Consumer Complaint No. 127 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. Nos. 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.1,45,860/- 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.25,000/- 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.
All of a sudden the wife of the complainant was suffering from some gynaecology problem. The complainant without delay went to the chamber of Dr. S.P. Roy Chowdhury at Burdwan. After examining the wife of the complainant the doctor advised for operation. The complainant communicated with the O.P. No.1 and stated the matter about his wife on 1.8.2015. Thereafter the complainant sent a letter to the O.P. No.1 on 4.8.2015 for co-operation to get benefit of their medical facilities.
After giving prior information to the O.P. No.1 the complainant admitted his wife at Mission of Mercy Hospital and Research Centre, Kolkata on 6.8.2015 under Dr. Sanjoy Sen. The doctor examined the patient and after clinical test the total abdominal Hysterectomy and Bilateral Salpingo-ophorectomo and Appendicectomoi of the patient was done under spinal anesthesia on 7.8.2015 and ultimately the patient was discharged on 14.8.2015. The complainant incurred all the medical expenses for treatment of his wife.
After returning home the complainant sent a letter dated 17.8.2015 to the O.P. No.1 requesting him to issue the requisite claim form along with necessary papers for disbursement of the case. The O.P. No.1 received the said letter on 17.8.2015. Thereafter the complainant submitted the claim form duly filed up along with all the medical papers and medical bills before the O.P. No.1 on 20.8.2015 and requested the O.P. No.1 to settle the claim as early as possible.
On 1.9.2015 the O.P. No.3 sent a letter to the complainant for providing further information/documents to proceed the reimbursement. On 30.9.2015 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. This O.P. further stated the in the present case the captioned claim of the insured/complainant, Nemai Chand Show has been processed by the aforesaid TPA (Third Party Administrator) in the account of the patient Mrs.Tanuja Show amounting to Rs.1,45,807/- as per claim form submitted by the complainant on 20.8.2015 seeking reimbursement of alleged expenses incurred for treatment of his wife at Mission of Mercy Hospital and Research Centre, which was diagnosed as Multiple fibroid Uterus, as per discharge summary and certificate issued by Mission of Mercy Hospital and Research Centre dated 14.8.2015. Thereafter the said TPA, Heritage health TPA Pvt. Ltd. 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/complainant inspite of several reminders. The O.P. No.3 vide its letter dated 1.9.2015 made some additional queries in connection with the patient, Tanuja Show, which are follows:-
- Proper original hospital final bill in P.P.N. Package Rate from treating hospital.
- Treatment Sheet from treating hospital.
- Investigation advice with reports.
- Original Hospital Break-up bill with supporting documents (consolidated bill not allowed.)
- Why excess amount taken from patient beyond P.P.N. Package Rate clarification from treating hospital.
and also requested in said letter dated 1.9.2015 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 1.9.2015 the 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 1.9.2015 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 28.11.2015. 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 also 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/bills like original hospital final bill, treatment sheet, original hospital break up bill, medical investigation reports, etc. Despites repeated demand letter 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 28.11.2016 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. Perused the documents filed by the parties. Now this Forum is to decide whether the complainant is entitled to realize the medical expenses of Rs.1,45,807/- from the O.P. No.1 for treatment of his wife and for compensation for harassment and litigation cost as prayed for.
Admitted position is that the Insurance Policy (Happy Family Floater Medi-claim Policy) purchased by the complainant and sum insured was Rs.10,00,000/-. Annexure-A is supported the document. The policy valid was valid from 31.3.2015 to midnight 30.3.2016 bearing policy No.313102/48/2015/3707. Annexure-D proved this fact. The complainant also filed documents in support of the treatment of his wife that his wife was operated upon at Mission of Mercy Hospital, Kolkata. The medical reports in this regard has been filed and duly intimated to the O.P. which was received by the O.P. It is proved by the letter of the complainant (Annexure-E). After the said operation all the medical expenses borne by the complainant from his own pocket at that time and he in terms of the policy submitted the claim form with
necessary papers for disbursement, which was received by the O.P.(Annexure-F). The medical bills are annexed serially to prove the fact that the total medical expenses is Rs.1,45,807/-. Annexure-G series has been filed to prove this fact. It contains relevant documents like copy of policy paper, claim form letter of which dated 4.8.2015, discharge certificate, laboratory report, patient’s total bill details with money receipt, doctor’s prescription etc. Perused all the documents.
As per requirement of O.P. the complainant submitted further information with documents and the letter dated 1.9.2015(Annexure-H) also proves this Forum. The additional documents received by the O.P. and the documents are also annexed here (Annexure- I series). Therefore, the O.P. closed the claim matter unreasonably on the ground of non-receiving the sufficient documents to settle the claim of the complainant. On the other hand we find that the complainant was very much diligent proves the case by submitting all the documents categorically and serially as per requirement of the O.P. with his claim form. O.P. did not response to the claim of the complainant and did not settle the matter which is nothing but deficiency in service on the part of the O.P.
This Forum find that complainant has been able to prove by sufficient documents that he incurred expenses of Rs.1,45,807/- for the treatment of his wife who had undergone for Abdominal Hysterectomy and Bilateral Salpingo-oophorectomy and Appendicectomy operation. Therefore, he is entitled to realize the same in terms of the policy which he purchased. We find that the complainant is entitled to get Rs.1,45,807/- towards medical expenses for treatment of his wife Tanuja Show. As the O.P. failed to settle the claim it unnecessarily causes mental pain, agony and harassment to the complainant. Therefore, if a sum of Rs.3000/- is awarded to the complainant as compensation for mental pain, which will not be insufficient. The complainant is further entitled to get litigation cost of Rs.2000/-. 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.1,45,807/- towards medical expenses, to pay Rs.3000/- as compensation towards mental pain, agony and harassment and to pay Rs.2000/- 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
