Date of Filing: 10.05.2018.                                                                Date of Disposal:  17.02.2023

Complainant                :Manas Banerjee, S/O Late Sadhan Banerjee, Resident of Pataihat, P.O. Dainhat, P.S. Katwa, Dist. Purba Bardhaman. Pin-713502.

-VERSUS -

Opposite Party            :1.SBI General Insurance Company Ltd. Burdwan Branch, Rep. by its Branch Manager, G.T. Road, SH-13, Nabarun Nagar, Ichhlabad, P.O. Sripally, Town & P.S. Burdwan, Dist. Purba Bardwan, Pin-713103.

2. The Director, SBI General Insurance Company Ltd., having its  Office at Nataraj, 101, 201 & 301, Junction of Western Express  Highway & Andherikurla Road, Andheri (East),  Mumbai-400069.

3. Medicare Insurance TPA Services (India) Pvt. Ltd, represented by its Manager, having its office at Paul Mansion, Ground Floor, 6B, Bishop Lefroy Road, Kolkatya, West Bengal, Pin-700020.

Present                                   : Mohammad Muizzuddeen             -Hon’ble President.

                                                : Mrs. Lipika Ghosh                         - Hon’ble Member.

                                                : Mr. Atanu Kr. Dutta.                     - Hon’ble Member.   

Appeared for the Complainant           : Sri Suvro Chakraborty                      Ld. Advocate.

Appeared for the Opposite Party        : Shri Shyamal Kumar Ganguli           Ld. Advocate.

FINAL ORDER

            On 10.05.2018, the complainant has filed the instant complaint u/S 12 of the Consumer Protection Act, 1986 against the OPs.

            The case of the complainant, in brief, is that the complainant incepted a Policy of Insurance (Medi-claim Policy) in the year 2013 for  covering the risk of his health from the OP Nos. 1 & 2 and the OP No.3 is a third party administrator in respect of the policy. After receiving the premium, the OP Nos. 1 & 2 issued certificate of policy in favour of the complainant and thereafter, he on each and every year renewed the same by paying premium amount to the OP Nos. 1 & 2 but in the year 2017-18, the policy number was 0000000000855469-04 which was valid from 29.03.2017 to 28.03.2018, total sum was insured Rs.1, 00,000/- and total premium amount was Rs. 2,657/- which was a cashless policy. During the continuation of the policy, the complainant began to suffer with his right ear and he went to Apollo Hospital at Chennai and as per advice of the doctor, the complainant took admission there. One surgery namely Tympano Plasty was done there. The complainant was admitted on 14.11.2017 and discharged therefrom on 17.11.2017. He informed the matter to the OPs but the OPs refused to give any benefit of the cashless policy and the complainant thereafter was compelled to take discharge therefrom on 15.11.2017 as he was not possessing sufficient amount for undergoing operation. It is further stated that on 16.11.2017, the Hospital Authority intimated him and his relatives that the OP No.3 TPA has approved Rs. 35,000/- out of total estimated expenses of treatment of Rs. 75,000/-. The Hospital Authority asked him and his relatives that for undergoing operation an amount of Rs.15, 000/- had to be paid by them towards the O.T. Charges and fees of doctor. As such the relatives arranged money by taking debt and admitted the complainant again on 16.11.2017 and the operation was done on 16.11.2017 and he was discharged on 17.11.2017. At the time of giving discharge, the Hospital Authority raised a bill of Rs.62, 360/- and intimated him that the OPs only paid Rs. 14,226 to them. However, his relatives arranged remaining amount of Rs. 48,134/- and paid it to the Hospital Authority. It is further stated that the time of discharge, the complainant and his relatives underwent a critical situation due to harassing nature of the OPs. The complainant then vide his letter dt. 03.02.2018 again made claim before the OPs. On receiving the said letter, the OPs only paid Rs. 1,469/- in the Bank Account of the complainant but they never intimated him regarding the reason of such lesser payment of settlement of his claim. Moreover, in spite of passing five months, the OPs did not bother to issue a single letter to him regarding the settlement of his claim. As such, on being frustrated, he lodged a complaint before the Consumer Affairs  Department, Kolkata, and after getting the letter from there, the OPs again paid Rs. 42,274/- on 02.04.2018 in the Bank Account of the complainant but they did not issue a single letter in respect of settlement of the claim. Till date there is a due of Rs. 4,391/- from the end of the OPs as the policy was a cashless policy. In this way, the OPs committed deficiency in service and unfair trade practice.

            The cause of action arose on and from 14.11.2017 and thereafter, the cause of action arose on several dates and is still continuing.

            Upon this background, the complainant prayed for directing the OPs to pay a sum of Rs. 4,391/- along with a direction to pay a sum of Rs.2,00,000/- as compensation for mental pain, agony and harassment and litigation cost of Rs.50,000/-.

            OP Nos. 1 & 2 have contested the case by filing W/V denying all the material allegations contending, inter-alia, that the complainant has no cause of action for the case and that the complaint is not at all maintainable in its present form and prayer and that the complaint is wholly misconceived and not sustainable in law and is  liable to be dismissed and that the complaint is barred by limitation but the OP Nos. 1 & 2 admitted the fact regarding the issue of the Medi-claim Policy along with risk and other facts regarding the policy No. and validity and the amount of the policy as stated by the complainant.

            The specific case of the OP Nos. 1 & 2 is that details payment of cash less payment was submitted herewith:- (i) By T 1211176233- the cashless claim wherein the OP paid Rs. 14,226/-, (ii) By T 1201181121 –the balance of cashless wherein the OP paid Rs. 44,711/-. The total payment was made by the OPs (Rs. 14,226/- + Rs. 44,711/-) = Rs. 58,937/- . The OP also made a pre-post claim T 120118592 of Rs. 1469/- out of total clam of Rs. 1580/- which is out of the purview of the present claim of Rs. 62,360/- submitted by the complainant. However, balance amount of (Rs. 62,360 – Rs. 58,937/- ) = Rs. 3423/- has not been paid for the below reasons of total cashless claim amount .

            Upon this background, the OP Nos. 1 & 2 claimed for dismissal of the case.

OP No.3 also filed W/V and denied all the material allegations.

The specific case of the OP No.3 is that the Hospital Authority forwarded the treatment documents to the OP No.3. The Cashless Department and the Doctor’s Panel of the OP No.3 after thorough scrutinization of the claim related to documents and considering the report of the investigation, strictly following the policy conditions as provided by the Hospital, duly settled the cashless claim of the complainant and duly came to a logical conclusion that the claim of the complainant is not payable in nature and adjudicated the said cashless claim to be “NO CLAIM”  in nature due to the underlying reasons:-

“The inception of policy is since 29.03.2017, the member is admitted with perforated tympanic Membrane Right Side and Requires Tympapanoplasty. As the doctor’s prescription the member had ear discharge since last one and half years (Pre-existing Clause-I). Moreover, there is one year waiting period for Tympanoplasty (Clause 3). Hence, cashless not accorded.

Upon this background, the OP No.3 has prayed for dismissal of the complaint.

                                           Decision with Reasons.

In order to prove the case, the complainant has filed evidence-on-affidavit but the OP Nos. 1, 2 & 3 did not file any questionnaire to the evidence of the complainant, even they did not file any evidence-on-affidavit. But OP Nos. 1 & 2 filed Written Notes of Argument.

Perused the complaint, Written Versions, Written Notes of Argument and evidence of the complainant, Xerox copies of documents filed by the complainant.

From the case record, it is clear that OP Nos. 1, 2 & 3 did not adduce any evidence in support of their Written Version. Mere filing of W/V is not the proof of the case on behalf of them, until and unless the evidence has been adduced in support of the W/V.

From the evidence of the complainant, it is found that the incident happened within the period of the coverage of the Insurance Policy i.e. Mediclaim Policy and the total bill was raised by the Hospital Authority of Rs. 62,360/- which was paid by the complainant though the policy was cashless in nature and the OP Nos. 1 & 2 also admitted that the Insurance Policy was cashless. Then the question arose as to why the OP No. 1 & 2 did not make payment at the time of discharge or subsequently after discharging from the hospital. As per admission of the complainant, the OP only paid Rs. 1,469/- in the Bank Account on 03.02.2018 and after lodging the complaint before the Consumer Affairs Department, Kolkata, the OPs paid Rs. 42,274/- on 02.04.2018 in his Bank Account i.e total payment was made Rs. (42,274/- + 1,469) = Rs. 43,743/- but the complainant admitted in his evidence that till date Rs. 4,391/- is still due from the end of the OPs as the policy is a cashless policy. But in the Written Argument, the OP Nos. 1 & 2 stated that as per policy condition, the claim was fully settled by payment of Rs. 58, 937/- against the claim amount of Rs. 62,360/- and the balance amount of Rs. 3,423/- has not been paid due to exclusion under the scope of the policy condition which is furnished in details in the Calculation Chart of the Written Notes of Argument but no document has been filed by the OP Nos. 1 & 2 in respect of his submission that the complainant is not entitled to get Rs. 3,423/- as per the policy which are totally excluded under the scope of the policy condition but the policy as filed by the complainant, nowhere it has been mentioned that those are excluded under the purview of the policy, rather when a patient is undergone an operation, it is quite natural that the whole cost of the operation will be paid by the patient and the patient is entitled to get the said cost of operation from the OPs as he issued cashless policy in his name. Therefore, the submissions of the OP Nos. 1 & 2 cannot be taken into consideration. There is no reason on behalf of the complainant as to how he came to a conclusion that Rs. 4,391/- is still due by the OPs to him and no calculation sheet has been submitted by the complainant and according to the Written Notes of Argument submitted by the OP Nos. 1 & 2, it is seen that Rs. 58,937/- has been fully settled by payment against the claim amount of Rs. 62,360/- and against it, the complainant did not file any Written Notes of Argument challenging the same. Accordingly, it can be said that Rs. 58,937/- has already been paid by the OP Nos. 1 & 2 out of the claim amount of Rs. 62, 360/- and they did not pay the balance amount of Rs.3,423/- as it was excluded under the scope of the policy condition but the same has already been discussed in the body of the judgment. Accordingly, that amount has to be paid by the OP Nos. 1 & 2 to the complainant. Therefore, the complainant is entitled to get only Rs. 3,423/- as still due amount to him by the OP Nos. 1 & 2.

Considering the above aspects and the situation of the case, we are of the view that the complainant is also entitled to compensation of Rs.20,000/- along with litigation cost of Rs. 5,000/- .

As a result, the case succeeds.

Hence, it is

                                                      ORDERED

that the Consumer Complaint No. 76/2018 be and the same is hereby allowed on contest against the OPs but without any cost.

OP Nos. 1 & 2 are directed to pay Rs.3,423/-(Three Thousand Four Hundred Twenty Three) only along with compensation of Rs.20,000/- (Twenty Thousand) only and litigation cost of Rs.5,000/-(Five Thousand) only to the complainant within 45 days from the date of receipt of the final order,  failing which the said amount shall carry interest @ 10% p.a. till realization.

The OP Nos. 1 & 2 are jointly and severally liable to pay the same.

Let a copy of this order be given to the parties on free of cost.

     Dictated & corrected by me.

                      President

     D.C.D.R.C , Purba Bardhaman.

               Member                                             Member                                             President

     D.C.D.R.C , Purba Bardhaman.   D.C.D.R.C, Purba Bardhaman.           D.C.D.R.C , Purba Bardhaman.