This complaint U/S 35 of C.P. Act, 2019 was initially filed against the Opposite Party (O.P.) 1) National Insurance Company Limited, Jalpaiguri Divisional Office, Debijhora Building, Thana Road, P.S. - Kotwali, P.O. & Dist. - Jalpaiguri, Pin Code- 735101 (W.B.), O.P. 2) Sri Brijmohon Marodia, S/O Late Ram Bilas Marodia, Raikat Para, P.S. - Kotwali, P.O. & Dist. - Jalpaiguri, Pin Code- 735101, who contested their case by filing Written Version (W.V.) separately.

The case of the complainant as per her complaint is as follows-

The complainant argued in his plaint that he made a health insurance policy being no. 153900501810000322 with a total sum assured of Rs. 4, 00, 000/- (Rupees Four Lac) only through the O.P. No.2, viz. Mr. Brijmohon Marodia and the validity of the said policy was from 22/05/2018 to 21/05/2019 and the premium amount of the said policy was Rs. 24, 673/- (Rupees Twenty Four Thousand Six Hundred and Seventy Three) only. The complainant also added that he had also included the name of his wife, viz. Smt. Sanju Agarwal, his elder son, viz. Sri Tarun Agarwal and his younger son, viz. Sri Sahil Agarwal in the said policy and he had been paying the required premium amount to the O.P. No.1 through the O.P. No.2 in a regular basis.

The complainant also argued that from 27/09/2018 to 07/10/2018 he admitted in Nivedita Nursing Home & Polyclinic (P) Ltd., Siliguri under the treatment and observation of Dr. C. P. Sharma and on/ after diagnosis he had been suffering from “Chronic Obstructive Pulmonary Disease with (acute) Exacerbation Decompensated COPD with (acute) exacerbation Excludes2: Chronic obstructive pulmonary [COPD] with acute (J44.0); Respiratory Failure, not elsewhere classified” and thereafter, after thorough scrutiny and diagnosis  the said doctor discharged him from the Nivedita Nursing Home & Polyclinic (P) Ltd. and referred him to any higher centre for further treatment and the complainant had received the cashless benefits of R. 87, 743/- (Rupees Eighty Seven Thousand Seven Hundred and Forty Three) only for his said treatment at the said Nivedita Nursing Home and   accordingly on 08/10/2018 the complainant got himself admitted in Sir Ganga Ram Hospital at New Delhi under the treatment of Dr. Anup Kumar Basu, Dr. Amit Dhamija and Dr. Abhinav Guliani and in the Sir Ganga Ram Hospital he had been diagnosis with “acute exacerbation of chronic obstructive pulmonary disease, Type 2 Respiratory Failure, Dyselctrolytemia Eczema”. The complainant also argued that after prolonged and protracted treatment procedure on 21/10/2018 he had been discharged from the said Sir Ganga Ram Hospital and thereafter, as per the advice of his treating doctor he passed a few more days at New Delhi for certain routine check- up. The complainant also added that he paid a total sum of Rs. 2, 98, 956/- (Rupees Two Lac Ninety Eight Thousand Nine Hundred and Fifty Six) only where Rs. 655/-, Rs. 499/-, Rs. 290/-, Rs. 533/- and Rs. 681/- was included as post hospitalization bills and pharmacy bills.

The complainant also argued in his plaint that after returning back from New Delhi on 11/012/2018 he handed over his all treatment related papers to the O.P. No.2 for submitting the same to the O.P. No.1 for reimbursement of his legitimate claim but the O.P. No.2 did not submitted those said documents to the O.P. No.1 but told the complainant that all his treatment documents already had been submitted to the O.P. No.1. The complainant also added that being frustrate subsequently he sent his elder son to the office of the O.P. No.1 to enquire the matter and knew that no such papers/ documents in connection to his treatment was submitted to the O.P. No.1 and after getting this information from O.P. No.1 when the elder son of the complainant met with O.P. No.2 then O.P. No.2 admitted his fault towards non- depositing the entire claim related documents of the complainant to the O.P. No.1 for disbursement of complainant’s legitimate claim. The complainant also argued that after that without any delay on 16/04/2021 he submitted his entire claim related documents to the O.P. No1 and in connection to this on 19/04/2021 the O.P. No.1 sent a letter to him stating that his claim was under process as per policy terms and conditions and on 11/05/2021 the O.P. No.1 sent an e-mail for providing them various information relating his reimbursement and on 13/05/2021 the complainant furnished his relevant answers against the queries of O.P. NO.1 and again on 19/05/2021 when the O.P. No.1 again sent a letter to him the complainant saw that the letter of O.P. No.1, dated 19/05/2021 was a replica of the letter of O.P. No.1, dated 11/05/2021.  The complainant also added that on 15/07/2021 he received a letter from O.P. No.1 for furnishing various details of treatment by his treating physician along with all prescriptions and past treatment papers and on 22/09/2021 again the complainant sent all his relevant documents to the O.P. No.1. The complainant also added that on 10/12/2021 he sent an e-mail from his son’s e-mail account to the representative of O.P. No.1, viz. Sri Kalyan Debnath, to enquire about the details of his claim matter and on 14/12/2021 the said Sri Kalyan Debnath again sent a letter to him for furnishing the original discharge summary and reasons for delay in submission his claim when the same had already been intimated in details to them by the complainant and finally on 07/02/2022 he received a letter from the said Sri Kalyan Debnath stating that his file had reached the O.P. No.1 after 896 days of delay. The complainant also argued that on 08/07/2022 he sent a letter to the O.P. No.2 to immediately look into the matter in connection to his genuine claim and on 26/07/2022 the complainant sent a letter to the Divisional Manage of O.P. No.1 and requested him to look into the entire matter and on 02/08/2022 he received one letter

under reference 150600/MISCCL/AS/PN/22 from the Divisional Manager of O.P. No.1 stating that the O.P. No.1 were not in a position to approve his claim due to the delay of 905 days in submission of his claim. The complainant also argued that on 03/08/2022 he wrote a letter to the Divisional Manager of O.P. No.1 all the reasons for his delay and for reconsideration the entire matter but did not get any result.                         

The prayers of the complainant are as follows-

1. To pass an order directing the O.P. No.1 to the complainant his legitimate receivable amount of insurance to the tune of Rs. Rs. 2, 98, 956/- (Rupees Two Lac Ninety Eight Thousand Nine Hundred and Fifty Six) only as per the Mediclaim Insurance Policy.

2. To pass an order directing the O.P. No.2 to pay the complainant a sum of Rs. 1, 00, 000/- (Rupees One Lac) only for delay and latches willfully and negligently committed by him towards non- depositing the complainant’s claim related papers and documents within the specified time period and for willful mis- representation and unlawful and illegal acts done thereby depriving the complainant of his legitimate insurance claim benefits.

3. To pass an order directing the O.P.s for payment of 12% per annum interest upon the claim amount.

4. To pass an order directing the O.P.s to pay to the complainant of Rs. 50, 000/- (Rupees Fifty Thousand) only as compensation against the constant tremendous mental stress and agony caused to him and his family members.

5. To pass an order directing the O.P. to pay to the complainant of Rs. 50, 000/- (Rupees Fifty Thousand) only for cost of litigation.

6. To pass an order directing the O.P. to pay to the complainant of Rs. [(Rs. 2, 98, 956/-) + (Rs. 1, 00, 000/-) + (Rs. 50, 000/-) + (Rs. 50, 000/-) = Rs. 4, 98, 956/-] (Rupees Four Lac Ninety Eight Thousand Nine Hundred and Fifty Six) only.

                        List of documents filed by the complainant:

1. Photocopy of entire Insurance Policy related papers and documents along with the premium payments made therein by the complainant.
2. Photocopy of Discharge Certificate of Nivedita Nursing Home & Polyclinic (P) Ltd., Siliguri.
3. Photocopy of the amount sanctioned by the O.P. No.1 Insurance Company through cashless mode.
4. Photocopy of Discharge Certificate of Sir Ganga Ram Hospital, New Delhi with bills.
5. Photocopy of Bills of Sir Ganga Ram Hospital, New Delhi.
6. Photocopy of the e-mail, dated 16/04/2021.
7. Photocopy of letter, dated 19/04/2021.
8. Photocopy of letter, dated 11/05/2021.
9. Photocopy of letter, dated 13/05/2021.
10. Photocopy of letter, dated 19/05/2021.
11.  Photocopy of letter, dated 15/07/2021.
12.  Photocopy of letter, dated 22/09/2021.
13.  Photocopy of e-mail, dated 10/12/2021.
14.  Photocopy of letter, dated 14/12/2021.
15.  Photocopy of letter, dated 08/07/2022.
16.  Photocopy of letter, dated 26/07/2022 with postal receipt.
17.  Photocopy of letter, dated 02/08/2022.
18.  Photocopy of letter, dated 03/08/2022 with postal receipt and track   consignment report.

             Regarding this instant case, the Opposite Party (O.P.) 1) National Insurance Company Limited, Jalpaiguri Divisional Office, Debijhora Building, Thana Road, P.S. - Kotwali, P.O. & Dist. - Jalpaiguri, Pin Code- 735101 (W.B.), O.P. 2) Sri Brijmohon Marodia, S/O Late Ram Bilas Marodia, Raikat Para, P.S. - Kotwali, P.O. & Dist. - Jalpaiguri, Pin Code- 735101, who contested their case by filing Written Version (W.V.) separately and as per their W.V. the case is as follows.

In his W.V. the O.P. No.1 denied all the facts of the complainant and argued that the O.P. No.1 did not have any knowledge about the alleged facts of supplying relevant treatment related papers and documents in the hands of O.P. No.2 by the complainant

on 11/12/2018 and thus O.P. No.1 could not say anything about it. The O.P. No.1 also argued that there was delay of lodging claim before the O.P. No.1 by the complainant for 896 days and for this reason, the complainant made a false story which was not acceptable to them without any proof and the O.P. No.1 was not liable for this. The O.P. No.1 also argued that the agent, viz. O.P. No.2 was not an authorized person to receive the claim application on behalf of the O.P. No.1 and the alleged agent could not be considered as the servant of O.P. No.1 that’s why the O.P. No.1 categorically repudiated the claim of the complainant for the delay of 905 days. The O.P. No.1 also added that there was no deficiency in service in the part of the O.P. No.1 and everything was done by them as per the rules and regulations of the company of O.P. No.1 and the Commission has no jurisdiction to adjudicate the present case and the instant claim case should be dismissed with cost.   

In his W.V. the O.P. No.2 also denied all the facts of the complainant and argued that he has been working as an agent of O.P. No.1 since 12 years or more but in this case he was not acquainted with anything regarding the treatment of the complainant and the complainant did not communicate with the O.P. No.2 unless the policy claim was submitted to the O.P. No.1 and even the complainant did not send one Tarun Agarwal personally to him and there was no role of O.P. No.2 regarding the latches and delay of sending the mediclaim related papers/ documents to the O.P. No.1 by the complainant.

Having heard, the Ld. Advocate of the complainant and on perusal of the Complaint and documents filed by the complainant the following points are taken to be decided by this Commission.

 Points for consideration

1) Whether the complainant is a consumer?

2) Whether the case is maintainable under the CP act 2019?

3) Whether this Commission has its jurisdiction to decide this case? 

4) Whether there is any deficiency in service in the part of the O.P. as alleged by the complainant?

5) Is the complainant is entitled to get any award and relief as prayed for? If so, what extent?                

Decision with reason:-

            All the points are taken up together for consideration and decision.

Seen and perused the complaint petition filed by the parties, supported by the affidavit, documents filed by the parties. We are also heard argument of both sides in full length.

In this case the complainant resides in Jalpaiguri and the O.P. No.1 National Insurance Company Limited, carrying his business in Jalpaiguri and the O.P. No.2 Sri Brijmohon Marodia, also resides in Jalpaiguri and thus this Commission has its territorial jurisdiction to decide this case.

In this case the complainant had a mediclaim policy of National Insurance Co. Ltd (O.P. No.1) being policy no. 153900501810000322 with a total sum assured of Rs. 4, 00, 000/- (Rupees Four Lac) only and from 27/09/2018 to 07/10/2018 he admitted in Nivedita Nursing Home & Polyclinic (P) Ltd., Siliguri under the and after that on 08/10/2018 the complainant got himself admitted in Sir Ganga Ram Hospital at New Delhi. The complainant also added that he paid a total sum of Rs. 2, 98, 956/- (Rupees Two Lac Ninety Eight Thousand Nine Hundred and Fifty Six) only where Rs. 655/-, Rs. 499/-, Rs. 290/-, Rs. 533/- and Rs. 681/- was included as post hospitalization bills and pharmacy bills. In this specific point the O.P. No.1 did not raise any objection and so, this Commission has no doubt to hold that the complainant is a very much consumer under the C.P. Act 2019 and this Commission also has its jurisdiction to decide this case.

The complainant resides in Jalpaiguri and the O.P. No.1 is also carrying his business in Jalpaiguri. Thus, there is no doubt that this Commission has its territorial jurisdiction to decide this case.

As per documents and evidences filed by the complainant it is clear that he had a mediclaim policy of National Insurance Co. Ltd (O.P. No.1) being policy no. 153900501810000322 with a total sum assured of Rs. 4, 00, 000/- (Rupees Four Lac) only and from 27/09/2018 to 07/10/2018 he admitted in Nivedita Nursing Home & Polyclinic (P) Ltd., Siliguri and found that he had been suffering from “Chronic Obstructive Pulmonary Disease with (acute) Exacerbation Decompensated COPD with (acute) exacerbation Excludes2: Chronic obstructive pulmonary [COPD] with acute (J44.0); Respiratory Failure, not elsewhere classified” and thereafter, the said doctor discharged him from the Nivedita Nursing Home & Polyclinic (P) Ltd. and referred him for further treatment and accordingly on 08/10/2018 the complainant got himself admitted in Sir

Ganga Ram Hospital at New Delhi and in said hospital he had been diagnosis with “acute exacerbation of chronic obstructive pulmonary disease, Type 2 Respiratory Failure, Dyselctrolytemia Eczema” and after protracted treatment procedure on 21/10/2018 he had been discharged from the said Sir Ganga Ram Hospital. It is also clear from the letter dated 19/04/2021 filed by the complainant that he claimed a total sum of Rs. 2, 98, 956/- (Rupees Two Lac Ninety Eight Thousand Nine Hundred and Fifty Six) only to the O.P. No.1 being claim no. 103165314.

In this case, the O.P. No.1 told that the they did not have any knowledge about the alleged facts of supplying relevant treatment related papers and documents in the hands of O.P. No.2 by the complainant. The O.P. No.1 also argued that there was delay of lodging claim before the O.P. No.1 by the complainant for 896 days and the O.P. No.1 was not liable for this. The O.P. No.1 also argued that the agent, viz. O.P. No.2 was not an authorized person to receive the claim application on behalf of the O.P. No.1 and the alleged agent could not be considered as the servant of O.P. No.1 and that’s why the O.P. No.1 categorically repudiated the claim of the complainant for the delay of 905 days as per the rules and regulations of the company of O.P. No.1.  

The O.P. No.2 also denied all the facts of the complainant and argued that he has been working as an agent of O.P. No.1 since 12 years or more but in this case he was not acquainted with anything regarding the treatment of the complainant and the complainant did not communicate with the O.P. No.2 unless the policy claim was submitted to the O.P. No.1 and even the complainant did not send anyone to him and there was no role of O.P. No.2 regarding the latches and delay of sending the mediclaim related papers/ documents to the O.P. No.1 by the complainant.

In this instant case, it is also clear from the documents and evidences filed by the parties that there was a delay in submission of 905 days by the complainant for submitting his claim to the O.P. No.1 but in this regard the complainant stated in his plaint that he handed over his entire treatment related papers/ documents to the O.P. No.2, who was the agent of O.P. No.1 but the O.P. No.2 did not submitted the same to the O.P. No.1. The O.P. No2 denied this fact. The O.P. No.1 also denied that the O.P. No.2 was not their authorized agent but the O.P. No.2 clearly stated in his W.V. that he was an authorized agent of O.P. No.1 and has been working as an agent of O.P. No.1 since 12 years or more.

It is fact that, the complainant had a mediclaim policy of National Insurance Co. Ltd (O.P. No.1) being policy no. 153900501810000322 with a total sum assured of Rs. 4, 00, 000/- (Rupees Four Lac) only and he filed his claim related papers/ documents of Rs. 2, 98, 956/- (Rupees Two Lac Ninety Eight Thousand Nine Hundred and Fifty Six) only to the O.P. No.1 for the delay of 905 days and for this reason the O.P. No.1 categorically repudiated the claim of the complainant.  

In support of his statements, the complainant referred a judgment- Om Prakash vs. Reliance General Insurance on 4 October, 2017, THE SUPREME COURT OF INDIA, CIVIL APPEAL NO. 15611 OF 2017 (Arising out of SLP (C) No. 742 of 2015) where it stated that-

Rejection of the claims on purely technical grounds in a mechanical manner will result in loss of confidence of policy-holders in the insurance industry. If the reason for delay in making a claim is satisfactorily explained, such a claim cannot be rejected on the ground of delay. It is also necessary to state here that it would not be fair and reasonable to reject genuine claims which had already been verified and found to be corrected by the Investigator. The condition regarding the delay shall not be a shelter to repudiate the insurance claims which have been otherwise proved to be genuine. It needs to emphasis that the Consumer Protection Act aims at providing better protection of the interest of consumers. It is a beneficial legislation that deserves liberal construction. This laudable object should not be forgotten while considering the claims made under the Act.

Another judgment was referred by the complainant- National Insurance Co. Ltd. v. Hukam Bai Meena (2018) SCC Online (NCDRC) 328, DATED 01-08-2018 where it stated that-

This     Commission held that as per Circular No. IRDA/HLTH/MISC./CIR/216/09/2011, issued by the Insurance Regulatory and Development Authority (IRDA), a genuine claim cannot be outrightly rejected on the ground of delay. The Commission further held that the insurer is required to enquire from the claimant as to what was the reason for the delay in submission of the claim and the claim should be rejected only where the insurer finds that it was liable to be rejected even if it had been submitted in time. Since no such opportunity was granted to the respondent, the decision of the State Commission was upheld and the revision petition was dismissed.

One another judgment was referred by the complainant- Gurmel Singh v. National Insurance Co. Ltd., (2022) SCC ONLINE sc 666, dated 20.05.2022 where it stated that-

Once, there was a valid insurance on payment of huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non-submission of the duplicate registration, which the appellant could not produce due to the circumstances beyond his control.

The Commission here adopted the principal laid down in the above noted cases.

In this situation, the Commission always follows the decision of the Hon’ble Apex Court of India and this Commission has no right to ignore the decision of the Hon’ble Apex Court of India.

So, in this instant case, this Commission holds that there is a deficiency of service from the part of the O.P. No1, the National Insurance Company Limited and the complainant is entitled to get Rs. 2, 98, 956/- (Rupees Two Lakh Ninety Eight Thousand Nine Hundred Fifty Six) only from the O.P. No.1.        

Hence, it is therefore,

ORDERED

That the Consumer Case No. 82/2022 be and same is allowed in contest against the (O.P. No.1) National Insurance Co. Ltd.

The National Insurance Co. Ltd (O.P. No.1) is directed to pay Rs. 2, 98, 956/- (Rupees Two Lakh Ninety Eight Thousand Nine Hundred Fifty Six) only to the complainant within 30 days from the date of this order failing which the complainant is entitled to get @ 6% simple interest per annum from the date of filing of this case, i.e., from 22/09/2022. The O.P. No.1 is also directed to pay Rs 5,000/- (Rupees Five Thousand) only for mental pain, agony, harassment and litigation cost and also to deposit Rs. 5,000/- (Rupees Five Thousand) only in the Legal Aid Account of this Commission within 30 days from the date of this order.    

Let a copy of this judgment be given to the parties directly or through their representative Ld. Advocate for compliance free of cost.