Tripura

West Tripura

CC/7/2017

Sri Mohammed Ali Choudhury. - Complainant(s)

Versus

The Divisional Manager, New India Assurance Company Ltd. & Others. - Opp.Party(s)

Self

02 May 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
WEST TRIPURA :  AGARTALA

CASE   NO:   CC- 07 of  2017

Mohammed    Ali Choudhury,
S/O- Late A.R. Choudhury,
PEC Brick Field, Jyostna Building,
South Ramanagar, Agartala, 
West Tripura.            ….....…...Complainant.

           VERSUS

      1. The Divisional Manager,
New India Assurance Co. Ltd.,
Club Road, Capital Complex,
Silchar- 1,
Cachar, Assam.

      2. The Branch Manager,
New India Assurance Co. Ltd.,
Mantribari Road, Agartala, 
West Tripura.

3. Sri Koushik Ghosh,
Claim Executive
Heritage Health TPA Pvt. Ltd.,
IRDA License No. 009-495195 WB1998,
Regd Office, FTCO 99562,
Macliod House, 5th Floor,
Z, Hare Street, Kolkata-700 001,
Ref-Claim No.HH221707027-M.A.Choudhury.    
                         .......... Opposite parties.

                      __________PRESENT__________

 SRI A. PAL,
PRESIDENT,
  DISTRICT CONSUMER  
DISPUTES REDRESSAL FORUM,
      WEST TRIPURA, AGARTALA. 

SMT. Dr. G. DEBNATH
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

SRI U. DAS
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

 

C O U N S E L

    For the Complainant        : In Person.                        
                      
    For the O.Ps No.1 & 2        : Sri G.S. Das,
                          Sri Kushal Deb,
                          Sri Subhankar Deb,
                            Advocate.

    For the O.P. No.3            : None appeared.    
             

 

        JUDGMENT  DELIVERED  ON:   02.05.2017

J U D G M E N T

        This case arises on the petition filed by by Mohammed Ali Choudhury U/S 12 of the Consumer Protection Act. Petitioner's case in short is that he is a customer of Medical Insurance scheme of New India Assurance Company Ltd. premium was paid under the agreement. During the continuation of the policy his wife was treated at Medinova Hospital, Silchar on 11.08.16 and he had to spent Rs.65,648/. His wife was released from the hospital on 16.08.16 and he submitted bill for medical reimbursement on 30.08.16. His claim was accompanied with the documents slip of the hospital for payment of Rs.22,675/-. The claim is still pending since 30.08.16. All request was turned down. So, he claimed the amount along with other charges for mental harassment. He claimed Rs.99,000/- as compensation. 

2.        O.P. New India Assurance Company Ltd. appeared, filed Written statement denying the claim. It is stated that O.P. No.3 Koushik Ghosh is the settling authority of the claim. The claim is to be settled by him only not by the New India Assurance Co. Ltd. so liability is to be fixed on O.P. No.3, not New India Assurance Co. Ltd.

3.        O.P. No.3, Koushik Ghosh, Claimed Executive did not appear to contest the case. 
4.        So on the basis of contention raised by the parties following points cropped up for determination:
        (I) Whether the claim of the petitioner was unnecessarily delayed by the New India Assurance Co. Ltd. ?
        (II) Whether there was deficiency of service by New India Assurance Co. Ltd. and petitioner is entitled to get any compensation?
        
5.        Petitioner produced the Group Mediclaim Policy, Payment Receipt, Claim Form, Discharge Summary of Medinova Hospital, Final bill, 3rd party administrators papers, Group Medical Insurance Master Policy certificate, procedure for availing cashless service and other papers. 
        Petitioner also given statement before the court.

6.        O.P. on the other hand produced the statement on affidavit of Asit Roy Chowdhury, Administrative officer of New India Assurance Co. Ltd. 

        Case was heard against O.P. No.3 exparte.
 
7.        On the basis of all these evidence on record we shall now determine the above points.

Findings:

8.        We have gone through the 3rd Party Administrative Memorandum of New India Assurance Co. Ltd. By that Memorandum New India Assurance Co. Ltd. was tied up with 17 Nos. of TPAs 3rd Party Administrators for settlement of claim. Heritage Health TPA is a 3rd party administrator. O.P. No.3 Koushik Ghosh is the Claim Executive of Heritage Health TPA. Claim form was placed before the TPA through LIC. From perusal of all documents it is clear that TPA is to decide the claim and place it before the New India Assurance Co. Ltd. for payment. Here in this case TPA Heritage Health failed to settle the claim till today. 

9.        Claim Executive, Koushik Ghosh wrote letter to LIC. LIC is the proposer of the policy and Heritage Health TPA is the settlement authority when the petitioner produced original money receipt for Rs.22,675/- against the hospital final bill. According to the petitioner final bill was submitted with the claim form. Photocopy of the claim form is produced before Forum along with that final bill. We have gone through the final bill of Medinova Diagnostic Centre. From that it is found that total bill was Rs.32,675/-, Rs.10,000/- advance was paid earlier. Rs.22,675/- is to be paid. Inspite of production of the final bill Claim Executive of the Heritage Health TPA Pvt. Ltd.  failed to settle the claim. 

10.        Asit Roy Chowdhury, Administrative Officer of New India Assurance Co. Ltd. stated that claim not submitted before the Insurance Company and the claim is not pending before them. This is not a proper answer to the problem. New India Assurance company itself appointed the TPA for settling the claim. When the claim is not settled within the reasonable period then definitely New India Assurance Co. Ltd is to take step and pursue the TPA for settlement of claim. Closing the hands and doing nothing is improper. There is no documents before us to support that petitioner approached the New India Assurance Co. to take up the matter with the TPA. Petitioner stated that he submitted the claim on 30.08.16. claim is still pending. Due to delay and deficiency of service  by New India Assurance Co. he suffered. 

11.        We have gone through the Group Mediclaim Insurance Master Policy and found that petitioner is a policy holder of New India Assurance Co. New India Assurance Co. can not avoid its responsibility as because it has appointed TPA for settlement of claim through memorandum. LIC is the proposer of the policy and after collection of the premium the sum is to sent to the New India Assurance Co. In our considered  opinion New India Assurance Co. is under obligation to take up the matter with the TPA for settlement of the claim. But it failed to do so in reasonable period. They are to look into the problem of the customer. It was not done and there is negligence of TPA in respect of deciding the claim within the reasonable period as they did not inform the new India Assurance Co. So there is deficiency of service as ultimate service provider of the policy was New India Assurance Co. From the papers and documents it is found that petitioner is the policy holder of the Mediclaim and his claim was delayed because of deficiency of service of O.P. No.3 being appointed by New India Assurance Co. It true that mistake was done while naming the Insurance company at the beginning but it was corrected and New India Assurance Co. appeared.

12.        We direct the New India Assurance Co. to take up the matter with the TPA Heritage Health for settlement of the claim and make the payment to the petitioner in respect of illness of his wife within 15 days. For the deficiency of service we direct the O.P. New India Assurance Co. and claim Executive Heritage TPA to pay Rs.10,000/-. Case is decided accordingly.     

Announced.

 

SRI A. PAL
PRESIDENT,
DISTRICT CONSUMER  DISPUTES 
REDRESSAL FORUM,
WEST TRIPURA,  AGARTALA.

 

SMT. DR. G. DEBNATH,
MEMBER,
 DISTRICT CONSUMER DISPUTES 
REDRESSAL FORUM, 
WEST TRIPURA, AGARTALA    SRI U. DAS
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.