FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER.
This is a complaint case u/s 12 of the CP Act, 1986. The brief facts of the case is that the Complainants Sri Tukun Ghosh had a Mediclaim Policy bearing No. 100700501810002589 with the OP 1 & 2 for the period from 28.06.2018 to 27.06.2019
wherein the complainant himself, Mousumi Ghosh and Mrinalinee are the insured members for a total coverage of Rs. 2,25,000/- . Individual coverage was Rs.75,000/-.Complainant’s daughter Mrinalinee Ghosh because of high fever had to admit in Aurobindo Seva Kendra on 12.08.2018 for treatment. The total bill for her treatment was Rs. 31,721.62. After making the payment the patient got discharged from the said hospital. Thereafter claim form along with all relevant documents were deposited to the OP on 12.09.2018. Thereafter TPA asked to submit the original money receipt of hospital final bill of Rs.22,000/- and also the prescription of the Doctor dated 18.08.2018 while the fact remains that there was no medical bill of Rs. 22,000/- . However there were two medical bills, one of Rs. 26,493/- and the another one of Rs.5,228.62 only. Both the original bills were submitted to the Insurance company during claim form submission and to this effect the complainant issued reply on 18.12.2018 to them denying such alleged bill and further asking them to settle the claim of Rs. 31,721.62 only. Thereafter the complainant submitted all duplicate bills or money receipts with the OP provided by the hospital. Inspite of receiving that letter the OP remained silent, they have neither settled the claim nor repudiated the same. The cause of action arose on 12.09.2018 when the complainant submitted the claim form to the OP and thereafter on 18.12.2018 the date of sending demand notice for reimbursement of the claim.
The OP 1 & 2 have contested the case by filing W/V contending inter alia that the case is not maintainable in law and in fact. It is false, vexatious ,suppression of facts and liable to be dismissed in limini. The complainant did not submit the original money receipt of Rs.22,000/- against his hospital bill for Rs.26,493/- out of which he has submitted original money receipt of Rs.4493/- which he has attached as last annexure in his petition and did not submit prescription of the doctor dated 18.08.2018 as demanded by the OP 3 in their query letter dated 25.10.2018. The bill no. 1800335143 for Rs. 26493/- which is attached with the petition is not an original money receipt.. The complainant did not submit original money receipt of Rs.22,000/- and the prescription of the treating doctor dated 18.08.2018. As such the claim was not settled. Since the claim was not closed or repudiated it was the duty of the complainant to submit or inform about submission / non submission of the required document for which the question of deficiency of service does not arise.
The case has been proceeded ex parte against the OP 3 vide order dated 12.06.2019.
Points for Determination
On the pleading of parties the following points have necessarily come up for determination.
- Whether the OP 1 & 2 have got deficiency in service.
- Whether the OP 1 & 2 are indulging unfair trade practice.
- Whether the Complainant is entitled for the relief/reliefs as prayed for.
Decision with Reasons
Points Nos. 1 to 3 :-
All the points are taken up together for the sake of convenience and brevity in discussion.
Complainant and the OP 1 & 2 have tendered their Evidence on Affidavit. Both the complainant and the OP 1 & 2 have filed replies against the Questionnaire set forth by their adversaries .Both have submitted their BNA also.
We have travelled over all the documents placed on record.
Facts remain that the complainant Sri Tukun Ghosh had a Mediclaim Policy bearing No.100700501810002589 with the National Insurance Company being represented by the OP 1 & OP 2 where the complainant himself, Mousumi Ghosh and his daughter Mrinalinee Ghosh are the insured members . The policy was in force for the period from 28.06.2018 to 27.06.2019 . During the said period the complainant’s daughter Mrinalinee Ghosh got admitted in Aurobindo Seva Kendra on 07.08.2018 for treatment of her ailment as per advice of the treating doctor vide prescription dated 07.08.2018. After discharge from the said hospital on 12.08.2018 the complainant submitted his claim form duly filled in along with all medical bills to the OPs claiming a total amount of Rs.31,721.62 which has been spent for the treatment.. As per system the claim papers were examined by the OP 3. The OP 3 here is the authorized TPA of the said Insurance Company. As evident from the record the OP 3 vide letter 20.09.2018 asked the complainant to submit the original money receipt of hospital final bill of Rs.22000/- and the prescription of the treating doctor dated 18.08.2018 for taking decision in the matter.. The complainant vide letter dated 18.12.2018 replied the said letter informing all the OPs and requested them to settle the claim within 15 days from the date of receipt of this letter. But the letter of the complainant was not responded by any of the OPs for the reason best known to them. From the documents annexed by the OP 1 & 2 with regard to the terms and conditions of the said National Mediclaim Policy under clause No. 5.5.4 where it is mentioned that the completed claim form is to be supported with the listed documents and to be submitted within the prescribed time limit where the original bills, payment receipts ,original cash memo from the hospital supported by proper prescription are the requirements amongst others. Since the original documents as per clause no. 5.5.4 of the terms and conditions of the policy have not been submitted by the claimant as alleged the OP Insurance Company could have denied the claim by citing the said terms and conditions of the policy as mentioned above. But instead of doing so they sat idle over the issue keeping the complainant in dark. They have neither settled the claim nor repudiated the same. As per IRDA (protection of policy holders interest) Regulations 2017 in respect of Health Insurance Policy claims are required to be settled within 30 days from the date of receipt of the last necessary document. In cases which warrant investigation, the claim is to be settled within 45 days. Moreover, in case of delay in settlement of claim, the insurer is required to pay a penal interest @ 2% above the bank rate. In this context, the judgment of the Hon’ble Supreme Court of India in respect of the dispute in between the United India Insurance Co. Vs. M K G Corporation on 21.08.1996 reported in AIR (1996) 6 SCC 428 in Case No: Appeal (Civil) 6075 -6076 of 1995 is relevant. In the said judgment the Hon’ble Supreme Court of India has specified the time limit for taking decision to two months with the wording “We think that a reasonable time of two months would be justified for them to take decision whether claim requires to be settled or rejected in accordance with the policy”.
Here in this case the complainant gave his reply vide his letter dated 18.12.2018 and the OP insurance company felt no importance to deal with the letter by taking a decision either by admitting the claim or by repudiating the same. Ultimately, the complainant has been forced to knock the door of this commission by registering his complaint on 26.02.2019 praying for justice. This is a gross deficiency in service on the part of the OP Insurance Company. Taking no decision on the issue and keeping the Insured in mental agony for an indefinite period definitely tantamount to deficiency in service and give rise to indulgence of unfair trade practice.
As such, we are of the considered view that the complainant has proved his case and the points in the determination have been decided positive.
In the result, the complaint succeeds.
Hence,
Ordered
That the complaint case be and the same is allowed on contest against the OP 1 and 2 and ex parte against the OP 3 with the following directions:-
- The OP 1 and 2 are directed to make the payment of claim amount of Rs. 31,721.62/- with 6% simple interest from 18.12.2018 to till the date of actual payment.
- The OP 1 and 2 are further directed to make a payment of Rs. 5,000/- to the complainant as litigation cost.
The above orders are to be complied with by the OP 1 and 2 within a period 30 days from the date of the order else the Complainant will be at liberty to put the order in execution as per rules.
Order be communicated to the Complainant as per rules and the judgment be uploaded forthwith on the website of the Commission for perusal of the parties.
