MRS. FIROZA KHATOON, PRESIDENT
The complainant’s case is that since 2012 – 2013 she is holder of a Medical Insurance Policy of National Insurance Company Ltd., and paid premium regularly till date. This case relates to the Mdeiclaim policy for the period on and from 19.03.2020 to midnight of 18.03.2021.
The complainant states that in the year 2020, during lock down period most of her family members including her husband Sri Goutam Chakraborty was affected by fever. The health condition of her husband became serious and on 24.08.2020 at 2 p.m. was admitted to S. C. Bagchi Arogya Sadan Pvt. Ltd. at Santragachi, Howrah on payment of Rs.26,000/- (Rupees twenty six thousand) only in cash. Her husband was tested Covid positive vide report dated 24.08.2021. The said Nursing Home suggested to shift the patient to any Covid Hospital. Her husband was discharged on 26.08.2020 from S. C. Bagchi Arogya Sadan Pvt. Ltd. and the complainant paid the final bill for the treatment of her husband by using Debit Card of her husband. In the mean time the mother in law of the complainant namely Rita Chakraborty who was admitted in hospital on 25.08.2020 died of Covid 19 and other co-morbidities on 27.08.2020. Complainant’s father and mother both were affected for Covid 19 and admitted in hospital and subsequently the father of the complainant died on 05.09.2020. The complainant informed the opposite party all the facts via email. Thereafter, the complainant submitted Mediclaim of Rs.71,409/- (Rupees seventy one thousand four hundred nine) only on 12.10.2020 for the expenses incurred for treatment of her husband along with original final bill, other original medicine bills & reports, original discharge certificate, cancelled cheque etc., but opposite party no.3 vide letter dated 09.11.2020 asked the complainant to submit original money receipt against the final Bill, original Plate/Film of Echo Amp etc. and all original reports during hospitalization etc.
According to the complainant due to attack of Covid 19 of most of her family members, they had to depend on others for admission, release, treatment in hospitals, for purchasing medicines etc., as such some original money receipts were misplaced. Therefore, the complainant collected duplicate money receipts and all other original documents from the said Nursing Home S. C. Bagchi Arogya Sadan Pvt. Ltd.
On 23.11.2020 the complainant submitted those documents with the opposite parties. The complainant affixed an affidavit disclosing the facts of misplace of the original bills etc. and also submitted the same with the opposite parties.
Thereafter, vide letter dated 26.01.2021 the opposite parties repudiated the claim on the grounds of non submission of original money receipts .Finding no other alternative the complainant send a legal notice upon opposite parties but to no effect. Barring the original money receipts for payment of the hospital bills, the complainant filed all other original documents with her claim form. The act of the opposite parties is completely harassive and deficiency in service in nature. Finding no other alternative the complainant filed the instant case for redressal of his grievances.
Opposite party nos.1 & 2 by filing written version state that on 12.10.2020, the opposite party no.3 received claim form along with documents of the complainant. But it was not submitted within 15 days from the date of discharge of the insured from hospital.
Opposite party nos.1 & 2 further state that in spite of repeated reminders by opposite party no.3, the insured fail to submit the original money receipts. The complainant submitted duplicate copies of money receipts. So, vide letter dated 26.04.2021 the opposite parties claimed the original money receipts for settlement of insurance claims as per terms and conditions of the policy. The opposite parties state that the complainant though got ample opportunity to submit the original receipts but fail to do so. The opposite party no.3 closed the claim for non submission of mandatory document. However closing of the claim does not restrict to submit original money receipts to enable opposite party no.3 to re-open the case and to proceed further. According to this opposite parties there is no deficiency in service on their part and the complainant is not entitled to get any relief as prayed for.
Opposite party no.3 by filing separate written version states that the complainant is a policy holder of National Mediclaim Policy being no.101600/50/19/10013909 (19.03.2020 to 18.03.2021), and sum insured Rs.1,00,000/- (Rupees one lakh) only and cumulative bonus Rs.40,000/- (Rupees forty thousand) only along with her husband Mr. Goutam Chakraborty. It is admitted by opposite party no.3 that the husband of the complainant Mr. Goutam Chakraborty was admitted in S. C. Bagchi Arogya Sadan Pvt. Ltd. on 24.08.2020 and was discharged on 26.08.2020. The claim form along with documents were received by the opposite parties on 12.10.2020. On 15.10.2020 and 09.11.2020 the opposite parties requested the complainant to submit some documents to enable them to processes the claim. Thereafter on 23.11.2020 the complainant sent some documents for settlement of the claim. According to opposite party no.3 in spite of repeated reminders the complainant fails to submit the original money receipts. In place of original money receipts the complainant submitted duplicate copies of money receipts. Thereafter, on 26.04.2021 the Insurance Company sent a letter to the complainant stating that the original money receipts are required for settlement of the claim as per policy terms and conditions. In spite of ample opportunity the complainant did not file the original money receipts and finally the Insurance Company close the claim for non submission of mandatory documents. According to opposite party no.3 there is no deficiency in service on the part of the opposite parties. As such the complainant is not liable to get any relief as prayed for.
Points for decision
Considering the rival pleadings of the both parties the following points are framed:
- Is the complainant a consumer in terms of Consumer Protection Act, 2019?
- Is the case barred by limitation?
- Is the consumer entitled to get any relief as prayed for?
Decision with reason
In order to prove the case the complainant has submitted affidavit in chief along with documents. The complainant also filed affidavit in reply to the questionnaire of the opposite parties.
The document submitted on evidence by the complainant are as follows:
Photo copy of policy : document-1; photo copy of final bill/money receipts dated 26.08.2020 : dcoument-2; photo copy of medicine bill dated 27.08.2020 : documet-2/1; photo copy of medicine bill dated 27.08.2020 : docoument-2/2; photo copy of receipts of debit card of Axis Bank : document-2/3 & 2/4; photo copy of discharge summery of Goutam Chakraborty : document-3; photo copy of claim form : document-4; photo copy of repudiation letter dated 26.04.2021 of opposite party no.1 : document-5; photo copy of letter dated 04.01.2021 and letter dated 10.02.2021 : document-6 & 6/1; photo copy of letter dated 14.06.2021 by opposite parties : document-7 and photo copy of advocates letter dated 23.06.2021 by complainant : document-8.
Point no.1
This important point is taken up for consideration and discussion.
In course of argument Ld. Advocate for the opposite parties did not utter single sentence against this point.
On scrutiny of material on record and evidence of the parties, it appears that the complainant is a consumer in terms of Consumer Protection Act, 2019.
From document-1 (Insurance policy) it appears that the name of the insured are the complainant, her husband Goutam Chakaraborty, daughter Saranya Chakraborty and mother Smt. Chinmoyee Ghosh and the policy was effective on and from 19.03.2020 to mid night of 18.03.2021 and premium was paid.
In view of the above discussion this point is decided in favour of the complainant.
Point no.2
This point is taken up for consideration and discussion.
From the material on evidence of the record it appears that the insured Goutam Chakraborty was admitted at S. C. Bagchi Arogya Sadan Pvt. Ltd. on 24.08.2020 and discharged on 26.08.2020 (document-3) during the validity period of the policy.
The opposite parties first repudiated the claim filed by the complainant on 26.04.2021 (Document-5) and the instant case has been filed by the complainant on 09.09.2021.
Therefore, it is apparent on the face of the record that the case is not barred by limitation under section 69 of the Consumer Protection Act, 2019.
Considering the discussion made above this point is also decided in favour of the complainant.
Point no.3
Now this important point is taken up for consideration and discussion.
From the pleadings and evidence of both the parties it appears that the opposite party nos.1 to 3 have not denied in their written versions and evidence the following facts:
- that the complainant, her husband Goutam Chakraborty, daughter Saranya Chakraborty and mother Smt. Chinmoyee Ghosh have taken a mediclaim policy with effect on and from 19.03.2020 to mid night of 18.03.2020. During the validity of such insurance policy one of the insured Goutam Chakraborty was admitted in S. C. Bagchi Arogya Sadan Pvt. Ltd. on 24.08.2020 and discharged on 26.08.2020 (document-3).
- the complainant filed mediclaim for sum of Rs.71,409/- (Rupees seventy one thousand four hundred nine) only, the amount incurred for the treatment of her husband Goutam Chakraborty.
- that the complainant save and except the original money receipt of S. C. Bagchi Arogya Sadan Pvt. Ltd., filed all other original documents along with claim form. On 26.04.2021 the opposite party no.1 sent a letter to the complainant stating that the claim is not payable due to non submission of necessary documents before opposite party no.3.
- that the complainant submitted duplicate copy of money receipts issued by S. C. Bagchi Arogya Sadan Pvt. Ltd. with the opposite parties in place of original money receipts.
- that the complainant filed reasons for non submitting the original money receipt. The complainant stated that the original money receipts issued by the S. C. Bagchi Arogya Sadan Pvt. Ltd. has been misplaced during the Covid-19 pandemic period. In the year 2020, the complainant lost her father and mother in law owing to virus attack of Covid-19 and most of the family members of the complainant were affected by the virus of Covid-19 during that year.
- that the complainant had to depend on others for admission of her husband and other near ones of her family in hospitals, for discharge and for purchasing medicines in those acute abnormal days which the whole world had witnessed. The complainant owing to such extreme abnormal situation in her family misplaced the original money receipts issued by S. C. Bagchi Arogya Sadan Pvt. Ltd.
- that the complainant collected duplicate money receipts and other original documents from the said S. C. Bagchi Arogya Sadan Pvt. Ltd.
It appears from the evidence of the complainant that on affidavit she submitted regarding the misplacement of the original money receipts of S. C. Bagchi Arogya Sadan Pvt. Ltd.
Money receipts are required to submit in order to prove that the insured has actually paid the money to the concerned for his treatment.
No allegation against the complainant that the amount mentioned in duplicate bill has not been paid to S. C. Bagchi Arogya Sadan Pvt. Ltd. for the treatment of the insured.
Neither in written versions nor in their evidence the opposite parties denied the issuance of duplicate money receipts by S. C. Bagchi Arogya Sadan Pvt. Ltd. in respect of the patient Goutam Chakraborty who undergone treatment in the said S. C. Bagchi Arogya Sadan Pvt. Ltd. on and from 24.08.2020 to 26.08.2020. The opposite parties also not alleged that the duplicate money receipts had been manufactured for the purpose of the mediclaim by the complainant. Nowhere in the four corner of the written versions opposite parties challenged the authenticity of the duplicate money receipts filed by the complainant with them. The only objection raised by the opposite parties that on the basis of any duplicate money receipts any mediclaim cannot be settled according to the terms and conditions of the policy.
The opposite party nos.1 & 2 in their written versions and evidence categorically stated that ‘closing of the claim does not restrict the insured from submitting the above mentioned mandatory documents to enable TPA to reopen the case and proceed further.
Now the question before us is to decide as to whether on the basis of the duplicate money receipts issued by the S. C. Bagchi Arogya Sadan Pvt. Ltd., the opposite parties can settle the claim of the complainant.
It is fact that the Hon’ble Apex Court in General Assurance Society Ltd. –Vs- Chandumull Jain and Another held that the policy document being a contract has to be read strictly and also observed “In Interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves.”
In United India Insurance C. Ltd. –Vs- M/s. Harchand Rai Chandan Lal, the Hon’ble Apex Court reiterated the same principle stating that an insurance policy is a contractual agreement between the parties and its meaning has to be construed strictly in terms of the conditions of the policy and nothing can be added or subtracted from it.
The facts of the above mentioned cases are quiet distinguishable from the facts of this case.
In the year 2020 the whole world had witnessed an abnormal and unprecedented situation during attack of virus Covid-19 which led to pandemic across the world. Practically the impact of Covid-19 pandemic and its consequences are felt by each and every individual of the world. The virus Covid-19 has killed a massive number of people across the world irrespective of class, gender, age, race and medical history. Normal life of human was totally shattered. No one was allowed to go out of their houses except for dire need. Lack of income, food, medicines were common phenomena during that period.
The pandemic era has led to problems for all people especially family affected by Covid-19 virus as they had to struggle for daily needs, treatment and other essentials and also had to depend on others for supply of the same. Misplacing any document in that abnormal particular situation cannot be overlooked by the Commission.
Due to social distancing norms the IRDA in March, 2020 by issuing a circular directed the insurance companies to promptly settle Covid-19 related hospitalization claims and after coverage for allowable medical expenses during quarantine period according to policy terms. Such claims may be disallowed only following a thorough examination by the ‘Review committee’ of insurance claim. Considering the pandemic situation IRDA also allowed extra grace period of one month for payment of premium to all life insurance policies due in March, 2020 relaxing the terms and condition of the policy.
The tele-medicines also introduced into consideration for settling claim as per circular of IRDAI.
Insurance is like an umbrella that protects us from uncertainties in life. People usually expect the insurance providers to assume financial security in case of adversity such as disease or death.
Since life has been turned upside down by the pandemic for insurers, policy holders, insurance agents and other stake holders, it is expected that suitable measures should be adopted for steering the ship in stormy waters.
When the whole world including India is tending towards transition to digital, the Insurance Industry should also focus of enhancing the claim settlement process easier. This would not only ensure increased efficiency, but also provide customers with faster pay outs.
It is need less to reiterate that the opposite parties not denied that the duplicate money receipts issued by S. C. Bagchi Arogya Sadan Pvt. Ltd. or the same has been manufactured for the purpose of claim Document-2/3 and Document-2/4 online payment receipts of the amount through Axis Bank A.T.M. card also supports the authenticity of the duplicate money receipts.
Therefore in such circumstances it can safely be held that acceptance of duplicate money receipts for settling the claim of the complainant would not be any deviation from any of the terms and conditions of the policy.
The entire facts and circumstances clearly suggests that the insurance company disallowed the mediclaim of the complainant without thorough examination of it by the review committee as per guideline of IRDA.
It is not a case of the opposite parties that the complainant has not spent the claim amount submitted by her towards the treatment of her husband Goutam Chakraborty within the period of the insurance policy. Therefore it will be unjust if we reject the claim amount as prayed by the complainant for the treatment of her husband within the policy period for misplacing the original money receipts, when the duplicate money receipts issued by S. C. Bagchi Arogya Sadan Pvt. Ltd. submitted by the complainant and Document-2/3 ad Document-2/4 remained unchallenged and un-rebutted in evidence.
Having considered the elaborate discussion made above we are of the opinion that the spirit of the guidelines of IRDAI from time to time during pandemic period has not been followed by the opposite parties. The manner in which the claim of the complainant was dealt by the opposite parties is certainly deficiency in service causing harassment to the insured person.
Therefore, we have no hesitation to hold that the complainant is liable to get relief as prayed for.
From the documents filed by the complainant it appears from the submitted claim form (Document-4) which remained un-rebutted ad unchallenged in evidence that the total amount of claim was Rs.61,675 + 500 + 9,234 = Rs.71,409/- (Rupees seventy one thousand four hundred and nine) only. The complainant submitted money receipts of S. C. Bagchi Arogya Sadan Pvt. Ltd. for sum of Rs.61,675/- (Rupees sixty one thousand six hundred seventy five) only, medicine bill dated 27.08.2020 for sum of Rs. 5,091/- (Rupees five thousand ninety one) only and medicine bill dated 27.08.2020 for sum of Rs.4,143/- (Rupees four thousand one hundred forty three) only along with photo copy of slips of A.T.M. Card of Axis Bank (Document-2 series). Therefore, the complainant has been able to file documents of total Rs.70,909/- (Rupees seventy thousand nine hundred nine) only. The complainant has not submitted any bill for Rs.500/- (Rupees five hundred) only for pre-hospitalization.
Having elaborate discussion made above, we are of the opinion that the complainant has been able to prove her case and she entitled to get relief in this case.
Hence, it is
O R D E R E D
that the complaint case be and the same is allowed on contest with cost.
the opposite party nos.1 & 2 are directed to pay a sum of Rs.70,909/- (Rupees seventy thousand nine hundred and nine) only along with 9% per annum simple interest from the date of repudiation of the claim i.e. on and from 26.04.2021 within two months from the date hereof in default to pay the same along with same rate of interest on and from 26.04.2021 till payment.
that the opposite party nos. 1 and 2 shall pay a sum of Rs.30,000/- (Rupees thirty thousand) only as compensation to the complainant within two months from the date hereof in default the opposite party nos.1 and 2 shall pay interest @ 9% per annum till payment.
Dictated and corrected by me
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President
