Date of Filing: 11.09.2017. Date of Dispose: 07.04.2022.
Complainant: Mr. Kartick Chandra Ghosh, S/O Lt. Saktipada Ghosh, Vill.& P.O.
Amarargarh, P.S. Sushgram, Dist. Burdwan, Pin Code: 313155.
-VERSUS -
Opposite Party: 1. The Divisional Manager, Oriental Insurance Company Ltd, having its
Divisional Office at: Ajit Banerjee Building (2nd Floor), Nachan Road,
Durgapur-13.
2. The Chairman, Oriental Insurance Comp[any Ltd., having its Registered
Office at a-25/27 Asaf Ali Road, New Delhi-110002.
3.Medi Assist India TPA Pvt. Ltd. having its head office at Tower D, 4th
Floor, 1 BC Knowledge Part, 4/1, Bannerghatta Road, Bangalore-560029,
represented by its Manager.
Present : Mohammad Muizzuddeen -Hon’ble President.
: Shri Sailaranjan Das - Hon’ble Member.
Appeared for the Complainant: Sri Debdas Rudra Ld. Advocate.
Appeared for the Opposite Party: Sri Souren Mitra Ld. Advocate.
FINAL ORDER
On 11.09.2017 the complainant has lodged this complaint u/s 12 of the Consumer Protection Act, 1986 against the OP Nos. 1, 2 & 3.
The case of the complainant, in brief, is that he is insured under Oriental Bank Mediclaim policy bearing No. 313400/48/2012/1908 issued by the OP No. 1 for a period from 06.01.2012 to 05.01.2013. The complainant paid Rs.3259/- to the OPs as premium of the policy. The maximum limit of the sum insured amount of the policy was Rs.2, 00,000/-. Thereafter, the complainant renewed the said policy from time to time up to the mid-night of 27.01.2017.
It is also the case of the complainant that suddenly he became seriously ill and suffered from certain chest-pain in the first week of September, 2016 within the validity period covered by the policy. The complainant and his family members became mental upset and shocked. So, for better treatment the family members of the complainant brought him to the Manipal Hospital, wherein he was treated under Dr. Subhas Chandra and the doctor opined that the complainant was suffering from Congestive Cardiac Failure. The complainant was admitted to the said Hospital on 07.09.2016 under the said doctor and was discharged on 08.09.2016 and the complainant incurred a sum of Rs. 15,701/- as medical expenses. After returning from the hospital, he intimated the said fact to the OPs on 12.09.2016 requesting them to issue the claim form for further correspondence. After observing all the formalities, this complainant submitted claim form duly filled up to the OP No.1 enclosing all the original documents i.e policy certificate, medical documents, bills etc. and requested the OPs to settle the claim. The OP no.3 sent a letter dt. 20.10.2016 to him requesting him to submit additional documents i.e. original discharge summary of the treating hospital, break-up of the final bill of the hospital etc. Thereafter, the complainant sent a reply letter dt. 27.10.2016 to the OP No.3 stating that there was no delay in submitting of the claim documents on the part of the complainant.
In the meantime, the complainant was again admitted to the said hospital on 13.12.2016 under the said doctor Subash Chandra and was discharged on 14.12.2016. He incurred a medical expenses of Rs.12,838/- and he intimated this fact also on 23.12.2016 and claimed the amount by filling up the form and again the OP No.3 requested him to submit additional documents including item-wise and scot-wise break-up of final bill, last 10 years prescription report to process the claim. Again, on 02.02.2017 the OP No.3 sent another letter requesting the complainant to provide the same documents as claimed by their earlier letter. The complainant went to the office of the OP No.1 on several times and told the above facts. He also requested the OP no.1 earnestly to settle the claim but no result. Finding no other alternative, he has lodged this complaint before the Ld. Forum due to deficiency in service and unfair trade practices on the part of the OPs. The complainant and his family members have been suffering from mental pain, agony and harassment and the complainant is entitled to get Rs.28,540/- only against Policy No. 313400/48/2016/2402 along with compensation of Rs.50,000/- towards mental pain, agony and harassment and litigation cost of Rs.15,000/-.
The OP No.3 appeared on 21.12.2018 and as the OP No.3 did not file written version, the case is heard ex parte on and from 05.02.2019 against the OP No.3.
OP Nos. 1 & 2 have contested the case by filing written version denying written version denying all the materials allegations, contending inter alia, that the complaint is not maintainable in its present form and prayer and that the Ld. Forum has no jurisdiction to adjudicate the dispute and that there was no cause of action for the case, and that the complaint is based on fully distorted version of truth and fraudulent one.
The specific case of the OP Nos. 1 & 2 that OP No.3 having its head office at Medi Assist. India TPA Pvt. Ltd at Tower D, 4th Floor, BC Knowledge Park, 4/1 Bannerghatta Road, Bangalore-560029 being authorized TPA of the Oriental Bank Mediclaim Policy vide Policy No. 313400/48/2012/1908 effective from 06.01.2012 to mid-night of 05.01.2013 . To process the submitted claim the consumer service department of Medi Assist. Insurance TPA Pvt. Ltd. repeatedly asked the policy holder to furnish the information i.e. (1) for providing the reason of delay submission of claim, (2) to provide item wise and SOCT wise breakup of Final Bill amounting to Rs. 12,838/- during hospitalization, as the same is mandatory for processing the claim and (3) for providing all past prescriptions with reports of last 10 years of the complainant which are also mandatory for processing the claim of the complainant. But, in spite of receiving all that request and reminds, the complainant has not been able to submit the same within the stipulated period and the said TPA is unable to process the claim for the above reasons. There is neither any negligence nor any latches on the part of the OPs.
Upon this background, the OP Nos. 1 & 2 prayed for dismissal of the case.
DECISION WITH REASONS
The complainant has filed evidence on affidavit to prove his case. The OP Nos. 1 & 2 have filed questionnaires to the complainant and the complainant has given reply to the said questionnaires.
The OP Nos. 1 & 2 have also filed evidence-on-affidavit. The complainant filed the questionnaires to the evidence of the OP Nos. 1 & 2. OP Nos. 1 & 2 also filed reply to the questionnaires of the complainant.
The OP No.1 has also filed Written Notes of Argument (W.N.A) but the complainant did not file any Written Notes Argument.
Now, we will like to discuss the evidence on record, both oral and documentary of both the parties as to how the case has been proved or not proved.
Ld. Advocate of both sides advanced their argument in this case. Admittedly, the complainant is the consumer under the OPs and he was insured under the OPs and the disputed mediclaim in respect of the Mediclaim Policy is also admitted. It is also admitted as per evidence of both sides that the complainant was medically treated at Manipal Hospital under Dr. Subhas Chandra for two times for which the complainant submitted the mediclaim, total cost of Rs.28,539/- against the Mediclaim Policy bearing No. 313400/48/2016/2402 but the OP No.1 has submitted that the OP No.3 was asked to process the original policy of the mediclaim vide Policy No. 313400/48/2012/1908 effective from 06.01.2012 to mid-night of 05.01.2013 with a request to the complainant for furnishing the information for providing cause of day submission of claim, to provide Item-wise and SCOT wise break-up of Final Bill amounting to Rs.12,838/- during hospitalization and for providing all past prescriptions with reports of last 10 years of the complainant which are mandatory and as the complainant failed to supply the same, the OPs were unable to process the claim. But from the evidence of the complainant, it appears that he was admitted for medical treatment on 07.09.2016 at Manipal Hospital under Dr. Subhas Chandra and was discharged on 08.09.2016 and the medical expenses was Rs.15,701/- and again he was admitted on 13.12.2016 in the said hospital under the said doctor and was discharged on 14.12.2016 and he incurred medical expenses of Rs.12,938 . Thus, he incurred a total expense of Rs.28, 539/- (Rs.15, 701/- + Rs. 12,838/-). According to the principle of law and rules, one person is entitled to submit the mediclaim for the period when he was suffered and medically treated and according to the mediclaim policy existed in the said period and not from earlier policy. In the instant case, the complainant has rightly submitted his mediclaim against the Mediclaim Policy No. 313400/48/2016/2402 as this policy is related to the period of medical treatment of the complainant.
From the Mediclaim Policy No. 313400/48/2016/2402 , it appears that the complainant was insured for Rs.2,00,000/- only for the period from 28.01.2016 to midnight of 27.01.2016 and from the medic al papers as well as from the evidence on record it is found that the complainant was medically treated in the year of 2016. As such this period does cover the period of treatment but the policy does not disclose the terms and conditions as raised by the OP in Para 4 of the written Version and the Written Notes of Argument. Apart from it, the Ld. Advocate for the OPs could not show any instance that those information should be given at the time of submitting the mediclaim, rather, it is the duty and the responsibility on the part of the OPs to claim all past prescriptions and medical reports of last 10 years of the complainant at the time of issuance of the concerned policy. Even more, it is also the duty and responsibility of the OPs to get the insured for medical tests and report, but the OPs could not produce any documents to show to that effect. Therefore, demanding the information as mentioned in Para 4 of the Written Version of the OPs could not give any fruitful result for lingering the mediclaim or repudiation of the mediclaim of the complainant.
Under the above facts and circumstances of the case and the foregoing discussions we are of opinion that there was a deficiency in service on the part of the OPs for not to materialize the mediclaim of the complainant and the complainant is entitled to get relief in the matter.
The OPs also harassed by way the complainant for their inaction to settle the claim of the complainant. As such the complainant is also entitled to get compensation for suffering from mental pain, agony and harassment and as he has to lodge the case for his mediclaim amount, he is also entitled to get litigation cost.
As a result, this case succeeds.
Hence, it is
ORDERED
That the Consumer Complaint No. 191/2017 be and the same is hereby allowed on contest against the OP Nos. 1 & 2 and ex parte against the OP No.3.
The complainant is entitled to get mediclaim amount of Rs.28,539/- (Rupees Twenty Eight Thousand Five Hundred Thirty Nine only) towards the sum insured against the Policy No. 313400/48/2016/2402 issued by the OPs and compensation of Rs.30,000/- (Rupees Thirty Thousand only) along with litigation cost of Rs.8,000/- (Eight Thousand) .
The OPs are directed to pay the said amount by account payee cheque to the complaint jointly or severally within one months from the date of receipt of this order, failing which the said amount (Rs.64,539/-) shall carry interest @10% p.a till final realization.
Let a copy of this order be given to the parties on free of cost.
Dictated & corrected by me.
President
D.C.D.R.C , Purba Bardhaman.
Member President
D.C.D.R.C , Purba Bardhaman. D.C.D.R.C , Purba Bardhaman.
