Dated : 10 Jul 2023

 HON’BLE SUDIP NIYOGI         PRESIDENT

FACTS

            Alleging deficiency in service and unfair trade practice against OP No. 1 and 2, the Complainant lodged this complaint on the facts as stated below:-

He i.e. the Complainant had taken insurance policy (Parivar Mediclaim) from OP No. 1 (National Insurance Company Ltd.) on 01/03/2016 by paying premium of Rs.16,761/- the basic covered sum of which was Rs.5,00,000/- and also paid required premium for 5 subsequent years upto 01/03/2021. Thus, the total amount of premium he had paid to OP No. 1 for the 6 years was Rs.1,75,962/-. The basic covered sum insured was Rs.10,00,000/- as on 01/03/2021. His Policy no. was 100304502010007975 for the relevant year 2020 – 21. Complainant on 10/09/2021 informed OP No. 2- the Disbursement Authority of OP No. 1 by mail that he would hospitalise his wife Mrs. Sudipta Das at Park Clinic i.e. OP No. 3 here in this case on 15/09/2021 for TAH+BSO Hysterectomy and removal of uterus, cervix and both fallopian tubes & ovaries and accordingly, on that day i.e. on 15/09/2021 his wife was admitted there and after successful operation, she was discharged on 21/09/2021. The amount of expenses in the hospital including operation and treatment was Rs.2,05,663.90/- which was paid by the complainant to OP No. 3. Subsequently, he made a claim of that amount from the insurance company and on 02/11/2021 he got reimbursement of Rs.65,025/- only from OP No.2. Complainant subsequently, made a claim of balance amount of Rs.1,40,638.90/- which was not paid to him. Later, Complainant lodged a complaint against OP No. 1 & 2 before the Central Consumer Grievance Redressal Cell, Consumer Affairs Department, Government of West Bengal where a tripartite meeting was held but ultimately, no fruitful result came out. So, Complainant prayed for a direction upon OP No. 1 & 2 to make the payment of balance amount of Rs.1,40,638.90/- and also for legal expenses, cost of harassment etc. 

            Here OP No. 2 did not appear and file any written version and contest the case. However, OP No. 1 and 3 filed separate written versions and contested the case. OP No. 1 denied the allegations made against them. According to them, the payment was made to the Complainant following the terms and conditions of the insurance policy. OP No. 3-the Park Clinic where the wife of the Complainant had been admitted and treated, contended that no claim of relief was made against them by the Complainant.

            Complainant and both the contesting OPs (1 & 3) filed their evidence. Questionnaires were also issued by the parties to which replies were also submitted. Both parties also filed their brief notes of argument. We considered all these and also the documents produced on behalf of the Complainant in c/w this case.

            The point for consideration is whether the complainant is entitled to the relief(s) as prayed for in this case. 

FINDINGS

            Admittedly, the Complainant had insurance policy (Mediclaim) with OP No.1 for himself, his wife and son at the relevant time. Admittedly, also that the wife of the Complainant had been admitted to OP No.3 Park clinic on 15.09.2021 for TAH+BSO Hysterectomy and removal of uterus, cervix and both fallopian tubes & ovaries and she was discharged on 21.09.2021.

            It is also found that the Complainant paid an amount of charges of the hospital to the tune of Rs.2,05,663.90/-. Subsequent thereto, Complainant made a claim for reimbursement of the said amount from the insurance company and he also submitted all the necessary documents with them and on consideration, OP No.2 reimbursed only Rs.65,025/- which according to them the Complainant was lawfully entitled to. But the Complainant was not at all satisfied with the said argument of the insurance company.

            According to the insurance company following the terms of the policy the insured was eligible to get cashless and/or reimbursement benefits in case of hospitalization due to illness or accident covered under the policy which provides that the hospitalization expenses incurred has to be customary and reasonable for the purpose of payment. Further, the case of the insurance company is that they have a package rate agreement with hospitals in the city including the hospital for some specified procedures including one undergone by present insured i.e. Complainant’s wife and the Park clinic i.e. OP No.3 provides surgery for PPN Package rate of Rs.42,000/-. So, the insurance company paid as specified in their evidence and written argument Rs.42,000/- for hospitalization, Rs.478/- for other expenses during hospitalization, Rs.20,845/- for pre-hospitalization bill and Rs.1702/- for post-hospitalization bill. Thus, Rs.65,025/- in total.

            Now, the most pertinent question is why the Clinic (OP No.3) charged more than the amount specified under PPN Package, when the Complainant had a Mediclaim for his wife who underwent the treatment.

According to the Insurance company, the Complainant while getting his wife admitted to OP No.3 Clinic did not disclose that he had Mediclaim with insurance company i.e. OP No.1. So, the Clinic did not charge following the PPN package. OP No.3 informed OP No.2 by email dated 09.02.2022, Mrs. Sudipta Das was admitted to the said hospital on 15.09.2021 without any reference to any insurance scheme and she was charged on actual basis.

On the other hand, Complainant claimed that he had verbally informed OP No.3 that he had Mediclaim. Not only that, what we find that the Complainant had intimated OP No.2 i.e. the Disbursing Authority of OP No.1 insurance company on 10.09.2021 by an email that his wife would undergo hospitalization at OP No.3 clinic on 15.09.2021 under Dr. Amitava Mukhopadhya for TAH+BSO Hysterectomy and removal of uterus, cervix and both fallopian tubes & ovaries and also requested to take the intimation as claim intimation and confirm. On receipt of the intimation OP No.2 issued one claim intimation no. which was “2834417”.

            Here Complainant preferred reimbursement benefit which is admittedly permissible under the terms of the policy/Mediclaim policy and he did not commit any wrong in not preferring the cashless benefit as both the benefits were permissible. On behalf of the insurance company much emphasis was given on the alleged act of the Complainant in not informing OP No.3 Clinic as to his Mediclaim. According to them, had he informed the same, the PPN Package would have been implemented. In absence of disclosure as to Mediclaim, Complainant has to bear the entire expenses beyond the limit of the amount of reimbursement that he is entitled to under PPN Package.

            It is to be noted here as usual, that Complainant obtained insurance policy/ Mediclaim for himself and the other members of his family including his wife in order to guard themselves from any unforeseen future expenditure arising out of health issues. So, when the actual occasion arises why the Complainant would suppress the said fact of Mediclaim / Policy coverage from the clinic/ hospital authority because that would be absolutely not for his interest. His bona fides have been amply displayed by the fact when he had informed the concerned Authority/ insurance company beforehand about the hospitalization and treatment of his wife including the name of the hospital, the date of admission and the nature of the treatment etc. and that information was duly acknowledged by OP No.2.

            In these circumstances, we do not find any reason to hold that the Complainant had withheld the information of his Mediclaim from the hospital authority. The Hospital authority cannot shirk their responsibility of doing the needful so that the purpose of obtaining Mediclaim by the Complainant is made fruitful.

            So, having considered the entire materials on record and on consideration of the submissions made on behalf of all the parties we think, the Complainant should get the relief in this case.

            Needless to mention it is that the instant complaint is quite maintainable before this Commission in accordance with the provisions of the CP Act, 2019.

            OP No.1 & 2 are under liable to pay Rs.1,40,638.90/- being the balance amount of the Complainant’s prayer for reimbursement along with interest @ 8% p.a. to the Complainant from the date of 02.11.2021, i.e. the date when OP No.2 paid the amount of Rs.65,025/- towards the Mediclaim of the Complainant. Both the said OPs are also liable to pay Rs.5,000/- towards cost of litigation.

            As no relief was sought for against OP No.3, the instant case is liable to be dismissed against them on contest.

Accordingly it is

ORDERED

That the instant complaint be and the same is allowed against OP No.1 on contest and ex parte against OP No.2 and dismissed against OP No.3 on contest.

OP No.1 & 2 are directed to make the payment of Rs.1,40,638.90/- (Rupees One Lakh Forty Thousand Six Hundred Thirty-Eight and Ninety Paise Only) along with interest @8% p.a. to the Complainant from the date of 02.11.2021, within a period of 45 days from the date of this order. If the aforesaid amount is not paid within the said stipulated period, the awarded sum shall carry interest @10% p.a.

OP No.1 & 2 are also to pay a sum of Rs.5,000/- (Rupees Five Thousand Only) towards cost of litigation to the Complainant.

If the abovesaid order is not complied with by OP No.1 & 2 within the said stipulated time, Complainant shall be at liberty to proceed in accordance with law.

Dictated and corrected by me