JUDGEMENT
This is an application U/s 12 of the C.P. Act, 1986.
The complainant’s short case is that he purchased a policy for medical treatment bearing No.313490/48/2012/46 on 21.6.2011 from O.P. No.1 under the scheme ‘happy family floater policy schedule’. The complainant received the cards of individual beneficiary in an envelope from concerned TPA having branch office 203a, AJC Bose Road, Kolkata-20.
On 24.4.2012 at about 19:15 complainant’s husband Kartick Chandra Nayak felt retrosternal discomfort and brought to the nearest Dr. P.Rout who referred the patient immediately at Vivekananda Hospital Pvt. Ltd., Durgapur for needful. The hospital authority admitted the patient in ICU after examining the patient on 24.4.2012 at about 20.04 and the patient was released on 25.04.2012 with a stable condition. The hospital bill paid by the complainant.
The intimation of hospitalization was given to the Divisional Manager, O.P. No.2 on 25.4.2012 and reimbursement claim of Rs.16,060/- submitted at the office of O.P. No.1 on 30.4.2012, which was passed and forwarded by concerned officer of the branch.
The O.P. N o.2 sent a letter to the complainant on 14.8.2012 stating that the claim amount is not payable under a specific condition (as per policy definition 2.3) which is hospitalization period is less than 24 hours and concerned TPA has already repudiated the claim. The complainant wrote a letter to the O.P. No.2 informing him that no such terms and conditions document has been attached or enclosed at all with policy paper and also requested him that she is a financially weak person and also requested to release genuine claim amount at earliest time. But O.P. No.2 remains silence. Finding no other alternative the complainant filed this case before this Ld. Forum for relief.
The O.P. No.1 & 2 have contested the case by filing written version, denying inter-alia all the material allegation as leveled against them. The O.P. also stated that the complainant enjoyed the Happy family Floater Policy during the period from 2009 to 2012 i.e. three years. The terms and conditions of the policy was remain unaltered i.e. in respect of clause No.2.3 stating the period of hospitalization where expenses of hospitalization are admissible only if hospitalization is for a minimum period of 24 hours subject to few disease. The said fact is well known to the complainant who herself admitted used the same policy in the previous year of 2010-2011 and the story of her ignorance about the terms and conditions of the policy seems hollow and her plea on ignorance of policy condition is not acceptable in the eye of law.
Point for consideration in this case;
- Whether there is any deficiency in service on the part of the O.P.s in this case?
DECISION WITH REASON
At the outset of the discussions over the dispute we should highlighted the policy i.e. name and style is “Happy Family Floater Policy Schedule”. If that be so, the O.P. at least takes all sorts of care to see that the family of the insurer be happy, otherwise the name of the policy will go bye.
It has alleged by the complainant showing the documents that nothing was enclosed in relates to terms and conditions of the policy. But it is true that complainant should be aware prior to get the policy regarding the terms and condition of the policy. But in the instant policy when the name of the policy is “Happy Family Floater Policy Schedule”, probably complainant did not think for a moment that anything adversely mentioned against the interest of insurer family and accepted the same. It should be pertinent to mention here that TPA who is O.P. No.2 ought to have explained all this things to the complainant but definitely in evitable did not happen, which is a definitely unfair trade practice acted by the O.P. No.3, TPA who are working under the control of O.P. No.1 & 2 for their gain.
If the complainant was aware regarding the policy conditions of 2.3, that after admission minimum period of 24 hours have to stay in the hospital, then definitely the husband of the complainant easily can cover the time by requesting the hospital authority, which is not unnatural rather the bill of medical treatment was enhanced. But the honest complainant did not like the same i.e. why the claim was repudiated.
We failed to understand if this type of repudiation clause i.e. 2.3 be welcome by a judicially or quasi-judicial procedure, then the litigants will be invited to act dishonest manner which is not warranted at least from the Chair of the Forum. We hope and believe that authority of O.P. No.1 & 2 will appreciate the same and do the needful in near future so that they also be benefited to satisfy the actual bill of medical expenses, not invited inflated bill.
Thus we hold inclusion of 2.3 is welcome the insurer to prepare false bill. Apart from that the condition of the policy should be given by the O.P. at the time of sending the policy which was not happened in the instant case. It should be borne in mind that before imposition of any terms and condition as they deemed be fit and proper, should be ventilated firstly to TPA thereafter the persons who wants to get the scheme. After publishing “Happy Family Floater Policy Schedule” is not suffice to say that family will be happy after getting the policy, which is the glaring example in the instant case.
Considering all pros and cons of the dispute and after hearing very valuable argument from the Ld. Advocate of the O.P.s we hold that to uphold the name and style of the policy, complainant should get the actual cost i.e. Rs.16,060.00 only from the O.P. within the stipulated period.
With that observation, it is
ORDERED
that the application U/s 12 of the C.P. Act is allowed on contest against the O.P. No.1 & 2and experte against the O.P. No.3. The O.P. No.1 & 2 is directed to pay a sum of Rs.16,060.00 to the complainant within 45 days from this date of this order, failing which the complainant is entitled to get 12% interest from the date of filing of the case i.e. from 16.1.2014 to till its realization. If the stipulated time is over then complainant is further entitled to get compensation of Rs.5000.00 and litigation cost of Rs.2000.00 along with actual cost of medical treatment and interest which have to be recovered by executing the order from this Forum. Let the plain copy of this order be handed over all the parties free of cost.
(Udayan Mukhopadhyay)
Dictated and corrected by me. President
D.C.D.R.F., Burdwan
(Udayan Mukhopadhyay)
President
D.C.D.R.F., Burdwan
(Durga Sankar Das)
Member
D.C.D.R.F., Burdwan
