The Complainant has filed this case under Section 35 of the Consumer Protection Act 2019 against the O.P’s. and praying for following relief / reliefs :-

1. Direction against the O.P’s. to pay disburse the claim of the Complainant an amount of Rs. 29,123/-.
2. Direction against the O.P’s. to pay a sum of Rs. 50,000/- as compensation for mental pains and agony causing due to unfair trade practice and deficiency of service of the O.P’s.
3. Direction against the O.P’s. to pay a sum of Rs. 20,000/- towards cost of legal proceedings.
4. Any other order to which the complainant is entitled as per law.

BRIEF FACTS OF THE COMPLAINT

1. The Complainant is a peace-loving citizen of India , a resident of  Debi Nagar, Maynaguri. P.O. Maynaguri.  P.S. – Maynaguri, Dist- Jalpaiguri, Pin- 735224 , which is situated within this Commission / she is Para Teacher by Profession.

2. The O.P. is Regional office of the renowned Insurance Company  of India namely The National Insurance Company Limited and engaged for the business of providing insurance in various sectors including Mediclaim etc.

3. That to meet the medical expenses without any financial problems the O.Ps. use to promote their Mediclaim Policy to the citizens / the O.P. No. 2 tie up with the O.P. No. 1 engaged for settlement of the Mediclaim of the customers of the O.P. No. 1.
4. That the complainant obtain a Mediclaim Policy being namely National Mediclaim Policy in the year 2019 / she renewed her policy on 05.08.2021 being No. 153900502110000901 which is valid from 05.08.2021 to 04.08.2022/ she again renewed Policy on 05.08.2022 being Policy No. 153900502210000733 ( Annexure P-1).
5. That the Complainant during validity period suddenly on 02.08.2022 filling some pain in hear lower abdomen and due to that pain the complainant went to Neutia Nursing Home with her father / after initial treatment at emergency the Doctor of the Neutia Get-well advised her to admit at the hospital.
6. That the Complainant was entitled for cashless benefit in her Mediclaim Policy. But though she suddenly felled pain went to Siliguri, neither she nor her family members took the policy card for enjoying the cashless facility (Copy of Prescription dt. 02.08.2022 as Annexure P-4)
7. That as per advice of the Doctor the Complainant was admitted on 02.08.2022 in the Neutia Get-Well Health center. ( Admission consent form and other documents are Annexed P-5) / that the father of the Complainant on 02.08.2022 informed the O.P. that the Complainant was admitted in the Neutia Get-Well Health Center for her treatment     ( intimation is Annexed P-6)
8. That the Doctors of Neutia Get-Well Health Center do some tests of the Complainant after admission of the Complainant on 02.08.2022 (Copy of test report is Annexd P-7)
9. That the Complainant was discharge from the Nursing Home on 03.08.2022 (Copy of discharge along with documents are Annexed P-8)
10. That the Complainant incurred an amount of Rs. 23,916/- from 02.08.2022 to 03.08.2022 for treatment at Neutia Get-Well. (Copy of Bill is Annexed P-9)
11. That the Complainant again on 05.08.2022 took admission in the Basu’s Clinic Health Pvt. Ltd did some test of the Complainant on 06.08.202.
12. That the Complainant was admitted at Basu’s Clinic Helth Pvt. Ltd on and from  05.08.2022 to 06.08.2022 being admission reference number 1679. (Copy of Bill is Annexed P-10)
13. That the Complainant paid a sum of Rs. 5,207/- at Basu’s Clinic Health Pvt. Ltd for her treatment and as per  advice of Doctors the Complainant did some test dt. 06.08.2022 ( Photo Copy of report is Annexed P-11) / The Complainant was discharged from Basu’s Clinic Health Center  on 06.08.2022 (Photo Copy of discharge Certificate is Annexed as P-12).
14. That the Complainant raised her claim an amount of Rs. 29123/- (23516 + 5207) to the O.P. No. 1 on 06.08.2022 and she also submit claim form along with all documents in connection to her claim on the  same date on 06.08.2022 (Copy of Claim Form is Annexed as Annexure P-13)
15. That the O.P. No. 2 engaged for settlement of various claim of the O.P. No. 2 for that reason the O.P. No. 2 on 15.09.2022 requested the Complainant to submit some documents by issuing a letter requesting her to submit the documents within 10 days from the date of receipt of the letter / on the basis of the claim of the Complainant the O.P. issued the claim No. being no. 1539005022999194358 (Photo Copy of Letter dt. 15.09.2022 is Annexed as Annexure P-14).
16. That on receipt of the letter sent by the O.P. the Complainant submits the necessary document on 13.10.2023 (Photo copy receipt of Document is Annexed as Annexure P-15).
17. That the complainant again on 01.12.2022 issued a letter and requesting the Complainant to submit some documents mentioned in the letter within 10 days from the date of receipt of the said letter.
18. That the complainant after receiving the letter submits the documents to the O.P. No. 2 but unfortunately on 20.01.2023 the O.P. No. 1 issued a letter on 150600 / MISCCL /AS /PN/ 22 dated 20.01.2023 and informs the Complainant that her claim has been repudiated by the O.P. No. 2 on 06.01.2023 (Photo Copy of repudiation letter dt. 06.01.2023 is Annexed as Annexure P-16).
19. That finding no other alternative the Complainant approached this Commission for settlement of her claim and on 25.03.2023 the date was fixed for hearing of pre-litigation case being no. PL- 11/2023 and on the date of the hearing the Complainant was present but the O.P. was absent and the matter was disposed of  by holding not settled (copy of order dt. 25.03.2023 is Annexed as P-17).
20. That the Complainant was admitted during the validity of her Policy and the Complainant for assured sum of Rs. 2,32,500/- for her treatment and as the O.P. No. 2 is agent / servant  of the O.P. No. 1 so it can be presumed that all the O.P’s. had repudiated the claim of the  Complainant though from Medical documents of the Complainant its evident that she was admitted for a period of 24 hours in both hospital.
21. It is also evident from the clause 3.8 of the Policy as well as the letter of repudiation issued by the O.P. No. 1 that the day care treatment means where hospitalization for the period of 24 hours is not required for the advancement of technology of the particular treatment.
22. That Doctors of Neutia Get-well adviced the Complainant for blood transfusion and due some anxiety for her health could not agree to blood transfusion as the Complainant feels that she will be falls in more trouble in her health if she go for the blood transfusion during her admission in Neutia Get-well, so, she was discharged from Neutia Get-well and went to Basu’s Clinic for blood transfusion and the Doctors of Basu’s Clinic did not thinks that hospitalization required for more 24 hours.
23. The O.P. No. 1 whimsically, illegally and without considering the facts and documents of the complainant repudiated the claim and they did not consider that due to the advance of Technology the hospitalization for 24 hours was not required and they also did not consider  the discharge certificate issued by Neutia Get-well Hospital where from it is clearly presumed that the Complainant was admitted to their hospital more than 24 hours    from 02.08.2022 to 03.08.2022 .
24. That the O.P’s had whimsically and illegally  repudiated the settlement of claim of the Complainant by holding that the complainant was admitted at the hospital less than 24 hours and due to non-settlement of the claim of the Complainant she was suffering from mental agony and depression and cause of action firstly arose on 20.01.2023 when the O.P. No. 1 intimate that they did not disburse the claim of the Complainant subsequently on 23.05.2022 when the O.P. No. 2 did not settle the claim of the Complainant in spite of receiving the representation and questionnaires form and lastly when the O.P. No. 2 did not appear before the  Commission on Pre-Litigation on 25.03.2023 and the cause of action is still continued.

In support of complaint the Complainant has filed the following documents.

1. Photo Copy of the Policy No. 153900502110000901 (Annexure-P-1).
2. Photo Copy of the Policy No. 1153900502210000733 (Annexure-P-2).
3. The photo copy of prospectus of loan (Annexure-P-3).
4. The photo copy of the prescription dated 02/08/2022 (Annexure-P-4).
5. The photo copy of admission consent form and other documents (Annexure-P-5).
6.  Photo Copy of sick intimation (Annexure-P-6).
7. Photo Copy of tests report (Annexure-P-7).
8. The Photo Copy of discharge along with some relevant documents (Annexure-P-8).
9. The Photo Copy of bill (Annexure-P-9).
10. The Photo Copy of bill dated 5/8/2022 to 6/8/2022 (Annexure-P-10).
11. The Photo Copy of report (Annexure-P11).
12. Photo Copy of discharge certificate (Annexure-P-12).
13. The Photo Copy of Claim (Annexure-P-13).
14. Photo Copy of letter dated 15.09.2022 (Annexure-P-14).
15. Photo Copy of receipt by documents (Annexure-P-15).
16. Photo Copy of receipt by documents (Annexure-P-7-16).
17. Photo Copy of receipt by documents (Annexure-P-17).

Notice was issued from this Commission for serving the same upon the O.P’s. and on receipt of notice the O.P No. 1 have appeared before this Commission through Vokalatnama . In his Written Version denied all the allegations of the Complaint, in the Written Version the O.P. has stated that the instant case is not maintainable either in law or on facts / there was no cogent cause for filing of the present case against this O.Ps./ the claim of barred by the principles of waiver, estoppels and acquiescence / the Complainant has filed this case suppressing the material facts / the case is speculative, vexatious and malafied / the case is not maintainable on the grounds of mis-joinder of necessary parties / the contents of the Complainant is fabricated, manufacture and concocted . The O.P No. 1 has also stated regarding Para No. 1 & 2 that the OP No. 1 has no knowledge about the personal life of the Complainant / Statement of Para No. 2, 4, 5 & 6 are admitted by the O.P’ No. 1/ Statement made in Para No. 7 are matter of record / Statement made in Para No. 9 the O.P’ has no personal knowledge about the same / the Statement made in Para No. 10 the O.P. has no comments / Statements made in Para No. 11 & 12 the O.P’ stated that the same are matter of record and subject to verification at the time of hearing / Statements made in Para No. 13, 14 & 15 the O.P’ has stated that the Complainant did not inform the same to the O.P’. which is the mandatory provision of Mediclaim Policy Holder. The O.P’ has also stated that the statements made in Para No. 16, 17 & 18 the O.P’ has stated that the neither the Complainant nor her family members intimated about the Complainant’s admission and discharge in Basu’s Clinic in time. In the Written Version the O.P. No. 1 has also stated that the statements made in Para 19, 20 & 21 of the Complaint the O.P. No. 1 was not aware about the bills, expenditure, fests, discharge of the patient and that’s why regarding bill the O.P. No. 1 has strong objection / regarding Para No. 22 of the Complaint the O.P. No. 1 has objection as the medical bills submission and scrutiny are matter of record /regarding Para No. 23, 24, 25 & 26 of the Complaint the O.P. No. 1 has stated that they have strong objection as the Complainant had submitted bills of two nursing home together in which as per statement the admission period of first Nursing Home from 02.08.2022 to 03.08.2022 and second Nursing Home from 05.08.2022 to 06.08.22 and in the Complaint the Complainant has not state the timing of admission and discharge. It is also stated by the O.P. No. 1 that the Complainant has failed to prove the connection between her treatment status in two Nursing Homes but at the time of raising claim and filing of this case the Complainant placed claim amount jointly which is barred by C.P. Act. It is also stated in the Written Version regarding the statements made in Para No. 27 of the Complaint the O.P. No. 1 states that repudiation of claim is as per terms and conditions mentioned in Clause No. 3.14 of the Policy particulars Page No. 1 where it is clearly mentioned that “ in Patient means an insured person who is admitted in hospital upon the Written advice of duly qualified medical practitioner for more than 24 continuous hours, for the treatment of covered disease / injury during the Policy period” and treatment normally taken on an outpatient basis is not included / regarding Par No 28 of the Complaint the O.P. No. 1 states that, if any violation of terms and conditions held by the consumer than there is no liability for allotting claim by the Insurance Company and in this case the Complainant was not admitted in Basu’s Clinic for more than 24 hours and when the Complainant placed her claim before the O.P. she jointly placed two claims together and therefore the claim is not maintainable / it is also stated in the Written Version that, the statements made in Para NO. 24 & 30 of the Complainant are matter of record and the statements of Para No. 31 is false as the Complainant got admission in Basu’s Clinic on 05.08.2022 at 12.45 P.M. and discharged on 06.08.2022 at 10.04 A.M. / regarding Para No. 32 the O.P. No. 1 has stated that, in clause No 3.8 the terms “ Day Care Centre” Specifically clarified and requirements is mentioned in the Policy book and Basu’s Clinic is not a day care centre / regarding Para No. 33 and 34 the O.P. No. 1 has strong objection and the statements made in Pare 35 to 41 of the Complaint are false and the O.P. No. 1 has denied the same / the statement of Para No. 42 of the Complainant is also denied by the O.P. No. 1 and there was no deficiency of service and unfair trade practice on the part of the O.P. By filing the W.V. the O.P. No. 1 praying for dismissed of the case.

Despite receiving notice, the OP No. 2 did not turn up to contest this Case and therefore the case is proceeding exparte against the OP No. 2.

Having heard, the Ld . Advocate of both the sides and on perusal of the Complainant, Written Version. Documents filed by them the following points are taken together to be considered by this Commission.

Points for consideration :-

1. Whether the Complainant is a Consumer?
2. Whether the case is maintainable under the Consumer Protection Act 2019?
3. Whether there is any deficiency in service on the part of the O.P’s. as alleged by the Complainant?
4. Whether the Complainant is entitled to get the relief as prayed for ?  

 Decision with reasons

All the points are taken up together for discussion to avoid unnecessary repetition and for the sake of convenience and brevity of this case.

In order to prove the case the Complainant has adduced evidence by filing Written Evidence in the form of an Affidavit. In the Written Deposition the Complainant has specifically stated that, she purchased Mediclaim Policy from the O.P. No. 1 and during the effective Policy Period she was suffering from pain in her abdomen and she was admitted in the Neotia Get-well Hospital on 02.08.2022 and she was discharged there from on 03.08.2022 and she paid a sum of Rs. 23,916/- for her treatment at Neotia Get-well Hospital. The Complainant has further stated that, she was again admitted to the Basu’s Clinic on 05.08.2022 for her treatment and was discharged there from on 06.08.2022 and she paid Rs. 5207/- at Basu’s Clinic.

At the time of argument Ld. Advocate of the Complainant submits that, the Complainant submitted claim form along with all medical documents in connection with her claim on 06.08.2022 when the O.P. issued a claim No- 1539005022999194358. It is also argument of the Complainant that, as per direction of the O.P. No. 2 dated 15.09.2022 the complainant submitted documents on 13.10.2022 and again on 01.12.2022 the O.P. No. 1 issued another letter to the complainant asking to submit some documents within 10 days from the date of the letter and there after the O.P’s by a letter dated 20.01.2023 informed the Complainant that her claim was repudiated on 06.01.2023 because the Complainant was hospitalized less than 24 hours. It is argument of the Complainant that, the O.P. whimsically and without any basis stated that, the father of the Complainant did not intimate the O.P. but the said allegation is not at all correct because the father of the Complainant intimate the O.P. on 02.08.2022 immediately after admission. It is further argument of the Complainant that, the Complainant has been able to prove her case against the O.P’s and to prove her case she filed all her medical documents which she submitted to the O.P’s. along with the claim form.

To falsify the case of the Complainant the O.P. No. 1 has adduced evidence in the form of an Affidavit. In the said evidence the O.P. No. 1 has corroborated the contents of their Written Version. In the evidence the O.P. No. 1 has stated that, they have rightly repudiated the claim of the Complainant as it violated the terms and conditions mentioned in Clause No. 3.14 of the Policy particulars Page No. 3. It is also argued that, the claim of the patient is considered only when he / she is admitted in hospital for more than 24 continuous hours and in the instant case the complainant was not admitted in the Basu’s clinic for more than 24 hours. It is also the argument of the O.P. that, she Complainant has not been able to prove her case against the O.P’s.

Having heard, the Ld. Advocate of both the side and on perusal of the entire record it is admitted fact that, the Complainant obtained mediclaim Policy from the O.P. No. 1 in the year 2019. It is also admitted fact that, the Policy of the Complainant was renewed on yearly basis and lastly it was renewed on 05.08.2022 being Policy No. 153900502210000733  which was valid upto 04.08.2023. It is not denied by the O.P’s that, the Complainant had not submitted claim form on 06.08.2022 for reimbursement of medical expenditure. It is also admitted fact that, after receiving the claim form of the Complainant the O.P issued a claim number being in No. – 1539005022999194358. It is also not denied by the O.P. that, the Complainant did not submit medical documents to them for processing the claim.

Only dispute in this case is whether the Complainant had raised two claims together which is not maintainable as per the provisions of the Consumer Protection Act. Another dispute in this case is whether the Complainant had violated the terms and conditions mentioned in Clause No. 3.14 of the Policy particulars and whether the Complainant was not admitted in the hospital for more than 24 hours ?

Now let us see how for the Complainant has been able to prove her case against the O.P’s or not?

From perusal of the reply given by the Complainant in response to the Questionnaires of the O.P. it reveals that, in Question No. 2 the Complainant replied that she took admission in Neotia Gete-well on 02.08.2022 at 12.24 p.m. and in reply to Question No. 3 she replied that, she was discharged from Neotia Gete-well on 03.08.2022 at 1.53 p.m. From those two answers given by the Complainant it is proved that, she was admitted in the Neotia Get-well for more than 24 hours. Accordingly the claim of the O.P. in respect to admission in the Neotia Get-well for below 24 hours is not sustainable. On the other hand the Complainant by submitting medical bill etc proves that, she paid a sum of Rs. 23,516 /- for her treatment in the Neotia Get-well hospital. But the said sum of Rs. 23,516/- has not been paid to the Complainant till date and the said non-payment of medical expenditure to the patient / Complainant is nothing but the deficiency of service on the part of the O.P’s.

With regard to another medical bill of Rs. 5207/- which the Complainant claims from the O.P. we find that, the Complainant in reply to Question No. 5 submits that, she took admission in Basu’s Clinic on 05.08.2022 at 12.45 p.m. and she also replied to Question No. 6 that she was discharged from Basu’s Clinic on 06.08.2022 at 10.04 a.m. From the said reply of the Complainant it is admitted by the Complainant that she was not admitted in the Basu’s Clinic for more than 24 hours. From the answer given by the Complainant with regard to the treatment in the Basu’s Clinic we can safely hold that, as she was not admitted for more than 24 hours she is not able to fulfill the terms and conditions of the Mediclaim Policy and therefore, she is not entitled to get the sum of Rs. 5207/- which she incurred for the treatment in the Basu’s Clinic.

Considering all we are of the view that, the Complainant has been able to prove the case to the effect that, she is entitled to get the Medical expenditure which she incurred for her treatment in the Neotia Get-well Hospital along with Compensation for deficiency of service.

Hence it is therefore,

O R D E R E D

That the instant Consumer Case being in No. 37/2023 is allowed on contest against the O.P. No. 1 and exparte against the O.P. No. 2 but in part. The O.P. No. 1 is directed to pay a sum of Rs. 23,516/- to the Complainant which she incurred for her treatment in the Neotia Get-well Hospital. The O.P. No. 1 is also directed to pay a sum of Rs. 10,000/- to the Complainant towards compensation for mental pain, agony as well as for deficiency of service on the part of the O.P’s. The O.P. No. 1 is further directed to pay a sum of Rs. 10,000/-  to the Complainant for cost of legal proceedings and the O.P. No. 1 is also directed to pay a sum of Rs. 10,000/- in the Consumer Legal Aid Account of this Commission. The O.P. No. 1 is also directed to pay interest @ 4 % per annum to the Complainant on the awarded amount with effect from the date of filing of this case till making payment of the entire amount.

The O.P. No. 1 is directed to pay the awarded amount within 45 days from this day failing which the Complainants will have the liberty to take steps against the O.P. as per law.

Let a copy of this Order / Judgement be given to the parties free of cost.