Ld Advocate for the complainant is present. Judgement is ready and pronounced in open Commission in 4 pages 2 separate sheet of papers.

BY -    SRI ASISH DEB, PRESIDENT

Brief facts of the complainant’s case are that the complainant is a permanent resident within this jurisdiction. The Complainant being the insured in respect of the Insurance Policy under the Opposite Party No.1 vide the continuing Policy No. 150305502210000221 since 2016 and the last of which was valid up to 24.06.2023 and the policy is still continuing having the present validity up to 24.06.2024 under the National Mediclaim Policy of O.P. No.1. The Insurance Policy was covered for the complainant and his spouse Mrs. Poonam Keswani (Battacharyya) and other family members for the coverage of his spouse presently for Rs. 2,70,000/-. The wife of the complainant suffered from some physical ailment and had to undergo medical treatment with surgery of ‘Laparoscopic Cholecystectomy’ under General anesthesia on 11.01.2023 at Narayana Superspeciality Hospital at 120/1, Andul Road, Howrah 711103. The treatment was undergone without cashless facility of the O.P. No. 1 as they have/had no cashless tie up with said Narayana Superspeciality Hospital and so the Complainant had to pay all the payments from his own and then in usual norms to reimburse the expenses made from the Insurance Co. though prior intimation was given for the treatment and of the operation to the O.P. No. 1.The total medical expenses and the bill of the Narayan Superspeciality Hospital for such treatment and operation was Rs. 1,02, 121.87 - discount of Rs. 8,383.77 = Rs. 93,738.00 + other costs and charges for investigations & examinations before the admission and operation in the said NarayanaSuperspeciality Hospital where operation was done on 11.01.2023 an discharged on 12.01.2023. As there was no cashless benefit, the Complaint had to pay all the expenses of his own and subsequently made a claim in the prescribed format of the O.P. No. 1 in their ‘Reimbursement Claim Form’ for the reimbursement of the total expenses of Rs. 1,02,653.00 with all original bills and vouchers including the Hospital main Bill and Pre-Hospitalisation Bills along with the certification of said ‘Narayana Superspeciality Hospital’ when the Opp. Party initiated a Claim vide No. 1503055022100451202. After receiving all those documents by the O.P. No. 1 they through their TPA i.e. O.P. No. 2 verified all those documents and paid only Rs. 55,765/- through NEFT out of total claim of Rs. 1,02,653.00 though all the original bills were submitted and kept by the O.P. No. 1. The O.P. paid only Rs. 55,765.00 out of the total reimbursement medical bill of Rs. 1,02,653.00 and nothing more nor shown any specific and acceptable reason for non payment of the rest amount of Rs. 46,888.00 which the complainant was compelled to pay for the treatment of his wife Mrs. Poonam Keswani Bhattacharyya who was / is covered under the Mediclaim Policy of the O.P. No. 1. It may be mentioned here that the O.P. No. 2 is engaged by the O.P. No. 1 for their own benefit to harass and deprive the genuine Policy holders of the O.P. No. 1 without cogent reasons but for their own benefits to remain in the good books of the O.P. No. 1. After receiving the amount of Rs. 55,765/- from O.P. No. 1 through O.P. No. 2, the Complainant wrote a letter to the O.P. No. 1 for giving him the details clarification of the assessment of arriving at Rs. 55,765/- out of total claim of Rs. 1,02,653/- on 31.03.2023 but no reply was received as to his letter nor any clarification was given. The Complainant waited a long for the reply from the Opp. parties and as no convincing reply was received from the Opp. parties it is presumed that they have nothing to reply but willfully for their own wrongful gain has not paid / reimbursed the total expenses made by the Complainant from his own fund. Such non-reimbursement of the medical bills and pre-hospitalisation investigations bills for the treatment and operation of the spouse of the complainant, puts the complainant with several mental pain and agony though the complainant was/is a bonafide customer & Policy holder of the O.P.-Insurer since 2016 having the sum insured and total coverage amount of Rs. 2,70,000.00 presently and to which the Insured is legally entitled to. These acts of the ops are definitely deficiencies in service being an Insurer. The cause of action of this case has arisen on 11.01.2023 the date of admission in the Hospital and on 12. 01.2023 date of releasing the patient from the Hospital compelling payment and on 05.04.2023 the date of settlement for payment of Rs. 55,765.00 out  Rs. 1.02,653.00 through Bank transfer and thereafter on 31.03.2023 the date of receiving the letter requesting to supply the details clarification of assessment of claim and thereafter day to day within the jurisdiction of this Commission. The Complainant has not preferred any other proceeding in any where in respect of the same matter or cause of action. Therefore , the complainant prays for directing the Opposite Parties; To pay the balance amount of Rs. 46,888.00, the rest amount of the medical bills which the complainant had paid to the Hospital and for other pre-hospitalisation investigations of the patient along with Interest, to pay just compensation to the complainant for the mental pain and agony and for the deficiency of service, to pay the litigation cost of Rs. 20,000.00 for this case, further and other relief(s) as the complainant is entitled to in the circumstances of this case.

Notices were duly served upon the ops. However, these ops have preferred to see that the case be decided ex-parte against it.

Points for determination are:

1. Is the case maintainable in its present form and in law?

2. Is the Complainant entitled to the relief(s) as sought for?

Decision with reasons

Both the points, being inter related to each other, are taken up together for discussion  for sake of brevity and  convenience.

We have carefully perused the affidavit of the complainant and evidence including discharge summery and bills produced by Complainant. On appraisal of the materials on records along with bundle of facts it appears that the complainant is a Consumer insured . The case is maintainable in its present form and in law.

        On analysis of the evidence of the complainant ,it appears that he has stated that the Complainant being the insured in respect of the Insurance Policy under the Opposite Party No.1 vide the continuing Policy No. 150305502210000221 since 2016 and the last of which was valid up to 24.06.2023 and the policy is still continuing having the present validity up to 24.06.2024 under the National Mediclaim Policy of O.P. No.1. The Insurance Policy was covered for the complainant and his spouse Mrs. Poonam Keswani (Battacharyya) and other family members for the coverage of his spouse presently for Rs. 2,70,000/-. The wife of the complainant suffered from some physical ailment and had to undergo medical treatment with surgery of ‘Laparoscopic Cholecystectomy’ under General anesthesia on 11.01.2023 at Narayana Superspeciality Hospital at 120/1, Andul Road, Howrah 711103. The treatment was undergone without cashless facility of the O.P. No. 1 as they have/had no cashless tie up with said Narayana Superspeciality Hospital and so the Complainant had to pay all the payments from his own and then in usual norms to reimburse the expenses made from the Insurance Co. though prior intimation was given for the treatment and of the operation to the O.P. No.1.The total medical expenses and the bill of the Narayan Superspeciality Hospital for such treatment and operation was Rs. 1,02, 121.87 - discount of Rs. 8,383.77 = Rs. 93,738.00 + other costs and charges for investigations & examinations before the admission and operation in the said Narayana Superspeciality Hospital where operation was done on 11.01.2023 an discharged on 12.01.2023. As there was no cashless benefit, the Complaint had to pay all the expenses of his own and subsequently made a claim in the prescribed format of the O.P. No.-1in their ‘Reimbursement Claim Form’ for the reimbursement of the total expenses of Rs. 1,02,653.00 with all original bills and vouchers including the Hospital main Bill and Pre-Hospitalisation Bills along with the certification of said ‘Narayana Superspeciality Hospital’ when the Opp. Party initiated a Claim vide No. 1503055022100451202. After receiving all those documents by the O.P. No. 1 they through their TPA i.e. O.P. No. 2 verified all those documents and paid only Rs. 55,765/- through NEFT out of total claim of Rs. 1,02,653.00 though all the original bills were submitted and kept by the O.P. No. 1. The O.P. paid only Rs. 55,765.00 out of the total reimbursement medical bill of Rs. 1,02,653.00 and nothing more nor shown any specific and acceptable reason for non payment of the rest amount of Rs. 46,888.00 which the complainant was compelled to pay for the treatment of his wife Mrs. Poonam Keswani Bhattacharyya who was / is covered under the Mediclaim Policy of the O.P. No. 1. It may be mentioned here that the O.P. No. 2 is engaged by the O.P. No. 1 for their own benefit to harass and deprive the genuine Policy holders of the O.P. No. 1 without cogent reasons but for their own benefits to remain in the good books of the O.P. No. 1. After receiving the amount of Rs. 55,765/- from O.P. No. 1 through O.P. No. 2, the Complainant wrote a letter to the O.P. No. 1 for giving him the detailed clarification of the assessment of arriving at Rs. 55,765/- out of total claim of Rs. 1,02,653/- on 31.03.2023 but no reply was received as to his letter nor any clarification was given.

        The aforesaid evidence of the complainant has remained unchallenged. The total medical expenses and the bill of the Narayan Superspeciality Hospital for treatment and operation was Rs. 1,02, 121.87 - discount of Rs. 8,383.77 = Rs. 93,738.00 . The Complainant paid Rs. 93,738.00 ;out of which the op1- paid Rs. 55,765/-. The ops have not turned up to explain as to why it did not pay the amount of  Rs. 93,738.00 in full. The ops have not assigned any reason for non payments of Rs.37,973/- (Rs. 93,738.00- Rs. 55,765/-).These acts of the ops ,being an Insurer, definitely amount to deficiencies in service .

       The complainant is entitled to get balance amount of Rs.37,973/- alongwith simple interest @ 10% per annum in the nature of compensation from the date of filing of this case till realisation and litigation costs of Rs.5000/-from the ops who are jointly and severally liable.

         Both the points are decided in favour of the complainant accordingly.

         The complainant’s case succeeds ex-parte.

Hence, it is

O R D E R E D

That the CC/78 of 2023 be and the same is allowed  ex-parte against the OP-1 and  the OP-2,

The OP-1 and  the OP-2, who are jointly and severally liable, are hereby directed to pay the balance amount of Rs.37,973/-alongwith simple interest @ 10% per annum in the nature of compensation from the date of filing of this case till realisation and litigation costs of Rs.5000/-to the complainant within 45 days from the date of this order,

The Complainant would be at liberty to put the order into execution.

Let a copy of the judgment be supplied to the complainant free of cost.