The present complainant Smt Soma Koley by filing this complaint has submitted that he purchased one insurance policy from the op after complying all formalities under policy having No. 101100/48/10/8500013057 valid up for 28.03.2012 and 29.03.2012 and to 28.03.2013 and complainant had been paying premiums regularly of against the said policy and continued the same by paying policy amount and it is the 6 year of the policy since taking of the policy.

          Fact remains complainant due to some suffering from IBD CROHN’s was admitted to Park Site Nursing Home where she was treated by the doctor Manoj Kumar Agarwal and she was admitted for the period from 14.12.2011 to 25.01.2012 and previous to that from 26.11.2011 to 27.11.2011 she was admitted and for spending huge money for treatment she submitted the claim before the op for reimbursement after complying all formalities for a sum of Rs.2,74,867/-.  But peculiar fact is that op on flimsy ground and in arbitrary manner sent a letter dated 27.04.2012 treating the claim of the complainant as closed citing the policy exclusion clause no. 4.1 of standard individual Mediclaim Policy and refused to release any claim amount without any justified ground and such sort of conduct on the part of the op has not fare and bonafide.  So by letter dated 03.05.2012  and 27.05.2012 complainant requested the op to reimburse the same for considering the same but ultimately no fruitful result was achieved by her and for which lastly for negligent and deficient manner of service of the ops, this complaint is filed.

          But in this case parties are op no1 National Insurance Co. Ltd. received the notice on 16.10.2012 of this complaint but thereafter op did not take any step not even appeared before this Forum.  Thereafter their Lawyer filed a petition praying for filing written version but ultimately taking several times they did not file the same for which the case is heard exparte.

         In the above situation we are deciding the entire claim on merit and relying upon the document filed by the complainant.

                                               Decision with reason

          On plain study of the complaint it is found that the complainant has prayed for redressal for reimbursement of Rs.2,74,767/- as insurance claim against mediclaim policy and for the treatment cost during the period from 24.01.2012 to 25.01.2012 and 26.11.2011 to 27.11.2011 and from the copy of the insurance policy as filed by the complainant it is found that complainant purchased insurance policy since 2006 and continued it till 2012 and from the said copy it is found that time to time sum assured of insurer was increased as per insurance policy of dated 19.03.2011 to 28.03.2012 thereafter also renewed policy from 29.03.2012 to 28.03.2013.  So, it is clear that continuously since 2006 complainant has been possessing a valid insurance policy per year.  So, no doubt she is a bonafide consumer as a mediclaim policy holder since 2006 till July 2013.

          But considering the medical report it is found that complainant was admitted to Park Site Nursing Home from 24.01.2012 to 25.01.2012 and previously from 26.11.2011 to 27.11.2011 and this period of treatment covers the risk of the complainant in respect of sum assured of Rs.4,00,000/-.  But any how op did not consider the same and rejected it without any valid ground.  However, it is found from the letter of the op  dated 27.04.2012 that the claim of the complainant was denied as per Clause 4.1 which proves that last four years of the policy claim was made by the policy holder and accordingly her claim was closed.  But considering the entire materials it is found that op has failed to prove that prior to the present policy No. 101100/48/10/8500013057 complainant released only any claim amount in respect of previous insurance policy and it is proved from the letter of the insurance company that insurance company has failed to prove that complainant got any insurance claim from the present policy which had been filed by her.  So, the entire letter dated 24.04.2012 is found baseless, rather which it is proved only for the purpose of repudiating the claim said letter was sent without any material.  But apparently after considering the material filed by the complainant Annexure- A page – 01 to 47 it is found that there is no such document to prove that prior to this complainant in any previous year against mediclaim policy she submitted claim and that was allowed by the op insurance company.

          When it is proved by the complainant that he never enjoyed any claim against any other previous policy then invariably as per provision of Clause- 4.1   complainant is entitled to the claim against the present policy which was/is valid and in fact op without any valid reason refused it what is no doubt uncalled for and unwanted.

          One matter must be mentioned in this regard because it will reveal that op had no cause to defend the allegation of the complainant for which op did not contest the case even after receipt of the summons of the complaint and even after appearing before this Forum through their Lawyer and prayed for time again and again without written version but ultimately left the fray.  What simply proves that op realized that it would not be possible for them to defend the claim of the complainant for which they have taken seat in their cold glass room by throwing the complainant to the Forum for relief but such act on the part of the ops is no doubt an unfair trade practice and for which the mediclaim insurance company has not been releasing the claim of the consumers as mediclaim policy holder which is not only proved in this case but in many cases it is proved that National Insurance company had adopted unfair path to repudiate all the valid claim of mediclaim policy holders through their agent TPA who are borne with such right to cancel and reject the claim of the insured in such a fashion.  Taking into all the above facts and materials and discussions we are inclined to say that the present complainant’s claim is bona fide and she is entitled to get it as per present valid policy and rejection of her claim by the op is unwarranted, uncalled for, immoral approach in nature and there was no justification or legal ground to reject it.  In the light of above observation, we find that complainant has proved her case for which she is entitled to get such relief as claimed.

          Hence, it is

                                                  ORDERED

          That the complaint be and the same is allowed with cost of Rs.2,000/- against the op.  Op is directed to pay a sum of Rs.2,74,767/- and also a compensation amount of Rs.27,000/- to the complainant within one month from the date of this order failing which for each day’s delay punitive damages to the extent of @ Rs.250/- per day till full satisfaction of the decree within stipulated period must be paid by op if it is not complied by the op within stipulated time as already provided in this judgement.

          This compensation part of Rs.27,000/- is awarded on the ground that op without any legal cause refused the said claim.

          Op is hereby directed to comply the order very strictly failing which penal action shall be taken against them for violation and disobeyance of the Forum’s order and for that purpose penal proceeding u/s 27 of C.P. Act 1986 may also be started.