07.04.2017.
None of the O.Ps denied said case of the petitioner.
Admittedly, petitioner submits medical re-imbursment claim with medical bill, voucher, prescriptions, report to the office of O.P.No-1 & upon intimation/receipt O.P.No-1 duly registered claim No:-T1206172737 & processed through O.P.No-2/TPA.
Specific case of O.P.No-1 is that through O.P.No-2 it sought medical documents required for processing claim on merits vide requirement letters dated 16.06.2017, 23.06.2017, 03.07.2017, 13.07.2017, 16.08.2017, 23.08.2017, 02.09.2017 but in vain (all reminder letters are produced).
According to petitioner O.P.No-2/TPA by a letter dated 13.07.2017 asked some papers and by another letter dated 11.09.2017 stating queries from the petitioner where there is no possible to answer this queries. The petitioner did not produce the query letter dated 11.09.2017, which is required for proper adjudication, as there is no whisper about said dated letter from the end of O.P.No-1.
The petitioner stated that subsequently she sent several reminder to O.P concern for settlement of the claim but no response. No such reminder letter(s) is/are produced.
A letter dated 3rd-OCT-2017 of O.P.No-2 is produced, which runs as:-
2. We are in receipt of the additional documents, which were sent to us. However, we still require the following:
Original Pre-printed numbered money receipt is required for the hospital bill amount of Rs.1186403/-
The reason for the prolonged hospitalization to be certified by the attending doctor.
All this documents as requested are essential to process your claim as per the policy terms & conditions. Your non-response to the required letters reflects that you are not interested in the said claim.
As no claim can be left open for an indefinite period, we are constrained to close your claim as “closed claim” in our system as per the policy guidelines of the Insurer.
The O.P.No-1 by letter dated 03-OCT-2017 informed the petitioner-we have reviewed the documents submitted by you for your claims in accordance with policy terms and conditions and we would like to inform you that additional requirement(s) are yet to be received from your end. Our TPA had shared these requirements vide their letter on behalf of S.B.I Gen. Ins. Co. Ltd dated 23-AUG-2017, 02-SEP-2017, 12-SEP-2017.
We shall be under no obligation to make any payment under this policy unless as we have been provided with the documentation and information, We/Our empanelled TPA has requested to establish the circumstances of the claim, its quantum or our liability for it, Unless the insured person has compiled with his obligations under this policy, Hence current claim stands rejected due to non-compliance of non-submission of requisite documents post 03 reminders.
The foregoing repudiation by us on liability is issued based on the fact as at present. We reserve the right to extend or modify this repudiation in the event of new/additional facts or circumstances brought to our knowledge, further advising for consideration by contacting SBI GIC Grievance Redressal Committee and/or representing to office of Insurance Ombudsman having jurisdiction of the policy.
It is apparent that petitioner did neither submit new/additional facts or circumstances/documents as required nor moved the SBI GIC Grievance Redressal Committee nor represent her case to Insurance Ombudsman.
On the other hand she filed complaint before Assistance Director Consumer Affairs and Fair Businesses Practices, Uttar Dinajpur for redressal which ended fruitless.
Under above facts and discussion, we are of considered view that there was no deficiency in service on the part of O.P.No-1 or O.P.No-2 in closing/repudiating the claim of the petitioner for non-submission of required documents and O.P.No-3 has no role in the matter, consequently there was no cause of action to file the complaint and the petitioner is not entitled to get any relief as prayed for.
In the result the case fails.
Hence, it is
O R D E R E D
that the C.C-52/2019 be and the same is dismissed on contest against the O.P.No-1 & 3 and ex-parte against O.P.No-2 but without any cost.
Let a copy of this order be given to the parties free of cost.
