Hon’ble Mr. Subhas Ch. Guin, Member.
The non-payment of claim of group mediclaim has dragged the Complainant, before this Commission for redressal of his grievance, who is an agent of Life Insurance Corporation of India in Cooch Behar Branch having agent code:- 0661455. That being a senior citizen he became a member of Group Mediclaim for agents and their spouse of LICI with a coverage for Rs.1,50,000/- for the year 2017-2018 having master Policy No.12030034180400000011 for which a sum of Rs.1470/- was paid by the Complainant to the competent authority as premium. But unfortunately on 29.11.17, the Complainant met with an accident and got admitted in Cooch Behar Mission Hospital for treatment with a head injury under Dr. Nirmal Palit who is a Neuro Surgeon. He was under the treatment of the said doctor from 29.11.17 to 05.12.17 which was intimated to the Branch Manager LICI, Cooch Behar Branch (O.P. No.1) for formality of the group mediclaim. Thereafter, the Complainant submitted a claim of Rs.1,47,499/-(One Lakh forty seven thousand four hundred ninety nine only) to the O.P. No.1 on 10.01.18 alongwith required original documents. On receipt of the said claim under group mediclaim policy, the O.P. No.1 sent the same to the Office of the Divisional Manager, LICI, Jalpaiguri Division, Dist- Jalpaiguri(O.P.No.2) with recommendation which later sent to the Medi Assist Insurance TPA Pvt. Ltd., 25, Brabourne Road, Kolkata-1 (O.P. No.3) for payment of the said amount. The O.P. No.1 also assured the Complainant that they would make arrangement for payment of the same within short period from their end. But despite repeated contact with the O.Ps. The payment of the claim was not made and the O.P. No.1 was dilly-dallying with the Complainant. Later, the O.P. No.1 had given an e-mail copy to the Complainant which revealed that the O.P. No.1 mailed a letter requesting the O.P. No.2 & 3 to make payment of the said claim of the Complainant expeditiously but all these efforts were in vain. Then, the Complainant informed the O.P. No.3 through e-mail for payment of the said claim on 22.05.18 which also yielded nothing causing the Complainant to face hardship and suffering from mental pain and agony. Thus by such wilful act of omission and Commission in non-settling of the aforesaid claim amount of the Complainant, the O.Ps have caused a deficiency in service. Having found no other alternative, the Complainant filed this case before the Commission for having justice against the O.Ps. The cause of action of the present case arose on 29.11.17 when the Complainant met with the accident and on 10.01.18 when he submitted the claim of Rs.1,47,499/- with requisite original documents to the competent authority for payment of the said claim and still continuing. The Complainant prayed for a direction to the O.Ps to pay the mediclaim amount of Rs.1,47,499/- in favour of him and pay a sum of Rs.1 Lakh for deficiency in service and Rs. 1 Lakh for mental pain, agony and harassment and Rs.15,000/- for cost of proceeding in favour him.
Notice were served upon the O.Ps. Despite service of the notice the O.P. No.3 did not turn up before the Commission to contest the case. So the case was decided to be heard ex-parte by the Commission vide its order No.05 dated 09.08.19. But on 16.02.23, the O.P. No.3 filed a petition to contest the case by filing Vokalatnama on the next day. The copy was served to the Complainant to which Complainant raised objection and claimed huge cost from the O.P. No.3 in case the petition being allowed as the case had come at the last date of hearing of argument and the Complainant being a senior citizen incurred a huge litigation cost for last 5 years. Accordingly, the O.P. No.3 was given an opportunity to contest the case on payment of cost of Rs.20,000/- to the Complainant as condition precedent. On the next date of hearing i.e. on 01.03.23 representative of the O.P. No.3 was present but did not pay the cost as per previous order dated 16.02.23. The Ld. Advocate for the Complainant submitted that their argument was over as such it should be fixed for passing Final Order. So it was fixed for passing Final Order on 20.03.23 ex-parte against O.P. No.3. The O.P. No.1 & 2 contested the case by filing written version, evidence on affidavit and written arguments. The O.P. No.1 & 2 in their defence plea stated that the Complainant, Sri Bimal Chandra Barman was an agent of LICI with code No-06661455 under Cooch Behar Branch of the O.P. No.1 and also a member of group mediclaim policy which was purchased from New India Assurance Company Ltd. The New India Assurance Company Ltd administered the scheme through its authorised third party administrator, M/S Medi Assist India TPA Ltd. This O.P. No.1 & 2 was merely a mediator and facilitator of the said scheme. So, this case was not maintainable against the O.P. No.1 & 2. He also stated that mediclaim master Policy No.12030034180400000011 was taken for the year 2018-19 by the Complainant but official record shows that number of the said policy was 1203003418040000010 which was renewed during the year with the New India Assurance Company Ltd. Thus it is clear from the fact that responsibility of serving claim to its members lies on insurer not on the facilitator. The O.P. No.1 & 2 also asserted that they had sent the claim paper submitted by the Complainant alongwith supporting documents to the TPA, New India Assurance Company Ltd., Kolkata vide letter with reference JDO/Sales/ Mediclaim/SG dated 30.01.2018 which was despatched on 01.02.18 by speed post. Moreover this OP had sent another letter being reference No. JDO/ Sales/Mediclaim/SG dated 31.07.18 to the TPA for early settlement of the claim. The O.P. No.1 also made correspondence with the O.P. No.2 and the O.P. No.2 inturn forwarded the same to the TPA requesting to expedite the settlement process of the claim. It was also submitted by the O.P. No.1 & 2 that the New India Assurance Company Ltd is a licensed third party administrator under Insurance Regulatory and Development Authority(Abbreviated as IRDA) had got full right and absolute authority to adjudicate the admissibility or inadmissibility of the claim. New India Assurance Company Ltd is an independent body under IRDA which had right, power and authority to accept/reject the claim on the basis of examination of requisite documents of the policy holder/claimant/insured. So, the O.P. No.1 & 2 have no legal right and power to interfere with the affairs, acts and activities of the New India Assurance Company Ltd. The TPA always makes contact with the claimant directly for any requirement or issues claim settlement discharge voucher to the claimant without intimating the O.P. No.1 & 2 in any manner. Moreover, the claimant needs not intimate the O.P. No.1 & 2 when the claim is settled. As the TPA does not make any contact with the O.P. No.1 & 2, so they do not have any information about the status of the claim. The Ld. Advocate for the O.P. No.1 &2 argued that as group mediclaim is a welfare scheme maintained by LICI for its club member agent, The O.P. No.1 & 2 was very much concerned for speedy and just settlement of the claim lodged by its agents covered under the scheme. It is the New India Assurance Company Ltd who settles all legitimate claims through its TPA on receipt of all claim paper duly filled in by the claimant. So the OP, LICI is not responsible for settlement of the mediclaim as alleged by the Complainant. Moreover it is also submitted by the Ld. Advocate of the O.P. No.1 & 2 that as a goodwill gesture we raised a query with the TPA about the status of the claim by e-mail dated 07.12.18 which TPA replied as some documents to be submitted in original which were submitted by the claimant in Xerox. As the claimant did not comply with the order of the TPA so the claim remained unsettled. So, the O.Ps LICI acted proactively in the whole matter so the question of deficiency in service or unfair trade practice on the parts of the O.P. No.1 & 2 does not arise. So the instant case is liable to be dismissed for these O.Ps.
Perused the case record and documents filed by the both parties. Heard the arguments advanced by the Ld. Advocates of both parties at length. The following points need to be discussed for adjudicating the case.
Points for determination
- Is the case maintainable in its present form and prayer?
- Is there any deficiency in service on the part of the O.Ps?
- Is the Complainant entitled to get any relief?
Decision with reasons
Point No.1.
The Complainant is an agent of the O.P. No. 1 & 2 and is a member of Group Mediclaim for agents and their spouse for which a sum of Rs.1470/- as premium for the year 2017-2018 had been deducted from his account by the O.P. No.1. The abovesaid premium was deposited to the New India Assurance Company who later engaged M/S Medi Assist India TPA Ltd as third party administrator for the same and at the time of claim of insurance, the same was submitted to the O.P. No.1 who later forwarded it to the O.P. No.2 & 3. Thus it is clear from the above facts that there is a consumer service provider relation among the parties. So the case is maintainable in its present form and prayer under C. P. Act. Therefore, the Point No.1 is decided in favour of the Complainant.
Point Nos.2 & 3.
The Complainant being an agent of Life Insurance Corporation of India, Cooch Behar Branch(Annexure-A) stacked his claim for Group Mediclaim for agents and their spouse for his treatment at Cooch Behar Mission Hospital(P) Ltd (Annexure-B) to the O.P. No.1(Annexure-C/3 to C/7). He also gave authorisation to M/S Medi Assist India TPA Pvt. Ltd to seek any medical information/records from the treating hospital or from the medical practioners who attended on the Complainant in connection with the said illness (Annexure-C/8). The said mediclaim bill was sent to the O.P. No.2 at Jalpaiguri Divisional Office (Annexure-D/9) for an early settlement on 25.01.18. Prior to that the O.P. No.1 also intimated the accident of the Complainant to the O.P. No.2(Annexure-d/10). The Ld. Advocate for the O.P. No.1 & 2 submitted three letter dated 15.02.18, 27.02.18 and 08.03.18 addressed to the Complainant by the O.P. No.3 stating inter alia that some original documents were required to be submitted before the O.P. No.3 for settlement of the claim within 10 days from the date of the said letters. There was no defence regarding the said letter by the O.P. No.3 as they decided not to contest the case. After a lapse of three months, the O.P. No.2 raised a query (Annexure-D/11) about the status of the mediclaim bill which was lying unsettled at the office of the O.P. No.3 to which the O.P. No.3 replied that they were working on the same and would receive an update soon. The Complainant also made an earnest request to the O.P. No.2 furnishing some requirement called by the O.P. No.2 (Annexure-D/12) but all were in vain. He also sent a reminder to the O.P. No.3 stating inter alia that he was in urgent need of money (Annexure-D/12) which yielded nothing in favour of the Complainant. Moreover, being an agent of Life Insurance Corporation of India a sum of Rs.1470/- was deducted from account of the Complainant as premium by the O.P. No.1 for the said mediclaim policy and documents relating to the claim of the said policy were also sent by the O.P. No.1 to the O.P. No.2 which in turn were sent to O.P. No.3. Thus the O.P. No.1 & 2 cannot avert the liability of the non-settlement of the said claim.
So from the aforesaid discussion it is crystal clear that Complainant left no stone unturned to get his claim of Group Mediclaim policy at the earliest as he was in urgent need of money for his further treatment. But he could not get his claim from O.Ps till date. Therefore, the Commission opines that there is gross deficiency in service on the part of the O.Ps. So, the Complainant is entitled to get relief for their gross deficiency in service. Hence the Point Nos. 2 & 3 are decided in favour of the Complainant.
In the result the instant case succeeds on contest.
Hence, it is
Ordered
That the complaint case No. CC/75/2019 be and the same is allowed on contest with cost.
So, the O.P. No.1, 2 & 3 are directed to pay the mediclaim amount of Rs.1,47,499/- to the Complainant jointly and/or severally. They are also directed to pay Rs.50,000/- for deficiency in service and Rs.50,000/- for mental pain, agony and harassment and Rs.10,000/- towards cost of proceeding to the Complainant jointly and/or severally within 30 days from the date of this order failing which total sum of Rs.2,57,499/- (Rupees Two Lakhs fifty seven thousand four hundred ninety nine only) will carry an interest @ 6% per annum till its realisation.
D.A. to note in the trial Register.
Let a plain copy of this Order be supplied to the concerned party by hand/by Registered Post with A/D forthwith, free of cost, for information & necessary action as per rule.
The copy of the Final Order be also available in the official website: www.confonet.nic.in.
Dictated and corrected by me.
