Consumer Complaint No. 128 of 2016
Date of filing: 28-07-2016 Date of disposal: 22.08.2017
Present :
Smt. Jayanti Maitra (Roy) Hon’ble President,
Sri Pankaj Kumar Sinha Hon’ble Member,
Mr. Nemai Chand Show, S/o. Lt. Tarapada Show,
Resident of 7/1A, G.T. Road, Burdwan, behind of
R.S. Concern, P.O., P.S. & Dist.-Burdwan,
Pin-713101.
Complainant
VERSUS
- The Branch Manager, The Oriental Insurance Company
Ltd., having its Branch Office at B.C.A., Building, Court
Compound, P.O., P.S. & Dist.-Burdwan, Pin-713101.
- The Chairman, The Oriental Insurance Company Ltd., having
Its registered office at A-25/27, Asaf Ali Road, New Delhi,
Pin-110002.
- The Director, Heritage Health TPA Pvt. Ltd., having its office
at NICCO House, 5th floor, 2, Hare Street, Kolkata-700001.
Opposite Parties.
Appeared for the complainant : Ld. Advocate Subrata Ghosh.
Appeared for the O. P. No. 1 : Ld. Advocate Ahibhushan De.
Appeared for the O. P. No. 2 : None.
Appeared for the O. P. No.3 : Ld. Advocate Gopal Basu.
JUDGEMENT
This is a case U/s. 12 of the C.P. Act for an award directing the O.Ps. to pay Rs.80,473/- towards the medical expenses for treatment of his wife which has already been incurred by the complainant, to pay Rs.10,000/- as compensation for mental pain and agony and to pay Rs.20,000/- as litigation cost to the complainant.
The complainant’s case in short is that his wife Mrs. Tanuja Show and their daughter Sarbani Show and son Sohan Show were insured under Happy Family Floater Medi-claim Policy, bearing policy No.313102/48/2011/2572 issued by the Oriental Insurance Company Ltd. through the O.P. No.1 for the period from 31.3.2011 to mid-night 30.3.2012. The sum assured amount of the said policy was Rs.10,00,000/-.
Thereafter said policy was renewed time to time and lastly renewed on 30.3.2015 bearing policy No.313102/48/2015/3707 for the period from 31.3.2015 to midnight 30.3.2016.
On 27.8.2015 the daughter of the complainant namely Sarbani Shaw had faced a massive accident by motor cycle, when she was entered into the gate of Burdwan Municipal Girls High School. The daughter of the complainant became unconscious and was seriously injured. Then the complainant with the help of the local people admitted the daughter in Sharanya Hospital. Most of the teeth of the daughter of the complainant are broken and head, right and left hands including chest were seriously injured.
The complainant intimated the matter about the accident of his daughter to the O.P. No.1 by letter vide letter dated 29.8.2015 and requested the O.P. No.1 to Advise them for better way of treatment to get the mediclaim assistance from any other institution. Thereafter the complainant again sent a letter dated 8.10.2015 to the O.P. No.1 stating that the complainant was going to Kolkata to admit his daughter in the Microlap at 24, Bepin Pal Road, Kolkata under Dr. Manas De for better treatment of his daughter and requested the O.P. to make arrangement of expenses incurred by him. The O.P. No.1 received the said letter on 3.10.2015 with their seal and signature.
The operation of his daughter was done on 10.10.2015 and ultimately his daughter was discharged on 11.10.2015. After returning home from the nursing home the complainant submitted the filled up claim form to the O.P. No.1 on 19.11.2015 along with all the medical papers and bills incurred by him towards the treatment of his daughter and requested to disburse Rs.80,473/- which he incurred for treatment of his daughter as early as possible.
On 1.12.2015 the O.P. No.3 sent a letter to the complainant for providing further information/documents to proceed the reimbursement. On 10.2.2016 the complainant after fulfilled the all quarries as per their requirements, submitted additional papers to the O.P. No.3 to settle the claim. But inspite of receiving all the requirement documents for settlement of the claim the O.Ps. did not take any steps regarding the settlement of the claim till date. The O.Ps. neither made a single response against the claim nor settled the said claim. The complainant went to the office of the O.P. No.1 and requested several times but to no effect. Having no other alternative to get relief the complainant has filed this case before this Ld. Forum. Hence, this case with the prayer as mentioned above.
Inspite of service of notice the O.P. No.2 did not appear in this case and did not contest this case. So, the case was heard ex-parte against the O.P. No.2
The O.P. No.1 contested this case by filing written objection while stating inter-alia that the complainant has neither any locus standi nor any cause of action, the instant complaint is barred by limitation. The O.P. No.1 further stated that the O.P. had issued a Happy Family Floater Policy, being renewed Mediclaim Policy being No.313102/48/2015/3707 for the period from 31.3.2015 to 30.3.2016 in the name of the Insured Nemai Chand Show for the sum assured of Rs.10,00,000/- and M/s. Heritage Health Services Pvt. Ltd. was the Third Party Administrator(TPA). The policy bond was issued by the O.P.No.1, Insurance Company. The O.P. No.1 states that the insurance under this policy is subject to conditions, clauses, warranties, endorsement, as per form attached. The said policy shall pay for hospitalization expenses for medical/surgical treatment at any nursing home/hospital in India as an in-patient defined in the policy. This O.P. No.1, the Oriental Insurance Company Ltd., Burdwan Branch Office, Burdwan strive to ensure that the insured get the best possible treatment from the Network Hospitals of this O.P. and also stated in the said policy that please contact with TPA or any of the Oriental Offices for preferred hospitals in the area of the insured before going for a treatment, so that this may help this O.P. No.1 serve the insured in the best possible manner. It is also stated in the said policy of insurance that the claim to be reported within 48 hours of admission, but before discharge and claim documents to be submitted within seven days of discharge. This O.P. further submits that the TPA shall reimburse to the hospitals (only if treatment is taken at Network Hospitals) with prior written approval of TPA or to the insured persons (if payment to the hospital is not agreed to or the insured persons opts for reimbursement of the claim) the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured persons upto the limit of liability specified in the policy and/or schedule of the policy but not exceeding the sum insured in anyone period of insurance for one or all the family members stand in the policy. In the event the policy is not serviced by the TPA such expenses shall be reimbursed to the Insured persons by the company. Be it mentioned that expenses on hospitalization are admissible only if hospitalization is for a minimum period of 24 hours. This policy schedule, proposal, declaration given by the insured constitute a complete contract. Only insurer may alter the terms and conditions of the policy and such alterations made by the insurer shall only be evidenced by a duly signed endorsement on the policy with the company stamp. The aforesaid TPA means any company/body who have obtained licensed from IRDA to practice as a Third Party Administrator and is appointed as TPA by the company. It further mentioned that as per Exclusion Clause the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of pre-existing health condition or disease of ailment or injuries.
This O.P. also submits that in the present case the captioned claim of the insured/complainant, Nemai Chand Show has been processed by the aforesaid TPA in the account of the patient, Sarbani Show amounting to Rs.80,473/- as per claim form submitted by the complainant/insured seeking reimbursement of alleged expenses incurred for treatment of his daughter at Micro Lap Hospital/nursing home at 24, Bepin Pal Road, Kolkata-26, which was diagnosed as Accident (dental/teeth ) injured, as per discharges summary and certificate issued by Micro Lap Hospital dated 11.10.2015 Thereafter the said TPA being the O.P. No.3 found that the said claim is inadmissible due to deficiency in submitted documents for which queries raised by them and was not complied by the insured inspite of several reminders. The O.P. No.3 vide its letter dated 1.12.2015 and 17.12.2015 made some additional queries in connection with the patient, Sarbani Show, which are follows:-
- Doctor advice for admission;
- Policy verification report;
- Doctor prescription on 25.9.2015;
- H.P. Report (Biopsy Report) and original receipt for Rs.1500/- from Drs. Tribedi & Roy;
- Xerox copy of patient photo identity (Voter’s Identity Card/Pan Card);
and also requested in said letter dated 1.12.2015 and 17.12.2015 addressed to the insured to provide them the above information/documents in immediately i.e. within 15 days to enable them to proceed for allowing reimbursement and also stated in said letter that in case of part compliance without satisfactory clarifications of their queries, they have no other option but to deny reimbursement and also requested to reply at the earliest in order to process reimbursement. This O.P. No.1 also submits that inspite of aforesaid queries made by the O.P. No.3 vide their letter dated 1.12.2015 and 17.12.2015the insured/complainant has not submitted/complied in part, though the aforesaid documents/clarification still awaited. The proceeding of the claim could not be finalized due to non-compliance of the essential requirements which were asked by the aforesaid Query Letter dated 1.12.2015 and 17.12.2015 with subsequent reminders and as such the claim file with their (TPA) observation “Not Pursued/ to be closed” was forwarded to this O.P. No.1 and thus the said claim of the complainant/insured was recommended for Closure by the said TPA, Heritage Health TPA Pvt. Ltd. and informed the same to the insured/complainant vide Claim Closure letter dated 14.01.2016. The O.P. No.1 also stated that since there was deficiency in submitting documents, additional query raised by the O.P. No.3 and no proper compliance was received from the insured/complainant and as such the claim file has been closed accordingly by the TPA. The said claim of the complainant is pending for final settlement by this O.P. No.1, Insurance Company for the reasons as stated above.
This O.P. No.1 also stated that there has/have not been any deficiency in service or unfair trade practice or negligence on the part of this O.P. No.1 and as such the instant complaint is liable to be summarily dismissed with cost.
The O.P. No.3 has contested this case by filing written version stating inter-alia that a copy of the complaint petition without any annexures purportedly affirmed by the complainant has been served upon this O.P.by the complainant and as a consequence, this O.P. is unable to make any comment/submission on ‘those annexures’ itself. This O.P. also stated that the instant case is bad both in law and in fact and it is not maintainable at all. The pretended issues raised against this O.P. in the instant complaint are baseless, arbitrary and it is not sustainable in the eye of law.
The O.P. No.3 further stated that the O.P. No.1 Insurance Company has appointed and empowered the O.P. No.3 as ‘TPA’ to deal with and to settle the claim submitted by the complainant. Upon receiving the claim form from the complainant/claimant, it is observed by the O.P. No.3/ TPA that the claim form has been submitted by the claimant without annexing all the required papers/receipts like doctor’s advice/ prescription , police verification report, H.P. Report, original receipt from doctor etc. Despites repeated demand letters and reminder letter on the part of O.P. No.3, the complainant/claimant has neither submitted all the required papers/reports/bills as demanded nor given any reply to the query letter issued by the O.P. No.3 and as a consequence, the O.P. No.3 has rejected the claim vide its letter dated 14.01.2016 addressed to the complainant/claimant stating that the claim file without observation ‘not pursued/ to be closed’ being forwarded to the policy issuing office for final review…..’
This O.P. No.3 is the TPA wholly appointed by the Insurance Company i.e. O.P. No.1 herein with the absolute power & authority to deal with the claim submitted by the claimant/complainant on behalf of the O.P. No.1/ Insurance Company and acted in accordance with law. In the instant case the O.P. No.3/TPA has put its best efforts to settle the claim of the complainant and as such there is not laches or negligence, unfair trade practice and deficiency in service on the part of the O.P. No.3
DECISION WITH REASON
Heard Ld. Lawyers of both the sides who made an elaborate argument in this case. Perused the documents filed by the parties. Admitted position is that the complainant purchased the mediclaim policy (Happy Family Floater Medi-claim Policy) bearing No. 313102/48/2015/3707 valid from 31.3.2015 to midnight 30.3.2016 and the sum insured was Rs.10,00,000/-. Sarbani Show, the daughter of the complainant and as one of the family member met with an accident and was seriously injured and she required treatment. The matter was intimated to the O.P. No.1 vide letter dated 29.8.2015 (Annexure-E). For better treatment she was visited by Dr. Manas Dey and received required treatment which was also intimated to the O.P. by letter dated 8.10.2015 (Annexure-F). Perused the copy of letters. The complainant has been able to prove this fact by producing sufficient documents and the photocopies of the prescription of the doctors and treatment papers of nursing home at Calcutta. The complainant has incurred expenses of Rs.80,473/-. Afterwards the complainant filled up the claim form to get reimbursement of the expenses under the policy with all the annexed medical bills (Annexure G series), which contained claim form, policy paper, discharge certificate, laboratory report, bill details with money receipts, doctor’s prescription. Perused all those documents.
The O.P. received the intimation and acknowledgment by seal and signature on 9.10.2015. The O.P. asked for additional documents and some queries mentioned in the letter. The complainant by his letter dated 10.2.2016 sent the entire requirements (Annexure-J) and requested the O.P. to settle the matter but without any response from the O.P. concerned. Therefore, the complainant has been able to prove that he has incurred total expenses of Rs.80,473/- for treatment of his daughter following the accident. Ld. Lawyer for the O.P. further submits that the complainant requested the O.P. to reimburse the medical expenses under the policy (Happy Family Floater Medi-claim Policy). It is only a simple claim of medical expenses under the Happy Family Floater Medi-claim Policy. Therefore, the O.P. cannot repudiate the claim of the complainant. But O.P. failed to settle the claim. It is nothing but deficiency in service on the part of the O.P. and it necessarily causes mental pain and agony along with financial loss of the complainant. This Forum finds that the complainant has been able to prove his case by sufficient documentary evidence that he incurred expenses of Rs.80,473/- for treatment of his daughter and he has entitled to realize the same in terms of the policy from the O.P. More over if a sum of Rs.2000/- is allowed as compensation towards mental pain, agony and harassment for the deficiency in service on the part of the O.P. then it will not be insufficient. The complainant is further entitled to get Rs.1000/- as litigation cost.
In view of our above discussions the case is succeeds. Fees paid is correct. Hence, it is
Ordered
that the complaint case is allowed on contest against the O.P. No.1 & 3 and exparte against the O.P. No.2. The O.P. No.1 is directed to pay Rs.80,473/- towards medical expenses, to pay Rs.2000/- as compensation towards mental pain, agony and harassment and to pay Rs.1000/- towards litigation cost to the complainant within 30 days from this day, failing which the complainant will be at liberty to put this award in execution in accordance with law.
Let the copies of this order be supplied to the parties free of cost.
Dictated and corrected by me, (Jayanti Maitra(Roy)
President,
D.C.D.R.F., Burdwan
(Jayanti Maitra (Roy)
President, (Pankaj Kumar Sinha)
D.C.D.R.F., Burdwan Member,
D.C.D.R.F., Burdwan
