FINAL ORDER/JUDGEMENT
SHRI REYAZUDDIN KHAN , MEMBER
This is a complaint case u/s 35 of the CP Act, 2019.The fact of the case in brief is that the complainant is a policy holder of National Insurance Company divisional office XVI having policy No.101900501810001595 since 12th June 2004.The Policy is a Cashless facility policy. The membership under the policy has been issued in the joint name of the complainant himself with his wife Smt. Nilima Chatterjee.Mrs Nilima Chatterjee was detected with Carcinoma of the right breast in the month of May 2017.From the inception of the detection of the ailment to the 12th June 2018 the complainant’s wife had been admitted many times for both surgery and Chemotherapy. The policy was renewed on 12th June 2018.Earlier the complainant’s wife cashless insurance claim was settled and reimbursed smoothly with no trouble at all.The complainant’s wife was admitted in Apollo Gleneagles Hospital,Kadapara,Kolkata for Adjuvant Chemotherapy after renewal of the policy on the 15th June 2018.Initially,the Safeway TPA Services Private Limited(Appointed &Empowered by the Insurance Company to settle the claim and to act on behalf of the Ins.Co.) sanctioned Rs,30,000/- but later the whole cashless claim was denied after getting the discharge certificate and the final bill.The complainant stated that it is mentioned in the policy document under Clause 2.3 that Chemotherapy
will be reimbursed to the tune of 50% of the sum insured including CB.Safeway(Maximum limit under Section 2.3 for any one illness-50% of sum insured).The complainant had paid Rs,3,27,487/-towards treatment of his wife.The claim made by the complainant to the OPs was repudiated on the ground of one internal circular which was totally hidden from the complainant who is the insured of National Insurance Company Limited since 2004.The complainant made the complaint on 10.07.2018 to the Grievance Cell of the OPs with an acknowledge No.IRDA-07-18-009573.They made reminder too on 12.08.2018 but the OPs had not redressed the complainant’s grievance. The complainant also lodged a complaint to the IRDA,Hyderabad on 17.07.2018.The cause of action arose on 10.07.2018 and also on 12.11.2018 when the complainant sent the advocate letter.The complainant further stated that they suffered mental agony and pain due to non receipt of the claim amount from the OPs Insurance company and hence prayed for to direct the OPs to pay the cashless claim of Rs,3,27,487/- to the complainant with the compensation of Rs,1,00,000 for mental agony,harassment and pain .
The OPs have contested the case by filing their WV contending inter alia that the case is not maintainable in law and fact,there is no cause of action and pretended issues raised in the instant complaint are baseless and arbitrary and hence is liable to be dismissed. The complainant having a “National Mediclaim Policy”being policy no.101900/50/18/10001595 for the period of 12.06.2018 to 11.06.2019.The insured person diagnosed as “CA-Right Breast” on 15.06.2018 and she has been admitted into Apollo Gleneagles Hospital with the chief complainant of Adjuvant Chemotherapy and after treatment on the same day she has been discharged. The complainant submitted the cliam form claiming of Rs,3,27,487/-annexing relevant medical reports ,bills etc.with the TPA.The TPA on its observation letter dated 18.07.2018 stated that “The insured has availed treatment in hospital on 15.06.2018.The patient is a K/C/O CA right breast and underwent Adjuvant Chemotherapy is given in addition to the primary or initial therapy to maximize its effectiveness. As per circular of Ins Co.NICL “ho/tech/him/circular/2017-18/005/cmd Master circular no.12/2017-18 dated 28/06/2017”.“Adjuvant Chemotherapy is payable only if it forms a part impatient treatment in case of hospitalization, not payable if hospitalization is done only for administration of medicine/drugs”.So, the claim was recommended for repudiation by the TPA.Keeping in view of the TPA the claim was repudiated.OP further stated that the above mentioned Circular has been circulated among all the branched, divisional offices of the OP/Insurance Co,displayed in the Notice Board in public domain.The Insurance co. is compelled to follow the policy T&C and insurance norms and can not act beyond the said policy T&C and norms.The repudiation of the claim was done in accordance with law and there is no deficiency of service,negligence and harassment & mental agony caused to the complainant by the OPs.The instant complaint purportedly filed by the complainant suffers from suggestio falsi and hence liable to be dismissed in limine.
Points for Determination
In the light of the above pleadings, the following points necessarily have come up for determination.
1) Whether the OPs are deficient in rendering proper service to the complainant?
2) Whether the OPs have indulged in unfair trade practice?
3) Whether the complainant is entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos. 1 to 3:-
All the points are taken up together for sake of convenience and brevity in discussion.
The fact of the case in brief is that the complainant Dr Sourav Chatterjee a member of a mediclaim policy issued by National Insurance Company Limited,the wife of the complainant Smt. Nilima Chatterjee is also the beneficiary of the said scheme. The complainant has come up with the allegation of non settlement of bills placed before the TPA.The TPA Safeway Services Pvt. Ltd (Appointed & Empowered by the Ins.Co.to settle the claim and to act on behalf of the Ins.Co) upon scrutiny of the claim documents submitted by the insured/hospital,it was observed by the TPA that the claim was not admissible on the ground of a circular issued by the National Insurance,Health Insurance management Department dated 28/06/2017 via circular No.ho/tech/him/circular/2017-18/005cmd Master circular No.12/2017 dated 28.06.2017 where it is mentioned that “Adjuvant Chemotherapy is payable only if it forms a part of impatient treatment in case of hospitalization and not payble if hospitalization is done only for administration of medicine/drugs.
Here it was alleged by the complainant that the said circular was not conveyed by the OPs to the complainant while he was signing the renewal of policy on 12.06.2018 though the circular was published on 28.06.2017.It is a stated fact that the complainant is the policy holder since 2004 and the same policy renewed on 12.06.2018 but the OPs failed to provide any information to its client regarding the new circular before renewal of the policy.It leads to suppression of facts and negligence of service to its client while keeping them in dark regarding the new circular.It was the responsibility of the OPs the Ins.co.to provide each and every piece of information to the insured parties and keep them upto date regarding the changes, adding of new provisions in the policy, this must made known to the client either in the prospectus or in the policy or through endorsement, but the OPs completely failed to do so.Only mentioning of the circular of Ins Co.NICL “ho/tech/him/circular/2017-18/005/cmd Master Circular No.12/2017-18 dated 28.06.2017 can not serve the purpose and establish the case at all.It need detailed explanation to defend the case at this stage.
Considering all the actions and inactions of the OPs against the claims submitted by the complainant we are of the opinion that there is deficiency in service as well as unfair trade practice on the part of the OPs. The poor application of mind on the part of TPA should be seriously viewed by the Insurer herein the National Insurance Company Ltd.being the OPs. They cannot escape their responsibility by simply forwarding the ball to the court of the TPA for taking exclusive decision on their behalf. The IRDA guidelines dated 19.03.2021 to all the CEOs of Life, General and Standalone Health Insurance Companies Ltd. and TPAs is very much relevant where it is specifically mentioned in point No. 4 that “Insurer shall ensure that the repudiation of the claim is not based on presumptions and conjectures”. It has been clearly mentioned in another circular of IRDA dated 20.09.2011 that “the insurer’s decision to reject a claim shall be based on sound logic and valid grounds
In the result, the consumer complaint succeeds.
Hence,
Ordered
That the complaint case be and the same is allowed on contest against OPs with the following directions.
1.The OPs are directed to reimburse jointly and severally a sum of Rs. 1,75,000/ (One Lakh Seventy Five Thousand)only as mentioned above to the complainant.
2.The OPs are further directed to pay jointly and severally a sum of Rs. 25,000/- to the complainant as compensation towards harassment and mental agony.
3.The OPs are also directed to pay jointly and severally a sum of Rs. 10,000/- to the complainant as litigation cost.
The above order is to be complied by the OPs within a period of 45 days from the date of this order. In default, the complainant will be at liberty to put the order into execution.
Copy of the judgment be delivered to the parties free of cost as per the C.P. Act and Judgment be uploaded in the website of the Commission for perusal of the parties.
