The Complainant filed a petition u/s. 35 of the C.P. Act, 2019 against the O.Ps. The brief facts of the case is that the complainant covered himself as well as his family’s life with the O.Ps company through an insurance policy vide No. P/191139/01/2022/001020 which was valid from 15:41 hrs on 28^th August, 2021 to midnight of 27^th August, 2022 and the customer code of the complainant is AA0008876014 which policy covered himself and his wife Smt. Mita chakraborty and two daughters namely Smt. Annyesha Chakraborty and Smt. Akanshya Chakraborty and the sum assured of said insurance policy is Rs. 5,00,000/- (Five Lakh). On 09/09/2021 complainant’s wife became seriously ill due to some gynaelogical problem and as per advised of her doctor she was compelled to take admission of SREE KRISHNA NURSING HOME, Alipurduar for her medical treatment and she was released from said nursing home on 13/09/2021. The next date on 27/10/2021 she again became seriously ill and the complainant taken her before Dr. K.P. Biswas and said doctor advised to take her another hospital for her better treatment. Considering the health position of patient and the advise of the doctor, seeing no other alternative on 27/10/2021 the complainant taken her at NEOTIA GETWELL HEALTH CARE CENTRE, Siliguri and the doctor of the said nursing home namely Dr. Abhisekh Kumar Sing advised her for some pathological and other examinations on that said very date i.e. on 27/10/2021 and the complainant did the same.  On the report it was found a) Small air foci in the urinary bladder. b) Fistulous tract between the posterior wall of fundus of urinary bladder and upper end of vagina with evidence of passage of contrast from the urinary bladder into the vagina and the doctor of said nursing home suggested he for one major and risky operation which may be done by the said doctor but after two weeks since the day suggested some medicine for that period.

            That in the meantime the complainant claimed the treatment expense from the insurance company and deposited all original documents through their agent and on 26/04/2021 they refused to pay any amount for the treatment on that ground that in the certificate issued by Dr. K.P. Biswas dated  09/10/2021 where one date was tempering on their eye.

            After return to the home the condition of the patient was going very serious, so that they compelled to take decision to go to Chennai  for her better treatment and they went to Chennai and registered the name of the patient at Apollo Hospital and appeared before Dr. Deepak Raghavan on 18/11/2021 where he also suggested for major operation which will be done second week of December, 2021 and he also returned to consultant anesthetist for fix up the date of operation. The Apollo Hospital, Chennai given estimate of operation which was huge amount. So that the complainant returned back with her wife at Alipurduar as they have no such amount of money at that time. Thereafter the complainant consulted with the local doctors and they advised to complainant to take his wife at Manipal Hospital, Bangalore. Considering the detoriation health condition of the patient the complainant was compelled to take money as loan from his friend circles and went to Bangalore with his wife on 15/01/2022 and registered the name of his wife in the Manipal Hospital, Bangalore and on that date Dr. Deepak Dubey examined her and suggested some test. After that the said Dr. advised to admit immediately and a major operation is needed. On that request of complainant the Manipal Hospital authority requested to the O.Ps for approval for cashless treatment to their insured member Smt. Mita Chakraborty but the O.Ps also refused to approve the cashless treatment through their letter dated 19/01/2022. On 17/01/2022  the patient was admitted and on 19/01/2022 operation was done and the said hospital discharge her on 21/01/2022. After discharge the complainant and his wife came back at Alipurduar on 23/01/2022 by air and road. Till today   the patient Smt. Mita Chakraborty is bed ridden and she is unable to walk also he totally depend on costly medicine as per advice of doctor. Complainant beard huge amount of money for her treatment out of which SREE KRISHANA NURSING HOME, Alipurduar taken Rs. 43,800/- on 13/09/2021 and Rs. 1,142/- ib 13/09/2021 through their medicine counter namely Roy Medico, total Rs. 44,942/-. The complainant also filed five bills issued by Manipal Hospital, Bangalore, total amount of Rs. 2,20,660/-. After release from the nursing home the complainant claimed the insurance amount as per provisions of the O.Ps within time and as per direction of the O.P the complainant sent all the original papers and bill to the company through the agent of O.Ps but O.Ps request the said claim only on pretext that one certificate issued by Kr. K.P. Biswas at initial stage i.e. 09/10/2021 where a date was tempered by doctor. The O.Ps paid only Rs. 5,350/- which was first claimed and totally different from this treatment.

            Thereafter the complainant several times connected with O.Ps and their agent also and on 26/09/2022 they refused to pay the same.

            Ultimately the complainant has filed this case and praying for Rs. 2,79,232/- as claiming amount and Rs. 4,00,000/- for his mental agony and harassment and also claim Rs. 20,000/- as litigation cost, total claim of Rs. 7,99,232/-.

            To prove this case the complainant filed evidence-on-affidavit, written argument and some documents by firisty.

1. Annexure – A (The copy of said policy Vide No. P/191139/01/2022/001020).
2. Annexure – B (The copy of said Dr. K.P. Biswas advice prescription for admission).
3. Annexure – B1 (The copy of test report of patient by Dooars Clinical Laboratory).
4. Annexure – C (The copy of discharge certificate).
5. Annexure - C1 ( One certificate issued by Dr. K.P. Biswas on 09/10/2021).
6. Annexure – D (The copy of said referral slip issued by K.P. Biswas).
7. Annexure – E (Copy of doctors prescription).
8. Annexure – F (Radiology report).
9. Annexure – G (Copy of repudiate letter issued by O.P dated – 26/11/2021).
10. Annexure – H (Copy of advice of Dr. Deepak Reghaban of Apollo Hospital, Chennai dated – 18/11/2021).
11. Annexure – I (Prescription of Dr. Debey dated – 15/01/2022).
12. Annexure – J (Letter issued by O.Ps to the Manipal Hospital, Bangalore dated – 19/01/2022).
13. Annexure – J1 (Letter issued by the O.Ps to the complainant dated – 19/01/2022).
14. Annexure – K (Admission, operation and discharge certificate in the name of Smt. Mita Chakraborty dated 17/01/2022 to 22/01/2022).
15. Annexure – K1 (Fit certificate issued by Manipal Hospital, Bangalore to journey in Air).
16. Annexure – L, L1, M, N, N1 and N2 (Copy of bills issued by Newtia Getwell Health Care Centre dated – 27/10/2021)
17. Annexure – O, O1, O2, O3 and O4 (Copy of bills issued by Manipal Hospital, Bangalore).

The instant case was admitted on 06/01/2023 Order No. 2. To contest this case on 08/02/2023 O.P Nos. 1 and 2 appeared before this Commission and filed written version, evidence, written argument and filed some documents on 12/07/2023.

These documents are given below:-

1. Customer information sheet, Family Health Optima Insurance Plan with terms and conditions.
2. Letter dated 05/10/2021 issued by Star Health Insurance to Chinmoy Chakraborty.
3. Letter dated 09/10/2021 issued by Star Health Insurance to Chinmoy Chakraborty.
4. Letter dated 24/10/2021 issued by Star Health Insurance to Chinmoy Chakraborty.
5. Letter dated 08/11/2021 issued by Star Health Insurance to Chinmoy Chakraborty.
6. Letter dated 23/11/2021 issued by Star Health Insurance to Chinmoy Chakraborty.
7. Repudiation of claim letter dated 26/11/2021 issued by Star Health Insurance to Chinmoy Chakraborty.

The specific case of the O.Ps are that there is no cause of action against the O.Ps under the C.P. Act. The O.ps stated the insured Mrs. Mita Chakraborty was admitted for treating “Total Abdominal Hysterectomy (TAH) and Bilateral Salpingo Oophorectomy (BSO) at Sree Krishna Nursing Home from 09/09/2021 to 13/09/2021. The O.P insurance company was approached for availing reimbursement facility for an amount of Rs. 43,8000/- vide claim form along with discharge summary, indoor case papers (ICP), prescription dated 09/09/2021and final bills. On scrutiny of documents certain queries were raised vide letter dated 09/10/2021 requesting the complainant to submit the following documents.

1. Biopsy reports along with investigation done during the admission.
2. USG abdomen report.
3. Operation sheets prior to the admission.
4. Letter from the treating doctor stating the duration of current ailment.
5. Complete blood investigation.

Two reminders requesting the same submission was communicated to the proposer vide letter dated 24/10/2021 and 08/11/2021. However  since the complainant ailed to submit the said requested documents even after giving 30 days time and the claim was rejected vide letter dated 23/11/2021. The O.Ps also stated that from the limited documents submitted by the complainant on 23/11/2021 it was observed that the date of first consultation paper was tempered with in prescription dated 09/10/2021 wherein the date was changed from 28 to 29 of August, 2021. The O.Ps stated that in his plea that this act amounts to misrepresentation and misdescription of “Material Facts” as per clause 4(1) of policy terms and conditions. The complainant failed to submit O.P sheets prior to the current admission as well as complete blood investigations inspite of reminders due to which the claim was repudiated for 26/11/2021 for want of documents as per clause 4(18) of policy terms and conditions.

            The O.Ps further stated that when the complainant approached before the C.A. & F.B.P. and Lok Adalat. The complainant was requested to submit the following documents supporting the timelines mentioned in prescription dated 09/10/2021 to further evaluate the claim once again a. exact duration of Anaemio with first medical papers b. Cause of Anaemia c. First consultation papers w.r.t issues in uterus which let to TAH. The reason for requesting such documents was that the treatment of TAH and BSO was done due to severe Anaemia as per prescription dated 09/09/2021 but the complainant is unwilling to cooperate with the opposite parties / insurance company.

            The O.P company also stated in their plea that the source of the current diagonosis of vesico vaginal fistula is anaemia since the said diagnosis was due to TAH which cropped up from having anaemia. This can be further substantiated from prescription dated 28/01/2022 wherein the cause of anaemia is mentioned to be bleeding in vagina for few weeks.

            Both O.Ps stated that no deficiency in service on their part and as such the complainant is not entitled to get any relief from the O.Ps.

            We have gone through the materials on record very carefully and also perused the documents which are lying on case record. Considering the above pleadings the following issues are necessarily come up for the proper adjudication of this case.

     POINTS FOR CONSIDERATION

1. Is the complainant a consumer u/s. 2(7)(ii) of Consumer Protection Act, 2019 ?
2. Has this Commission jurisdiction to try the instant case?
3. Is there any deficiency in service on the part of the O.Ps?
4. Is the complainant entitled to get any relief/reliefs as prayed for?

DECISION WITH REASONS

            Considering the nature and character of the case all these points are interlinked to each other as such all the points are taken up together for consideration for the sake of brevity and convenience. The case has been filed u/s. 35 of the Consumer Protection Act, 2019 by the complainant.

Point Nos. 1 & 2:- This is admitted that the complainant Mr. Chinmoy Chakraborty took Family Health Optima Insurance Policy covering himself, his spouse Mr. Mita Chakraborty and dependent two children for sum of Rs. 5,00,000/- vide Policy No. P/191137/01/2020/000221 for the period from 27/05/2019 to 28/05/2020 which was subsequently renewed vide Policy Nos. P/191139/01/2021/000069 for the period from 23/06/2020 to 22/06/2021 and P/191139/01/2022/001020 for the period from 28/08/2021 to 27/08/2022. So there is no hesitation to hold that the complainant is a consumer within the meaning of u/s. 2(7)(ii) of C.P. Act, 2019 and the complainant and his family members resides within the jurisdiction of this Commission and the O.Ps offices situated within the territorial jurisdiction of this Commission. Therefore, this Commission has territorial jurisdiction to try this case as per u/s. 34 of C.P. Act, 2019.

Point Nos. 3 & 4:-  It is the case of the complainant that the complainant covered himself as well as his family’s life with the O.ps company through an insurance policy , sum assured of said policy is Rs. 5,00,000/-. On 09/09/2021 complainant’s wife namely Smt. Mita Chakraborty became seriously ill due to some gynaelogical problem and as per advised of her doctor she was compelled to take admission at SREE KRISHNA NURSING HOME, Alipurduar for her medical treatment and she was released from the said nursing home on 13/09/2021. After that on 27/10/2021 she again became seriously ill and the complainant taken her before Dr. K.P. Biswas and the said doctor advised to take her another hospital for her better treatment. the complainant on the said date taken her at Neotia Getweel Health Care Centre, Siliguri and some pathological and other examinations were done on that said very date i.e. 27/10/2021. After that for better treatment the complainant take decision to go Chennai and they went to Chennai and registered the name of patient at Apollo Hospital and appeared before Dr. Deepak Raghavan on 18/11/2021 where he also suggested for major operation and given the estimate of operation which was huge amount. So the complainant returned back with her wife at Alipurduar and thereafter, they went to Manipal Hospital, Bangalore on 15/01/2022 and registered the name of his wife in that said Hospital and as per advice of Dr. Deepak Dubey some examination had been done. After some examination the doctor suggested to admit immediately for a major operation. On the request of complainant the Manipal Hospital authority requested to the O.Ps for approval for cashless treatment to this insured member Smt. Mita Chakraborty but the O.Ps refused to approve the cashless treatment through this letter dated 19/01/2022. Operation was done on 19/01/2022 and the said hospital discharges her on 21/01/2022 and the complainant and his wife came back at Alipurduar on 23/01/2021 by air and road.

Now the question is there any deficiency in service on the part of the O.Ps? or Is the complainant is entitled to get any relief / reliefs as prayed for?

After hearing both the parties, we are of the considered view that although the complainant took family health optima insurance policy covering himself, his spouse and dependent two children for insured of Rs.5,00,000/- vide policy No. P/191139/01/2022/001020 which was valid from 15:41 hrs on 28^th August, 2021 to Midnight of 27^th August, 2022 and after his wife treatment and operation the complainant claimed the treatment expense from the insurance company and deposited some original documents and bills through their agent but the O.Ps refused the said claim only on pretext that one certificate issued by Dr. K.P. Biswas at initial stage i.e. 09/10/2021 where a date was tempered by doctor.

We have seen from the case record that the O.P insurance company was approached for availing reimbursement facility for an account of Rs. 7,000/- vide claim from along with discharge summary, investigation records, indoor case paper (ICP) and final bills. Accordingly an amount of Rs. 5,350/- was paid vide NEFT having UTR No. 53221844355680 dated – 20/02/2022. This payment of Rs. 5,350/- was supported with billing assessment sheet, which clearly shows reasons for nonpayment against certain items based on available submitted documents, policy terms and conditions as well as IRDA guidelines. Accordingly the said sheet also mentioned that there was no break up for medicine bill of Rs. 1,650/- towards hospitalization expenses. We also seen that when the complainant approached towards settling the balance claim amount before the C.A. & F.B.P. and Lok Adalat the complainant was requested to submit the break up for medicine expenses incurred of Rs. 1,650/-. However the O.Ps Insurance Company is unable to process with the same unless the said break up is provided for Rs. 1,650/-.

We have seen from the case record that two reminder requesting the same submission was communicated to the proposer vide letters dated 24/10/2021 and on 08/11/2021 and when the complainant approached before the C.A. & F.B.P and Lok Adalat, the complainant was requested to submit some essential documents complainant. However since the complainant failed to submit the said requested documents even after giving thirty days time. The complainant failed to submit O.P sheets prior to the current admission as well as complete blood investigation inspite of reminders. From the limited documents submitted by the complainant on 23/11/2021 i.e. prescription after the said rejection was sent to the complainant, it was observed that the date of first consultation papers was tempered with in prescription dated 09/10/2021, wherein the date was changed from ‘28’ to ‘29’ of August, 2021. This act amounts to misrepresentation and misdescirption of material facts as per clause 4(1) of policy terms and conditions.

As per IRDA rules incomplete documents is another mistake of the complainant. The insurance company needs specific documents, bills, medical certificates to process the claim. Failing to submit those documents can result in the repudiation of the claims. Incorrect or false information in the claim can lead to claim repudiate.

It is essential to provide accurate and honest information to avoid complications during the claim process. The insurance company checks the details provided by the policy holder and any inconsistencies found can lead to the denial of the claim.

Thus it is crucial to follow the claim process such as filing the claim within the stipulated time, submitting the necessary documents and providing accurate information.

We find that at first the O.Ps paid some claim of the complainant without any objection on the basis of the letter Annexure – C1. We also find that the Manipal Hospital, Bangalore wrote a letter to the O.Ps for cashless treatment as wife of the complainant as a valid health insurance with the O.Ps. But Annexure - G reveals that due to the tempering of the doctors letter dated 09/10/2021 the said claim i.e. cashless treatment can not be accepted. Now, we consider Exhibit - C1 which is disputed according to O.Ps as it is tempered as alleged. From the documents (Annexure – C1) we find it is a prescription of a Dr. K.P. Biswas and on the body of this prescription after point No. 3 the date was written 28/08/2021 but subsequently it was over writing by 9 in place of 8 that means 29/08/2021. We also find that on the right side of the tempering date as alleged another date i.e. 28/08/2021 has been written by the doctor with his signature and seal and after careful scrutiny of the case record we find that the Annexure C1 after point No. 1 that date is mentioned as 29/08/2021 which is the first diagnosis date so the tempering as alleged by the O.Ps has no leg to stand as because in other two place of Exhibit - C1 the correct date was 29/08/2021 has been written and the O.Ps as intentionally refused to allow the cashless treatment of the wife of the complainant only on the ground of the said tempering.  But we find that there is no such tempering in the said Exhibit - C1 one place there is an over writing of the date but in other two places the said date has been written specifically without any over writing of the doctor with his signature and seal. The O.Ps have refused the claim for cashless treatment on that flimsy ground which is not at all correct.

It also appears that after completion of the treatment the complainant has submitted all his documents to the office of the O.Ps and all the relevant documents has been filed to the O.Ps but the O.Ps did not clear the claim mainly on the ground of tempering of Annexure C1 and also for non-supplying of all documents but from the case record we find that the several documents Annexure - D2 and O4 have been filed by the O.Ps for his claim petition as desire by the O.Ps inspite of that the O.Ps did not release the claim amount of the complainant mainly on the ground of the tempering on Annexure C1 which is not at all  tempered and the view of the O.Ps in this regard totally wrong. The whimsical Act of this O.Ps tantamount to the harassment of the complainant and his wife as because the complainant has a valid insurance policy with the O.Ps which covered he himself, his wife and two daughters and inspite of that insurance he did not get any monitory relief from the O.Ps. The act of the O.Ps clearly indicates that they have avoided the payment of insurance claim in any flimsy ground. The rule 4(1) of the policy terms and condition is not applicable here as because there was no tempering on the prescription Annexure - C1.

It appears that the insured pay the premium for their health insurance with an expectation that at the time of their requirement then will get the benefit from the insurance company. But in most of the cases we find that the insurance company taking the premium years together when the claim petition is filed they have taking the avoiding tendency for releasing money which require to the customer or their monitory benefit. Here the similar case has been done the complainant has paid the premium one after another but when he has filed the claim petition the insurance company are trying to detect the defect of their claim and most of that cases the said defects are in flimsy ground. This is nothing but the harassment to the customer.

We find there is definitely a deficiency in service from the side of the O.Ps by taking a flimsy ground to avoid the payment to the complainant inspite of his genuine and valid documents. The complainant is entitled to get relief from this case. After considering the facts we find that the complainant is entitled to get Rs.  2,79,232/- along with interest for the cost of treatment including operation, medicine etc. He is entitled to get Rs. 2,00,000/- as his mental agony and harassment. The complainant is not entitled to get any flight fare, train fare etc. which he has claimed as because no such documents are filed and there is no provision of the policy in this regard. The complaiannt is also entitled to get Rs. 10,000/- as litigation cost.

Thus all the points are disposed of accordingly in favour of the complainant.

            Hence, for ends of justice; it is;-

  ORDERED

that the instant case be and same is allowed on contest against the O.Ps. The complainant do get an award amounting to Rs. 2,79,232/- (Two Lakh Seventy-Nine Thousands Two Hundred Thirty-Two) for his insurance claim for medical treatment along with interest of 6% Per Annum from the date of filing to till the realization of the amount. The complainant is also do get an award amounting to Rs. 2,00,000/- (Two Lakh) as compensation for his harassment, mental agony and sufferings and also Rs. 10,000/- (Ten Thousands) as his litigation costs; total decreetal amount of Rs. 4,89,232/-(Four Lakh Eighty-Nine Thousands Two Hundred Thirty-Two) excluding interest. The O.Ps are liable to pay the said award amount and they are hereby directed to comply this order within 30 days from this day, failing which legal action will be taken against him.

           Let a copy of this final order be sent to the concerned parties through registered post with A/D or by hand forthwith for information and necessary action.

Dictated & Corrected by me