Assam

Dibrugarh

CC/41/2016

MR. MURARILAL KEJRIWAL - Complainant(s)

Versus

THE BRANCH MANAGER, UNITED INDIA INSURANCE CO. LTD - Opp.Party(s)

MRS. SWARNALI BORGOHAIN

20 Jul 2017

ORDER

The case of the complainant in brief is that the complainant had taken family Medicalim policy being Policy No.1303012815P1012694017 which was valid from 04-05-15 to 03-05-16. The policy was issued by OP No-1. Said policy was renewed for another year by paying necessary  premium to OP No-1 being policy No.1303012816P101710119 and the validity period was from 06-05-16 to  05-05-17. In January, 2016 during the validity of the aforesaid policy the complainant getting CAG report from Asian Heart Institute, Mumbai came to know that he was suffering from heart problem and Doctor advised him to undergo Cardiovascular and Thoracic surgery. Accordingly, on 01-02-16 the complainant undergone surgery at Asian Heart Institute, Mumbai as indoor patient. He was discharged on 07-02-16 from the hospital. For the treatment of the aforesaid surgery he incurred about Rs.6,00,000/- for surgery. Thereafter, the complainant lodged a claim before the OPs by sending duly filled up claim form and original bills and receipt including discharge certificate, Radiological and Pathological report. Later on, the complainant received four queries from OP No.2 and the complainant accordingly sent all the reply against all the queries separately and requested them to settle the claim early. After lapse of considerable period when complainant did not receive any reply from the OPs regarding his claim, he enquired the matter to which the OP again asked him to provide original cash memo of Rs.5,26,000/- of final bill of Asian Heart Institute, Mumbai but the original cash memo has already been sent to OP on 18-03-16 along with claim form. Even then the complainant in response to the above request  somehow managed to get a duplicate copy of receipt of Rs.5,26,000/- from Mumbai and sent the same to OP No-2 on 01-07-16 requesting once again to settle the claim. Surprisingly, the OP No.2 on 16-07-16 sent back the bunch of papers along with his forwarding letter dated 01-07-16 to him, asking the complainant again to provide cash memo of Rs.5,26,000/-.  The complainant thereafter, getting no other alternative, issued notice to the OPs on 25-07-16 asking them to settle the claim within fifteen days from the receipt of the notice. The OPs duly received the said notice but did not give any heed upon the notice and remain silent. The above act of the OPs proves serious negligence and deficiency in service for which the complainant had to suffer sufficient damage in terms of loss of physical and mental agony for which OPs are liable to pay adequate compensation. Hence, the complainant filed the present case with prayer to pass order directing OP to pay principal cover amount of family Mediclaim policy along with interest @18% per annum from 18-03-16, also prayed to pay compensation of Rs.50,000/- for mental agony and suffering along with cost of Rs.20,000/- for litigation.

After registering the case notices were issued to OP No.1 and 2 which were duly received by both the OPs. The OP No.1 contested the case by filing written statement whereas, OP No.2 nether submitted written statement nor contested the case, as a result of which case against OP No.2 proceeded exparte.

OP No.1 in his written statement stated inter-alia that the case of the complainant is not maintainable in law as well as in fact. Further, it is contended that the OP No.2 hold licence issued by IDRA, a statutory body to provide service through OP No.1 as “ Third Party Administrator” which are embodied in clause 3.37 in the family Mediclaim policy issued to the complainant. It is further contended that after receiving the documents from the complainant OP No.1 sent to OP No.2 as the TPA for processing and settlement of the claim. OP No.2  repeatedly asking the complainant for the relevant documents required for settlement of the claim and OP No.1 was also contacted to the complainant over phone to visit office of OP No.1 to discuss and solve the matter but the complainant did not turn up. The complainant has failed to fulfil the requirement by submitting relevant documents like cash memo/ money receipts of the alleged expenses incurred during the treatment for assessing the amount payable to the complainant. Besides, the OPs never repudiated the claim for which there is no cause of action in this case. OP No.2 asked repeatedly the complainant  for original money receipts so that the claim can be processed and settled at early but the complainant did not submit required documents to OP No.2 for which claim could not be settled. As such, there is no any negligency or deficiency in service on the part of the OPs. As such, the OP prays to dismiss the case against OP No-1.

          In this case complainant gave evidence by swearing affidavit and exhibited as many as 28 (twenty eight) documents in support of his case. On the other hand, OP No.1 examined Mrs. Minoti Hazarika of Dibrugarh as DW-1 and exhibited original policy as Ext-A and other documents as B(1) to B(93).

          Complainant and OP No.1 submitted their written argument.

 

DISCUSSION, DECISION AND REASONS THEREOF:

Upon going through the evidence, documents and the written argument advanced by the parties, it is found that the complainant is a Mediclaim policy holder being Family Medicare Policy No.1303012816P101710119 which was valid from 06-05-16 to 05-05-17. Ext-A is the original policy submitted by the OPs.  Hence, there is no dispute regarding the holding of Mediclaim policy by the complainant and was valid at the time of operation. From the evidence of the complainant it appears that in the month of January, 2016 after getting CAG report from Asian Heart Institute, Mumbai the complainant came to know that he is a heart patient and the Doctor at Mumbai advised him to undergo Cardiovascular and Thoracic surgery. Accordingly, the complainant on 01-02-16 undergone the surgery  at Asian Heart Institute, Mumbai as indoor patient and thereafter, he was discharged on 07-02-16. For the aforesaid surgery and the treatment the complainant incurred an amount of Rs.6,00,000/- and thereafter, came to Dibrugarh. He lodged a claim on 18-03-16 sending all the original bills, receipts, discharge certificate, Radiological, Pathological report, copy of policy along with duly filled claim form under registered post with A/D receipt to OP No-1 with a copy to OP No.2 for settlement of the claim. However, the OPs instead of settling the claim repeatedly asking the complainant to provide original cash memos of Rs.5,26,000/- of final bill which was issued from Asian Heart Institute, Mumbai. Following are documents submitted by the claimant in support of his claim. Annexure-III is the Coronary Angiogram report, Annexure-IV is the discharge summary, Annexure-V is the Inpatient Cash Bill (summary) and Inpatient Cash Bill (Details), Annexure V(A) Patient Intimation Slip and Annexure-VI through which the claimant sent the claim form i.e. Annexure-X. Annexure-XI through which the complainant answered the queries made by OP No-2. Even after the repeated reply the OP No.2 again and again asking the complainant to submit the receipt of Rs.5,26,000/-. The OP No.2 vide Annexure-XIII again asked the complainant to provide the original cash memo of Rs-526000/- of final bill from Asian Heart  Institute.(Deposit Number –IPDP63531 date-31.01.2016 Rs.244000/-, Number-OADE69513 date-27.01.2016 Rs-20000/- Number-IPDEP63521 date-30.01.2016 Rs-100000/- Number-IPDEP63522 date-30.01.2016 Rs-100000/- Number-IPDEP63693 date-05.02.2016 Rs-62000/-), though the matter was clearly explained in Ext-XI letter dated 07.05.16.  From Annexure-XV it appears that the complainant managed to get a duplicate copy of money deposit receipt amounting to Rs.5,26,000/- Asian Heart Institute, Mumbai and sent the same on 01-07-16 stating that the Asian Heart Institute, Mumbai did not grant him any separate money receipt for payment of final bill of Rs.5,26,000/- and instead of that they have issued a patient intimation slip dated 07-02-16 mentioning details about the payment made by the complainant amounting to Rs.5,26,000/-. Annexure-XVI is the said patient intimation slip. Annexure-XVII, XVIII, IX and XX are those Inpatient Deposition Receipt. But the said papers were returned back by the OP asking the complainant to provide cash memo with the intimation not to settle the claim of the complainant. The notice i.e. Ext-2 which was sent to OP was also remain un-replied. Under the circumstances, it appears clear that there are serious negligence, deficiency on the part of the OPs.

The OP No.1 on the other hand, stated that he is not negligent  and is not liable in this case since OP No.2  hold licence issued by the IDRA, a statutory body to provide service to their company as TPA (Third Party Administrator). All the claims are settled by OP No.2 and not by OP No-1. As such, the OP No.2 is responsible and liability goes upon them because they settled the claim. The complainant lodged his claim and submitted original bills and receipts with forwarding letter dated 18-03-16 which were sent to OP No.2 as TPA for processing and settlement of the claim as per terms of the policy. Further, after receiving the said claim the OP No.2 had started processing the claim but as the complainant failed to submit the original cash memo/ money receipt the same could not be settled. The OPs repeatedly asking the complainant to submit the relevant documents required for the settlement of the claim. Not only that, the Branch Manager Sri Krishala Sengupta requested the complainant over phone to visit their office to discuss and solve the matter but the complainant did not turn up for which the matter could not be settled. There was no negligence or deficiency in service on the part of OPs. The claim could not be settled due to the failure of the complainant to fulfil the requirement by submitting relevant documents like cash memos and money receipt of the alleged expenses incurred during treatment. Besides, they have not repudiated the claim and hence no cause of action has arisen in this case.

While going through the evidence of the complainant it reveals clear from Ext-3 the Coronary Angiogram report and Ext-4 Discharge Summary that the complainant  undergone Cardio surgery at the Asian Heart Institute, Mumbai on 01-02-16 and was discharged on 07.02.17. After getting recovery from the surgery, the complainant lodged a claim on 18-03-16 sending all the original bills, receipts, discharge certificate, Radiological, Pathological reports. Further, it appears from the evidence and record that the OPs instead of settling the claim repeatedly asking the complainant to provide original cash memo of Rs.5,26,000/- of final bill instead of settling the claim. The OP claims that the claim could not be settled due to the failure of the complainant to fulfil the requirement by submitting relevant documents such as cash memos and money receipt of alleged expenses incurred during treatment.

The basic issue that needed to be considered in this case whether the settlement of the claim is delayed due to the failure of the complainant by not submitting the relevant documents such as cash memo and money receipt.

While perusing the evidence and the documents submitted by the complainant along with the documents submitted by the OPs it reveals clear that the complainant submitted  In Patient Cash Bill (summary) as Annexure-V wherein contains details about the expenditure incurred by the complainant. The complainant further submitted Patient Intimation Slip dated 07-02-16 as Annexure-V(A). Besides, the complainant submitted all other relevant documents in support of his claim. From the exhibited documents of OPs i.e. Ext B(1) to B(93) it is found that the complainant submitted Inpatient Cash Bill (summary) and Inpatient Cash Bill Details, Out Patient Cash Bill Details, External Out Patient Cash Bill Details, another In Patient Cash Bill (Summary) dated 07-02-16 and In Patient Intimation Slip date 07-02-16 and many other bills. Whereas, even after submitting all the bills and receipts the OPs repeatedly asking the complainant to furnish money receipt for payment of final bill of Rs.5,26,000/-. The complainant vide Annexure- XI again submitted Patient Intimation Slip dated 07-02-16 wherein details of deposit made by the complainant are given. In the said letter he clearly mentioned that Asian Heart Institute, Mumbai did not grant any separate cash memo for payment of final bill of Rs.5,26,000/- instead they issued Patient Intimation Slip mentioning the details even though he submitted the aforesaid Patient Intimation Slip and In Patient Cash Bill Summary. However, the OP was not satisfied with the same. Again vide Annexure XIII and XIV  issued another  letter requesting the complainant to furnish the details of the claims. The following is the content of the letter-

“We are yet to receive the following documents from Insured-

1. Provide the original cash memo of Rs-526000/- of final bill from Asian Heart Institute.(Deposit Number –IPDP63531 date-31.01.2016 Rs.244000/-, Number-OADE69513 date-27.01.2016 Rs-20000/- Number-IPDEP63521 date-30.01.2016 Rs-100000/- Number-IPDEP63522 date-30.01.2016 Rs-100000/- Number-IPDEP63693 date-05.02.2016 Rs-62000/-).

This is for your information please.”

 

The complainant vide Annexure-XV again submitted the documents as provided by Asian Heart Institute, Mumbai. Annexure –XVI is an In Patient Intimation Slip, Annexure–XVII In Patient Deposit Receipt, Annexure–XVIII In Patient Deposit Receipt, Annexure–IX In Patient Deposit Receipt and Annexure–XX is another In Patient Deposit Receipt by which the complainant deposited the amounts through the Annexure–XV  again stating clearly that Asian Heart Institute, Mumbai did not issue him any separate money receipt for payment of final bill of Rs.5,26,000/- and they have only submitted In Patient Slip and Inpatient Deposit Receipt.

From the above documents as submitted by the complainant it appears clear that the complainant has submitted all the required documents again and again for settlement of the claim whereas, the OP intentionally delaying the matter of settlement which is a deficiency in service on the part of OP. On perusal of the evidence of the complainant it is found that for the treatment of the aforesaid surgery, the complainant incurred about Rs.5,26,000/- for his treatment whereas, the sum assured in the Mediclaim policy was for Rs.1,00,000/- which the complainant is entitled. As such, we are in the view that the complainant has a valid cause for reimbursement of the expenses incurred for treatment in Asian Heart Institute, Mumbai during the period in question which was within the validity period of the policy subject to the maximum of the sum assured in the Family Mediclaim policy.

So far as liability is concerned OP No.1 submitted that OP No.2 hold licence issued the Insurance Development and Regulatory Authority (IDRA) a statutory body to provide service through OP No.1 a “Third Party Administrator”. As such, OP No.1 is not liable to pay any amount as prayed by the complainant because the claim of the complainant is to be settled by OP No.2 and OP No.1 has no role to play in settling the claim. Hence, OP No.1 cannot be held liable for deficiency in service. In this regard it is to be mentioned that OP No.1 issued the Insurance policy and acted on behalf of  OP No.2 while taking the policy, the complainant was not entered any agreement with OP No-2. OP No.1 is acting on behalf of OP No.2 and issued the policy. As such, OP No.1 shall not be absolved from the liability by saying that he is only selling the policy on the ground that the OP No.2 is only having authority to settle the claim. In the present case OP No.1 put the shoe as OP No-2. As such, OP No.1 and No.2 are equally and jointly liable for the deficiency in service. None of them can be absolved from their liability.

In view of the conclusion arrived at this Forum comes to an unassailable conclusion that the evidence led by the complainant has been able to prove and disclose material of deficiency in service and illegal trade practice committed by the OPs by delaying the settlement of the claim. That being the position the complainant is entitled to get the assured amount of the Mediclaim policy and also entitled to get compensation for committing such grave deficiency, because complainant has been subjected to suffer mentally and physically for the aforesaid act of the OP.

As such, this Forum doth order the OPs to pay assured amount of the Mediclaim policy with interest @ 9% per annum from the date of filing the present case till realisation and Rs.15000/- as compensation  for committing grave negligence for which the complainant suffered mental and physical agonies. Further, the OPs are directed to pay Rs.5000/- as cost of filing this case. All the above order shall be complied within one month from the date of this Judgment.

Send  copy of this judgment to OPs for compliance.