No settlement of medical insurance claim by the OPs has obliged the complainant to lodge this complaint for redressal u/s 12 of the CP Act, 1986.
The quintessence of the complaint goes that wife of the complainant Smt Swati Tokder being ill was admitted at Bhagirathi Neotia Women and Child Care Centre at Kolkata for operation of her Fibroid Uterus on 21.02.2017 and she was operated at the said medical centre by Dr. Kushagradhi Ghosh and discharged on 26.02.2017 from the said hospital. The complainant had an insurance policy with National Insurance Company covering his family for Rs. 3 lakh at a premium of Rs. 4,213/- for the policy No.150703/48/15/8500002647. The policy is a BOI National Swasthya Bima Policy. The complainant had submitted claim form with all medical reports and bills on 21.03.2017 to the OP-1 and claimed Rs. 1,41,241/- (One lakh forty one thousand two hundred forty one) only as total expenses of the said operation. As instructed by the OP-1 the complainant also submitted all medical documents along with bills and vouchers to MD India Health Care Service TPA Private Limited i.e. OP-2 on 18.05.2017. The complainant also requested in writing to the OPs for payment of full claimed amount on 06.04.2018. But till the date of lodging this complaint i.e. on 03.05.2018 no correspondence from the ends of the OPs has been made with the complainant. Now, the complainant in his version claimed the principal amount of Rs.1,41,241/- (One lakh forty one thousand two hundred forty one) only with an interest @10.2% p.a. and also a compensation amount of Rs.1 lakh and litigation cost of Rs. 40,000/- (Forty thousand) only.
The OP-1 had submitted a written version which the OP-2 has also considered as their version also. So the written version submitted by OP-1 has been dealt as the written version of both the OPs. In this written version the Ops have denied all allegations and questioned the maintainability of the complaint in respect of deficiency in service on the part of the Ops. In the para 8 of the written version the OPs have actually denied to make any payment of the claim according to the terms and conditions of BOI National Swasthya Bima Policy as the treatment has been done within 1 year from the date of execution of the said medical insurance policy. Moreover, they have told that the claim should be processed through the OP-2 who has not got all necessary documents from the complainant. They have claimed that Op-1 has no power to settle any mediclaim unless OP-2 takes a decision about the same as per guideline of IRDA.
On argument the Ld. Lawyer for the complainant stated to this Forum with documents like submissions of claim form to the OP-1, submission of claim to OP-2 with all necessary documents as per instruction of the Op-1 and the written communication requesting for settlement dt. 06.04.2018. The complainant in person has denied to be informed of the terms of the BOI National Swasthya Bima Policy on/before 17.03.2016. The Ld. Lawyer for the complainant stated that his client was quite in a dark about Para 4.3 of BOI National Swasthya Bima Policy or any part of it. The Insurance Company had never brought such terms and conditions to the knowledge of the policy holder before making the policy. Under the circumstances the claim prayed for in the complaint to this Forum may kindly be considered. The Ld. Lawyer for the OP had admitted that through the OP-1 has got documents and with claim form from the complainant but in spite of instruction from OP-1 as well as written request from the OP-2 the complainant had not yet submitted all necessary documents to the OP-2. He has also submitted a copy of the BOI National Swasthya Bima Policy and a draft repudiation statement dt. 18.05.2018 sent by MD India. On Interrogation by this forum the Ld. Lawyer for the OP failed to satisfy this Forum whether the policy holder herein the complainant had agreed upon the terms and condition as shown in their documents and also the draft of repudiation statement for approval dt. 18.05.2018 made by the OP-2 had been finalized.
Points for decisions:
- Is the complainant a consumer to the Ops?
- Is there any deficiency in service on the part of the OP-1 & OP-2?
DECISION WITH REASONS
From the above discussion it is crystal clear that the complainant is a consumer of the OP-1 and resultantly OP-2 as no OPs had denied the complainant as their policyholder with whom the OPs had made a little correspondence as per documents filed by both the parties.
The written version filed by both the parties and arguments with documents filed by both the parties (kept in record) reveal that what the Ld. Lawyer for the Ops has submitted as documents viz BOI National Swasthya Bima Policy and the draft repudiation statement for approval dt.18.05.2018 had never been reached to the policy holder, herein the complainant. It is clear that the clause 4.3 on the basis of which the payment for the claim has not yet been made has never been intimated to and agreed upon by the complainant. In adjudicating the instant case we may take refuge to the important point “Insurer who failed to provide terms and conditions of policy to complainant, has no right to repudiate claim arbitrarily” noted in the case Dr. J.R. Banik versus Managing Director, National Insurance Company Limited R.P. No. 1090 of 2014[2017 (2)CPR]. It is a fact that initially the OP has not provided terms and conditions along with medical insurance policy but in course of hearing in this Forum it has been submitted to this Forum. It is also surprising that after lodging the complaint to this Forum on 03.05.2018 a draft repudiation statement for approval has been prepared by the OP-2 on 18.05.2018 but it is not yet finalized. So the suspicion has loomed large within us in this regard. So we are of the opinion that a gross deficiency in service as well as negligence to the complainant had been committed by the OPs.
Hence, it is
O R D E R E D
That the OP-1 is directed to pay the claimed amount of Rs.1,41,241/- (One lakh forty one thousand two hundred forty one) only with an interest accrued thereon @ 8% p.a. with effect from 18.05.2017 up to the date of this order to the complainant within 30 days from the date of this order, failing which an interest 9% will be accrued thereon till the full realization of the whole amount including the principal amount and the interest. The OP-2 is directed to pay Rs. 5,000/- (Five thousand) only as litigation cost to the complainant within 30 days from the date of this order.
The case be and the same succeeds on contest.
Let a plain copy of this order be furnished to the parties forthwith free of cost.
