Order No. -15                                                                                                       Dt.-22/06/2015

        Shri Prabin Chettri, Member

        The case  record is placed before me for passing  final order.

        Brief fact of the case is that the complainant is a consumer of the O.P.(The New India Assurance Company Ltd.) since long alongwith her family in a family floater policy vide mediclaim policy. The petitioner due to her sudden illness got admitted at Anandaloke hospital and neuro sciences centre at second mile Sevoke road, Siliguri, since 16/01/2014 to 17/01/2014. The complainant is an aged lady and she is passing her days with her aged husband. The husband of the complainant informed the O.P. about his wife’s treatment in due course and such matter of intimation has not been disputed by the O.P. and their representative in subsequent correspondence. To meet the demands of medical expenditure, the aged couple insured their medical expenses by mediclaim policy issued by the O.Ps.( The New India Assurance Company Ltd.) with a hope that their bonafide claim will be settled expeditiously. That after getting discharged from the said nursing home after being recovered from trauma of said illness, the complainant informed the matter to the O.P. on 10/02/2014 alongwith necessary documents. The complainant’s husband received two letters dated 21/02/2014 and 27/03/2014 from one Medicare TPA services(1)Pvt. Ltd. stating inter-alia to adjudicate the claim of the petitioner they need some documents. In response of the letter dated 21/02/2014, the son of the complainant namely Md. Unush Ali informed the said 3^rd party (Medicare TPA Services(1) Pvt. Ltd.) of the O.P.(The New India Insurance Company) that they have already submitted all relevant original documents to substantiate his mother’s claim to the O.P.(The New India Assurance Company Ltd.). That after the said incident as there was/is no response from the end of the O.P., except some baseless assurance. The complainant sent a lawyer’s notice to the O.P. on 26/05/2014, which was duty received by them on the same day. But unfortunately inspite of repeated remainders there was no positive response from the end of the O.P. even  after sending a lawyer’s notice to the O.P. on 26/05/2014 they didn’t pay any heed.  Hence this case.

The O.P. has contested the case by filing a Written Version denying and disputing inter-alia the claims and contention of the complainant with prayer for dismissal of the case.

The specific stand of the O.P. is that they categorically stated that the complainant in response of the letters dated 21/02/2014 and 27/03/2014 issued by Medicare Tpa services(1) Pvt. Ltd to the complainant seeking some documents from the complainant neither submitted/sent those documents mentioned in two TPA’s letters to Medicare TPA services(1) Pvt. Ltd. nor this O.P. Insurance Company. The O.P. also states that TPA is authorized to access the claim and assessment of the claim the TPA is binding upon both the parties i.e. insured and insurer as per rules of the Janata Mediclaim policy clause  no. 5.2, 11.0, 12.0 13.0 etc. As the complainant didn’t comply the TPA’s direction in respect of requirement of documents mentioned in letters dt.21/02/2014 and 27/03/2014. TPA failed yet to assess the claim of the complainant and thus the claim is still pending to this O.P. company without repudiation and so this complainant has no right to file this petition of complaint against this O.P. The O.P. also objected the claim as per schedule under Janata Mediclaim Policy “1.0 coverage”. Hence the O.P. in this circumstances prays before us to reject/ dismiss the case with cost.

POINTS FOR CONSIDERATION:-

1) Is the case/ application maintainable as alleged?

2) Is the complainant a consumer as per provision of the sec 2(d) of the C.P.Act 1986?

3) Was there any deficiency of service on the part of the O.P. as alleged?

4) Is the complainant entitled to the reliefs as prayer for?  

DECISION WITH REASONS

       All points are taken up together for consideration and decision for the sake of convenience.

       Seen and perused the pleading of the parties and all other relevant materials on record including written arguments filed by the parties.

       The argument raised by the Ld. Lawyer of the O.P. that the claim is not legally maintainable as Pusho Bibi ( Complainant) got herself admitted in Anandaloke Hospital and Neuroscience centre, Siliguri for some hours without having any advice of a duly qualified physician to incur hospitalization expenses as per policy schedule “1.0. coverage”. There is no coverage as per policy for such hospitalization expenses. But this argument of the O.P. is rejected by the complainant’s Ld. Lawyer as because the complainant has been advised for admission in Anandaloke Hospital as it reflect from letter head pad of Anandaloke sonoscan Centre Pvt. Ltd. dated 16/01/2014. Therefore we have no hesitation to say that the case/ application is legally maintainable . The O.P. stated that the TPA is authorized to asses the claim and assessment of claim by TPA is binding upon the parties i.e. insured and insurer as per rules of Janata Mediclaim Policy vide clause no. 5.2, 11.0, 12.0 13.0 etc.

                 On the other hand the complainant in response of this letter dt. 21/02/2014, the son of the complainant/ petitioner namely Md. Unush Ali informed the said 3^rd party (TPA) of the O.P.(the New India Assurance Company Ltd.) through letter dt.20/03/2014 mentioning that the original copy of the required documents has been received by the O.P. (the New India Assurance Company Ltd.) on 10^th February 2014. After that no response have taken by the O.P. except some baseless assurance but unfortunately inspite of repeated remainders, there was no positive response from the end of the O.P. except some false assurance which is nothing but tactics to delay the settlement of bonafide claim of the complainant. The O.P. is less bothered even to honour the bonafide appeal of two senior citizens (Viz the complainant and her husband). The complainant/ petitioner and her husband purchased the mediclaim policy, vide no. 51230434130600000082, and the complainant / petitioner alongwith her family members is a consumer of the O.P.(New India Assurance Co. Ltd.) since long. So the complainant is a consumer as per provision of Sec 2(d) of the Consumer Protection Act 1986.

       The O.Ps. act is less bothered even to Honour the bonafide appeal of two senior citizens( Viz the complainant and her husband). The O.P. is delaying to settle the claim of the complainant after being frequent correspondence and noticed by the lawyer of the complainant dt.26/05/2014 almost a period of one (1) year.

        Therefore we came to conclusion that we have no hesitation to hold that the complainant is entitled to get the necessary medical expenditure alongwith a compensation for mental agony and pain, which the complainant has suffered due to negligent attitude of the O.P. as well as delaying to settle the claim that amounts to deficiency in service.

All points are disposed of accordingly.

In the result the case/ application succeeds.

Hence, it is

O R D E R E D

that the case/ application is allowed on contest with direction to the O.P.(The New India Assurance Company Ltd.) to pay the amount of Rs.22,597 as medical expenditure alongwith a sum of Rs. 5000/- as compensation for mental agony and pain, which the complainant has suffered due to negligent attitude of the O.P. and Rs.1000/- as litigation cost, within 30 days from the date hereof, in default it will carry interest @ 8 % p.a. till realization and the complainant shall be at liberty to realize the same by putting this order into execution in accordance with law.

         Let a plain copy of this order be supplied to the parties free of cost forthwith as per sec 5(10) of West Bengal Consumer Protection Rules,1987.