1. This complaint case has been filed against the O.Ps for not settling the Mediclaim of the complainant.
2. The complainant’s case in brief is that the complainant having cashless Health Insurance Policy with the O.P. having policy no. 171005/50/20/10000027. The complainant was found Covid 19 Positive and on becoming serious he was shifted and admitted to the Laxmi Narayan Hospital, Bypass Road, Purandaha, B. Deoghar. As per policy the complainant has intimated claim to the Branch Office of the O.P. well within time and the complainant have already supplied the entire required original copies of diagnosis and reports along with films, bills of medicines and hospital bed & ICU charges, discharge certificate, hospital documents and papers which were asked to supply by the complainant by O.P. No. 2.
3. The several correspondence were made between O.P. No. 2 followed by several emails communications and according to the said communications the complainant has already submitted entire documents as per direction of the O.P. No. 2 with her full satisfaction. But it is very painful to state that the complainant till now has not reimbursed or received any amount of treatment. It is surprisingly enough that the complainant has already submitted entire required documents along with duly filled up claim form but the O.P. No. 2 again asked the complainant to furnish : -

1. Original Duly filled claim form
2. Original final bill with breakup with proper bill number and payment receipt wrongly and illegally by sending Final reminder dt. 11.08.21 which the complainant has already sent by post as well as through email.

4. It is further submitted that the O.P. No. 2 whose role in the Mediclaim policy to simplify the claim procedure under health policy and payment/ reimbursement via insurance company but the O.P. No. 2 in spite of simplifying the claim procedure, unnecessarily harassing the complainant, which is highly unappreciated.
5. It is further submitted that TPA and the Insurance Company have their independent surveyor for verifying the genuineness of the nursing home and bills of the treatment. The claimant served a legal notice to the O.P. No. 1 on 15.09.21. The complainant also filed an application before Insurance regulatory and Development Authority, Consumer Affairs Department Grievance Redressal Cell on 19.06.21 for speedy disposal of his complaint.
6. The O.P. No. 1 again initiated the claim of the complainant and asked to furnish the entire documents once again by sending reply to the legal notice and the complainant again submitted the claim form and entire documents which were already supplied to the O.P. No. 1 on 08.11.21 which has been received by the O.P. No. 1 on 15.11.21 and till date O.P. No. 1 has not settled the claim of the complainant.
7. The cause of action arose on 18.04.21 when the complainant admitted for the treatment of Covid 19 to Laxmi Narayan Hospital, Deoghar and thereafter on 26.04.21 when the complainant discharged from Laxmi Narayan Hospital, Deoghar and further several dates when the complainant made correspondence for getting his insurance claim and the cause of action shall remain till the settlement of claim and payment made. The complainant claims following reliefs : -

1. To direct the O.P. No. 1 to pay Rs 79,621/- as medical reimbursement to the complainant.
2. To direct the O.P. No. 1 to pay Rs 50,000 for compensation for mental agony and harassment.
3. To direct the O.P. to pay the cost of litigation and
4. Any other relief or reliefs which the complainant is entitled to be passed.

8. The National Insurance Company appeared on 10.05.22 and filed his WS stating therein that the complainant’s case is not maintainable either in fact or in law. It is further submitted that the complainant has informed our office regarding the claim after receiving the information, our company O.P. no. 2 sent a first letter to the complainant on 01.07.22 and demand following documents : -

1. Original duly filled claim form
2. Original discharge summary
3. Original final bill with break up with proper bill number and payment receipt
4. Copy of registration certificate of hospital/ certificate of number of beds and other facilities available.
5. Cancelled cheque of insured
6. Copy of ID proof of insured and patient
7. All indoor case record
8. Covid positive report.

And after receiving first letter petitioner not submitted entire paper which was demanded by the O.P. then O.P. send second query on 17.07.21 and mentioned that kindly provide –

1. Original duly filled claim form
2. Original final bill with break up with proper bill number and payment receipt
3. Copy of registration certificate of hospital/ certificate of number of beds and other facilities available.
4. All indoor case record
5. Covid positive report.

9. After second letter on 17.07.21 petitioner not submitted entire paper as demanded by the O.P.s then O.P send third query letter  on 05.08.21 and mentioned kindly provide : -

1. Original duly filled claim form
2. Original final bill with break up with proper bill number and payment receipt
3. Copy of registration certificate of hospital/ certificate of number of beds and other facilities available.
4. All indoor case record
5. Covid positive report.

10. But after final reminder by registered post send on 11.08.21 the complainant has not submitted the fulfilled the demand of the O.P. and as per terms and conditions of the cashless Health Insurance Policy the petitioner claim was not payable. The O.P. No. 1 has not settled the claim of the complainant. The petitioner wants the claim without submitting requirement of the petitioner’s as demanded by the O.P. And if the petitioner submitted entire required documents which was mentioned in the letters of the O.P. then O.P. will proceed the petitioner’s claim and further prayed to accept the WS and dismiss the case of the complainant.
11. The main point for the determination in this case is whether the complainant is entitled to get any relief or reliefs as claimed!

                                                                  Findings

The complainant in support of his case has filed oral and documentary evidence which are as follows : -

CW1 – Sada Shiv Gupta

CW2 – Manoj Sharma

And also filed the following documentary evidences which are as follows : -

Exhibit 1 – is the photocopy of policy Medi claim form including reimbursement claim form.

Exhibit 2 – is the photocopy of letters of the complainant dt. 04.08.21 sent to O.P. no. 2

Exhibit 3 – is the photocopy of supplementary claim form

Exhibit 4 – is the photocopy of letter of the complainant written to the O.P. No. 2 dt. 23.08.21

Exhibit 5 – is the photocopy of discharge summary along with medical bills. Total 8 sheets.

Exhibit 6 – is the photocopy of certificate of provisional registration of Laxmi Narayan Hospital granted by District Registering Authority, Deoghar on 19.10.22

Exhibit 7 – is the photocopy of details of drug and doses given to the complainant from 18.04.21 to 25.04.21

Exhibit 8 – is the photocopy of office order issued by BDO Jarmundi in which he has mentioned that the complainant, Sada Shiv Gupta was found Covid 19 positive

Exhibit 9 – is the photocopy of Aadhar card of Sada Shiv Gupta

Exhibit 10 – is the photocopy of letter written by Sada Shiv Gupta to Branch Manager National Insurance Co. Ltd. Dumka

Exhibit 11 – is the photocopy of Insurance Medi claim policy no. 171005502010000027 effective from 17.03.21 to 16.03.22. Total 3 sheets.

Exhibit 12 – is the form policy schedule Pariwar Medi claim policy no. 171005501910000055 effective from 17.03.20 to 16.03.21. Total 3 sheets.

The O.P. in support of his case has not filed any affidavit of witness but he has filed the following documents which are as follows : -

Exhibit A – Browser of National Medi claim policy

Exhibit B – discharge summary dt. 26.04.22

Exhibit C – is also discharge summary certificate dt. 26.02.21

And apart from that the reports is also on the record which relates regarding the genuineness of the details raised by the O.P. No. 1 which was sent to the Laxmi Narayan Hospital for its verification by the commission on 11.05.22 and then the Hospital concerned has sent the report on 19.05.22 stating therein that all the details are true and genuine issued by the Hospital.

12. Heard the Learned Counsel of both the parties and also perused the case record, evidences oral and documents adduced on behalf of both the parties. From carefully scrutinizing and analyzing the evidences the main objection which was raised by the O.P. that the bill submitted by the complainant are not in proper form. They seems to the forced, fabricated and the O.P. No. 2 which is Genins TPA India repeatedly asks the complainant to adduce some documents but the complainant failed to adduce proper and required documents to him. As such, the claim of the petitioner was not paid.
13. The complainant in his show cause in Para 24 has clearly mentioned that if the petitioner submitted entire required documents which was mentioned in the letters of the O.P. No. 2 then the O.P. will proceed the petitioner claim. From carefully going through the documents filed by the complainant in this case it is apparent that the petitioner has already given and submitted the claim form, reimbursement, claim form duly filed up and supplementary claim form duly filled up and also the certificate and registration of the Hospital Laxmi Narayan which is Exhibit 6 clearly shows that Laxmi Narayan hospital is a registered medical Hospital and Exhibit 8 which clearly shows that the complainant was found Covid 19 Positive.
14. So far as the breakup of details and other medical bill is concerned Exhibit 5 is the discharge summary which is correspondence to Exhibit B and C. The Learned council for the O.P. raised that in Exhibit B and C although both are discharge summary but the amount mentioned there in are different, i.e; in Exhibit B it shows Rs 36,000 while in Exhibit C it shows Rs 37,375/-. Both are the same documents but going through them minutely in Exhibit B there is mentioned less amount Rs 1375/-  and after deducting the less amount the bill amount was shows as Rs 36,000/-
15. One objection from O.P. was raised in breakup bill was submitted by the complainant. But from carefully going through Exhibit 5 there are bills regarding the medicines which were given to the petitioner during the admission and each and every bills of medicine were clearly mentioned and there is also seal of the Laxmi Narayan Hospital who received the said amount. So fas as the drugs and other treatment which were given to the complainant during admission in the hospital is concerned Exhibit 7 clearly describes about this and there is details given in the Exhibit.
16. And demanding again and again from the complainant regarding the said documents which clearly indicates the intention of the O.P. not to pay Medi claim to the complainant. Although the O.P. has not rejected or refused the claim of the complainant he still says that if the petitioner submits entire required documents then is ready to proceed with the petitioner’s claim. So far as genuineness of the bill granted by the hospital Laxmi Narayn is concerned on the petition of the O.P. both the details were sent to the concerning hospital for its verification by this commission and the said hospital sent his report regarding the said bill that all the details were issued by his hospital which are genuine and true. Apparently it is clearly established that bill proceed by the complainant was not forced one not fabricated and it was true and genuine.
17. And the claim of the petitioner are seems to be true and genuine also and not paymenting the Mediclaim to the complainant by the O.P. is deficiency in services. The O.P. never denied the medi claim policy issued to the complainant. He admits this fact that the complainant has taken Medi claim policy from National Insurance Company Ltd. and during that period the complainant found Covid positive. As per Exhibit 11 the policy is effective from 17.03.21 to 16.03.22 but the complainant found Covid 19 positive on 18.04.21 and admitted for the treatment of Covid 19 positive to Laxmi Narayan Hospital and from there he discharged on 26.04.21.  Apparently the claim period was within the policy effective period. From the aforesaid discussion we come to the conclusion that complainant is entitled to get the reliefs as he claimed. It is therefore, we

                                                                              Ordered

                                    That the O.P. No. 1, The Branch Manager, The National Insurance Co. Ltd. is hereby directed to pay medical bills of Rs 76,621/- to the complainant. The O.P. No. 1, i.e; The Branch Manager, The National Insurance Co. Ltd. is hereby directed to pay Rs 50,000/- for mental agony and harassment to the complainant. The O.P. No. 1, The Branch Manager, The National Insurance Co. Ltd. is also hereby directed to pay cost of litigation of Rs 10,000/- to the complainant. The O.P. No. 1, i.e; The Branch Manager, The National Insurance Co. Ltd. is hereby directed to pay 12% p.a. interest on the principal amount from 16.08.21 till the payment.

                            All the payments should be made within 45 days from this order failing which the complainant is entitled to release above count through process of court.

                                          Let a copy of this order be served to both the parties free of cost. Let this document be deposited in the record              room and to be shown on the website of the commission.