Ld Advocate for the complainant is present. Judgement is ready and pronounced in open Commission.
BY - SRI ASISH DEB, PRESIDENT
Brief facts of the complainant’s case are that the Complainant has permanent residence within this Jurisdiction. The Complainant is a valid policy holder of New India Assurance Co. Ltd. at Tamluk Branch vide Policy No. 51260334182700000002, Period of Insurance from 03.05.2018 to 02.05.2019. The Complainant purchased the policy namely “New India Asha Kiran Policy” from O.P. No.1 with conditions as specified in the schedule and also mentioned in the schedule that if any Third Party Administrator (TPA is occurred the claim shouldbe made to heritage Health Insurance TPA Pvt. Ltd. i.e., O.P. No.2 i.e., the O.P. No.2 is sister concern of the O.P. No. 1. The Complainant has suffered Streaky Hemoptysis for 2/3 days with cough and expectoration for last 9 days associated with left side Pluritic chest pain for last 5 days as a result he was required to admit in Apollo Glen eagles Hospital, Kolkata on 06.07.2018 and such incident duly noticed the O.P’s. within time, mentioned in the policy.After 7 days of admission on 12.07.2018 when the Complainant was discharged came to know from Hospital Authority at 11:50 A.M. that O.P. No.2 deniedto make any cashless payment with reason which is not applicable. On the same day the Complainant made phone call with the O.P’s to know why O.Ps were not paying the Hospital Bill amount of Rs. 1,12,503/- which is bound by the O.P. to pay at the time of discharge. On the same day of discharge 4-5 hours conversation was made in between the Complainant and O.Ps thereafter finally O.P. No.2 send a authorization of Rs. 30,000/- (Thirty Thousand) against the Hospital Bill instead of Rs. 1,12,503/- (One lakh Twelve Thousand Five Hundred and Three only) at about 6:00 P.M. and refused to pay remaining part of hospital bill which was intimated by the Hospital at 8 P.M. In this situation at about 8:00 P.M. of the date of discharge the Complainant fall in big trouble of begging position as because of the Complainant is a resident of Purba Medinipur and the incident took place at Kolkata which is 120 K.M. far away fromhis residence and no one was present to help him and the Hospital authority also denied to continue the discharge patient. Thereafter the Complainant managed to pay remain hospital bill , 82,503/- by the help of relative and left the hospital. After discharge from the Hospital of Apolo Glenegals Hospital the Complainant made a written claim to the O.P. No.2 on 19.07.2018 to pay the claim amount as per term and conditions fixed by the O.P. at the time of purchase policy. Thereafter on the basis of written claim O.P. No.2 paid amount of Rs. 38,195/- after deduction amount of Rs. 44,308/- of the actual Hospital Bill but no explanation was made why Rs. 44,308/- was deducted. On 07.11.2018 at about 1:30 A.M. the Complainant meet a bike accident at Barrackpore as a result it is required to take admission at COLUMBIA ASIA HOSPITAL and after diagnosed by the expert doctor it is found that Rt. Proximal Tibia Fracture Plus Multiple Hemorrhage Blisters & Swelling Rt. Knee and Upper leg and surgeries was performed on 07.11.2018 by Saumitra. M. as “Knee spanning External Fixation Rt Lower Limb Aswptic Painting Sterile Drapping Blister Pucture Blood Aspiration from Rt. Knee2 Schantzscre I Femur & Schantz Screw in Tibia connected with Rods & Clamps Sterile Dressing Applied” and discharged on 11.11.2018 with a bill of Rs. 1,12,092/- After discharge from the COLUMBIA ASIA HOSPITAL the Complainant made a written claim to the O.P. No.2 to pay the bill amount but on several demand O.P. No.2 paid less amount of Rs. 1,02,484/- on 27.03.2019 but no explanation was made why Rs. 9,608/- was deducted from actual claim amount. As per advised of the doctors the Complainant admitted at SALT LAKE CITY MEDICAL CENTRE, AT Kolkata on 19.11.2018 to removal of External Fixator & Open reduction Internal Fixation of fracture and operation was done on 20.11.2018 under spinal anesthesia by the surgeon Dr. Saumitra Mishra and discharged on 22.11.2018 with a bill amount of Rs. 1,59,844/-. After discharge from the Hospital of SALT LAKE CITY MEDICAL CENTRE the Complainant made a written claim to the O.P. No.2 on 30.11.2018 to pay the claim amount as per term and conditions fixed by the O.P., at the time of purchase policy but the O.P. paid amount of Rs. 1,16,438/- which is Rs. 43,406/- less than the actual hospital bill but those O.P. did not explained why they are paying less amount. The Complainant repeatedly claimed to the O.P’s to pay deducted Hospital’s bill through written application with supporting documents but those O.P’s did not explained why deduction was made and not paid bill’s urgently. In this unlawful way O.P’s were not paying hospital bill’s within time as fixed by policy as a result the Complainant harassed and suffered mental agony by those O.P’s. The Complainant again and again contact with the O.P. No.1 for paying such deducted amount but in vain and both O.P’s willfully denied to pay such bill. It is apparent from the conduct of the O.P’s that there is deficiency in service as a result the Complainant had to incur heavy financial loss, harassed and mental agony. There are documents to prove the case of the Complainant and those are attached herewith in Xerox copies. The cause of action of this case has been arose on and from 12.07.2018, 10.08.2018, 27.03.2019and 26.03.2019 when those O.P’s denied to pay full hospital bills and which bill were paid within time. This case has been filed within time permitted by this code. Those requisite fees have been paid by virtue of demand draft as per procedure. In the circumstances stated above the Complainant humbly prays that your honour will be pleased to direct those O.P’s. to pay 1,00,000/- as compensation for not paid medical bill within period as per terms and conditions as specified in the policy, and to pay Rs. 20,000/- litigation cost for conduct of this case, and to give any other relief to the complainant which the Commission may deem fit and proper.
Notices of the case were served upon the ops -1&2 however the op1 only has contested the case by filing written version. The proceeding of the case ran exparte against the op-2.
The sum and substance of the written version of op-1 can be stated as follows-This Opposite Party No.1 herein submits that the Complainant herein availed of an Mediclaim Insurance Policy named ‘New India Asha Kiran Policy’ commencing from 03.05.2018 to 02.05.2019 subject to the strict terms and conditions of the Policy Certificate. The policy was availed by the Complainant Rajesh Pandey along with his spouse Kiran Pandey & daughter Ishitapandey with the TPA- Heritage Health Insurance TPA Pvt. Ltd., Nicco House, 5th Floor, 2, Hare Street, Kolktata-700001 who is the Opposite Party No.2 in the Complaint. The said TPA Heritage Health Insurance TPA Pvt. Ltd., was/is entrusted to look after and process all the claims in respect of and in regard to the above ‘Asha Kiran Policy’ and also payment is made/disbursed by the said TPA- Heritage Health Insurance TPA Pvt. Ltd. In respect of any mediclaim for and behalf of this O.P. NO.1 and they used to settled all mediclaims as per the provisions of the terms and conditions of the Policy on consideration of the exclusion clauses mentioned in the Policy conditions and alike others and claim of the complaint has also been settled by them and payment also disbursed through them after verification of all the medical documents, treatment sheets and eligibility/entitlement of coverage over the Insurance Policy and this OP. No.1 had/has nothing to do on their determinations and recommendations. Accordingly said TPA- Heritage Health Insurance TPA Pvt. Ltd. Has rightly assessed the claim and disbursed the fund to which the Insured Complainant was entitled to as per the terms and conditions of the Insurance Policy on consideration of the exclusion clauses set out in the Policy conditions and this O.P. also hereby craves leave for filing the Policy conditions as the Complainant has not filed the same. As such the complainant is not at all entitled to get the benefits over andexcess to the amount already paid to him on this Mediclaim policy and there is no deficiency of service and/or illegality on the part of this Opposite Party but the complainant has initiated this case before this Ld. For a without any cogent ground ad on some baseless and illegal claims which are not at all permitted in law as per terms of contract of Insurance Policy. It is further submitted that the instant case has been 9initiated by the complainant for getting some wrongful gain over the Policy which was availed by him for the first time and only for a year and not a continuous policy. The instant consumer case being otherwise bad the same is liable to be dismissed with exemplary costs to this Opposite Party.
Points for determination are:
1. Is the case maintainable in its present form and in law?
2. Is the Complainant entitled to the relief(s) as sought for?
Decision with reasons
Both the points, being inter related to each other, are taken up together for discussion for sake of brevity and convenience.
We have carefully perused and assessed the complaint on affidavit, written versions evidence of the complainant and op-1 and the documents on record.
We have given thoughtful consideration to the arguments advanced by the ofLd Advocates for the complainant and the op-1.
Having regards had to the facts and circumstances of the case in the light of evidence, it is evident that there is no dispute that complainant is a consumer having grievances against the OPs, as such the case is maintainable in its present form and in law.
On careful analysis and evaluation of the facts and circumstances of the case and evidence on record, it appears that On scrutiny and evaluation of the facts and circumstances of the on the anvil of the evidence on record and on the light of the rival submission of the Ld Advocates,it appears that the complainant received all his insurance claims settled as per rules of the claims settlement of the insurance policy. The crux of grievances against the ops is that it caused inordinate delay in disbursing the claim amount. On dealing with such grievanceswe find that the complainant got admitted in hospital on o6.07.2018 ops raised queries and after getting satisfactory reply from the staff of hospital it immediately disbursed the amount.The rule 2.4 ( Definition )CASHLESS FACILITY provided the scope to ops to cause preliminary enquiry before releasing the claim amount in the head of cashless facility. Had there been any delay it was made by the staff of hospital in providing details. Thehospital have not been made party so that they could offer explanation as to who was responsible for the delay whatsoever. The complainant has clubbed several causes of action in a single complainant, it is not tenable . The complainant has failed to establish his averments of complaint by cogent evidence. We do not find any element of deficiency of service on the part of the ops. The complainant is not entitled get any relief in this case.
Both the points are disposed of accordingly.
Thus, the case fails.
Hence, it is
O R D E R E D
That CC/451 of 2019 be and the same is dismissed on contest against op-1 and dismissed ex-parte against op-2. No order as to costs is passed.
Let a copy of the judgment be supplied to complainant and op-1 free of cost
