In the District Consumer Disputes Redressal Forum, Murshidabad
Berhampore, Murshidabad.
Case No. C.C/96 /2014
Date of filing: 15/07/2014. Date of Final Order: 28/2/2017
Mr. Suraj Mal Maroti.
S/O- late Banshilal Maroti.
of 26, Nirsingha Ghat Lane, P.O.- Khagra
Dist- Murshidabad, PIN-742103. ……………………………... Complainant
- Vs-
1). Manager.
United India Assurance Company Limited.
3/20/A, K.K.Banerjee Road. 1st Floor,
P.O.& P.S. - Berhampore.
Dist.- Murshidabad. W.B.
2). Manager,
Heritage Health TPA Pvt. Limited,
Nicco House,5th Floor,
2 No., Hare Street, Kol.-700001.…………….…………………. Opposite Party
Parijat Roy & Firdous Wahid Siddique. Ld. Advocate .…………………….…. for the complainant.
Mr. Siddhartha Sankar Dhar. Ld. Advocate………………………..for the Opposite Party No.1.
Before: Hon’ble President, Anupam Bhattacharyya.
Hon’ble Member, Samaresh Kumar Mitra.
Hon’ble Member, Pranati Ali.
FINAL ORDER
Sri Samaresh Kumar Mitra, Member.
The complainant files this complaint u/s 12 of C. P. Act, 1986 praying for an order directing the OP No1 to pay the Insurance Claim for Rs.2,00,000/- as submitted by the complainant and compensation for Rs.60,000/- from the OPs for mental pain and agony.
The case of the complainant, in brief, is that he obtained a individual Insurance Policy bearing No. 03/405/48/13/97/00000327 under Heritage Health TPA Pvt. Limited. Total sum assured is Rs.2,55,000.00 and total basic premium is Rs.14,500 and total net premium is Rs.13,156.00 . He has been paying premiums regularly to the OP No.1 so the complainant is a bonafide consumer of the OP and he is entitled to get financial benefit as per policy. The complainant became ill as he was suffering from enlargement of prostate gland and admitted at Woodland Multispecialty Hospital of Kolkata and underwent operation that incurred near about Rs.3 Lakh for treatment, medicine, operation and other charges in that hospital. The complainant accordingly denuded that Rs.3 lakh from the OP No.1 but the OP No.1 settled the matter through OP No.2 at the cost of Rs.45221.00. Inspite of repeated requests the actual amount has not been paid so the OPs are deficient in service as a consequence complainant suffered huge loss, pain and mental agony amounting to Rs.2 lakh. So the complainant getting no alternative filed the instant complaint getting amount of Rs.5 lakh.
The OP No.1 by appearing filed the written version denying the allegations as leveled against him he averred that the petitioner has a medi-claim policy which was valid from 26.07.2013 to 25.07.2014 and a sum of Rs.2,00,000/- was assured against the policy. The petitioner lodged a claim against the policy for his treatment at Woodland Multi Speciality Hospital Ltd and filed document before TPA i.e. Heritage Health TPA Pvt. Ltd but after examining the documents a sum of Rs.45,227/- was settled against the claim of the complainant. He also averred that after perusing the documents it was found that the money receipts for the sums of Rs.9700/-( bill dated 16.02.2014), Sum of Rs.50,000/- (bill dated 16.02.2014), Sum of Rs.30,000/- (bill dated 16.02.2014), Sum of Rs.2756.34 (bill dated 16.02.2014) have not been filed in original. The duplicate documents are not acceptable for processing the claim against such amount. As per provision of the Item No.5.6 of the policy the petitioner shall have to submit the original bills, receipts and other documents to the TPA. But the opposite party cannot reimburse any amount against the duplicate bills and receipts. If the petitioner be able to produce the original receipts then the opposite party will start the process and shall be able to pay the amount as per perms of the policy. The amount as mentioned above are the total expenses but he is not entitled to get the entire amount even if he has submits the original receipts he is entitled subject to provision as mentioned in item No.1.2 of the policy. That the opposite party No.2 send a letter regarding the assessment to the petitioner on 05.04.2014.The OP No.2 also asked the petitioner to provide the original Money receipts of Final Bill and the comp ability test report by a letter dated 04.3.2014 but the petitioner failed to provide those documents so the OP is unable to pay the amount as claimed by the petitioner. Hence, the OP has no deficiency in service so the petition is liable to be rejected.
The complainant filed evidence on affidavit in which he assailed that he has a health Insurance policy being No. 03/405/48/13/97/00000327 known as insurance health policy under Heritage Health Policy TPA private limited and the sum insured of the policy is Rs.2,55,000/-. As he has been paying premiums regularly so he is a bonafide consumer of the OP as such he is entitled to get all financial benefits. Due to enlargement of prostate gland he was admitted at Woodland Multispecialty Hospital at Kolkata and undergone operation and incurred a huge expenditure amounting to Rs.3,00,000/- including medical treatment and operation. After recovery from his ailment he demanded a sum of Rs.3,00,000/- from the opposite party but the OP No.1 settled the claim through the OP No.2 with a sum of Rs.45,221.00 without paying the actual amount. So the complainant filed the instant complaint before this Forum for getting reliefs as prayed for in the prayer portion of the complaint petition as he suffered a huge loss due to deficiency of service of the opposite party. He also denied that after examination of the document the complainant is entitled to get a sum of Rs.45,227.00 as a few original documents like money receipts amounting to Rs.9700/-, Rs.50000/-,Rs.30000/- and Rs.2756.34 have not been file in original and the OP No.2 send the letter regarding the assessment on 05/04/2014 or that he was asked to produce the original money receipt by a letter dated 04/03/2014 or that he failed to produce the same.
The OP No.2 did not put his appearance despite receiving notice so the proceedings run ex-parte against him.
Argument as advanced by the agents of the parties heard in full.
From the discussion herein above, we find the following Issues/Points for consideration.
ISSUES/POINTS FOR CONSIDERATION
- Whether the Complainant Suraj Mal Maroti is a ‘Consumer’ of the opposite party?
- Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?
- Whether the O.Ps carried on unfair trade practice/rendered any deficiency in service towards the Complainant?
- Whether the complainants proved their case against the opposite party, as alleged and whether the opposite party is liable for compensation to them?
DECISION WITH REASONS
In the light of discussions here in above we find that the issues/points should be decided based on the above perspectives.
(1).Whether the Complainant Suraj Mal Maroti is a ‘Consumer’ of the opposite party?
From the materials on record it is transparent that the Complainant is a “Consumer” as provided by the spirit of section 2(1)(d)(ii) of the Consumer Protection Act,1986. The complainant herein is the consumer of the OP, as he received a individual health Insurance Policy from the OP No.1so he is entitled to get service from the OPS.
(2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?
Both the complainants and opposite parties are residents/carrying on business within the district of Murshidabad. The complaint valued Rs.5,00,000/- for loss sustained by the complainant and as compensation for mental agony and other expenses ad valorem which is within Rs.20,00,000/- limit of this Forum. So, this Forum has territorial/pecuniary jurisdiction to entertain and try the case.
(3).Whether the opposite party carried on Unfair Trade Practice/rendered any deficiency in service towards the Complainant?
It appears from the case record and the documents as produced by the parties in dispute that the complainant took a Individual Health Insurance Policy-2010 from the OP No.1 for the period from 26.7.2013 to 25.07.2014 being policy No.031405/48/13/97/00000327 after taking the said policy the complainant became seriously ill and he was suffering from Enlargement of prostate gland and admitted to Woodland Multispecialty Hospital Limited at Kolkata and underwent operation as a result a sum of Rs.3 Lakh incurred for treatment, medicine, operation and other charges in that hospital. So the complainant accordingly demanded Rs.3 lakh from the OP No.1 but the matter was settled by the OP No.2 at the cost of Rs.45,221.00 which is meager and not sufficient in comparison with the actual expenses. As a consequence the complainant suffered huge loss, pain and mental agony amounting to Rs.2 Lakh for which he compelled to seek redress before the Forum for compensation and other expenses in the form of damages.
The OP No.1 in his written version denied the allegations as leveled against him and he assailed that the Mediclaim Policy of the complainant was valid for the period from 26.07.2013 to 25.07.2014 and sum assured Rs.2,00,000/- . He lodged a claim against the policy for his treatment at Woodlands Multi Speciality Hospital and submitted documents to the Heritage Health TPA Pvt. Ltd. After examination of documents sum of Rs.45,227/- was settled against the claim of the petitioner.
The OP No.1 also averred that after perusing the documents it was found that the money receipts for the sum of Rs.9700/-( bill dated 16.02.2014), Sum of Rs.50,000/- (bill dated 16.02.2014), Sum of Rs.30,000/- (bill dated 16.02.2014)and Sum of Rs.2756.34 (bill dated 16.02.2014) have not been filed in original and as per provision of the Item No.5.6 of the policy the petitioner shall have to submit the original bills, receipts and other documents to the TPA. But the opposite party cannot reimburse any amount against the duplicate bills and receipts. If the petitioner be able to produce the original receipts then the opposite party will start the process and shall be able to pay the amount as per perms of the policy. The amount as mentioned above are the total expenses but he is not entitled to get the entire amount even if he has submits the original receipts he is entitled subject to provision as mentioned in item No.1.2 of the policy.
On consideration of the material placed before it, including the terms of the policy, this Forum came to the conclusion that since the insured was admitted in the hospital within the covered period of the policy and took treatment from that multispecialty hospital and expensed huge amount from his pocket and thereafter claimed the amount from the Insurer but the insurer settled the claim with meager amount which is not appropriate in comparison with the actual expenditure then the complainant being aggrieved with the settled amount of Rs.45,227/- by the OP No.2 sought redressal before this Forum. The treatment received by the complainant is unquestionable but he could not produce a few original bills in support of his claim apart from lodging a complaint of theft of those original documents before the T.O.P Khagra Out Post, Khagra,Murshidabad. The complainant filed evidence on affidavit being notarized and demanded that he expensed those amount for his treatment and he is entitled to get reimbursed the expenditure from the insurer. The In- patient Discharge Bill of Woodlands Multi Speciality Hospital dated 16.02.2014 transpires that the total expenditure for the treatment of the complainant is Rs.2,57,510.00 including all sorts of service provided by the said hospital and the complainant paid entire amount of expenditure in three bills dated 10/2/2014,14/02/2014 and 16/02/2014. So there is no dispute regarding the expenditure and mode of payment of such treatment. The dispute cropped up in between the complainant and the OP when the complainant failed to submit a few bill receipts in original before the OP No.2 and the entitlement of service received by the complainant in relation to the bed which he ought to posses according to his policy terms. The agent of the OP No.1 assailed that the complainant possessed the bed which he is not entitled according to the policy as a result the expenditure of the treatment increased which the insurer is not liable to pay. But the agent of the Complainant in his argument assailed that he received the treatment from such hospital which is in the list of the OP No.1 and the bed allotted to the patient for treating his disease not for any other purpose. He further assailed that sum insured is Rs.2,55,000/- which he is entitled to get from the OP No.1. From the above discussion we may conclude that the duplicate money receipt that the complainant submitted before the OP is subject to be authenticated by the issuer. Though there is mandatory provision in the policy as to submission of original money receipt for payment of bills but in this particular case the complainant has made out a specific case as to the ground of non submission of original money receipt. The ground for non submission of the original money receipt is that the complainant lost the same and to that effect he has lodged G.D. in the P.S. for getting the duplicate original from the issuer.
To so the same the complainant has filed Xerox copy of impugned G.D.
Furthermore we do not find any cogent evidence as well as any objection from the side of OP Insurance Company as to the genunity of the concerned Xerox copy of money receipts. Considering the above facts and circumstances as discussed
above though there is provision of filing original money receipts we do not find any bar on the point of entitlement of the expenses incurred on the basis of Xerox copy of money receipts in absence of genunity. Furthermore for the better protection on the point of genunity if any the OP No.1 is at liberty to confirm the genunity of the said money receipt from the issuer. 1.2 of the Health Insurance Policy- Gold states as follows; In the event of any claim(s) becoming admissible under this scheme, the company will pay through TPA to the Hospital, Nursing Home or the insured person the amount of such expenses falling under different heads mentioned below, as are reasonable and necessarily incurred thereof by on behalf of such insured person, but not exceeding the sum insured in aggregate mentioned in the schedule hereto.
A. Room, Boarding and Nursing expenses as provided by the Hospital/ Nursing home not exceeding 1% of the sum insured per day or the actual amount whichever is less. This also includes nursing care, RMO charges, IV Fluids/ Blood transfusion/injection administration charges and similar expenses.
B. Intensive care Unit (ICU) expenses not exceeding 2% of the sum insured per day or actual amount whichever is less.
C. Surgeon, Anesthetist, Medical practitioner, Consultants, Specialist Fees.
D. Anesthetist, Blood, Oxygen, Operation Theatre Charges, Surgical appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, Cost of prosthetics devices implanted during surgical procedure like pacemaker, Orthopaedics implants, infra cardiac valve replacements, vascular stents, relevant laboratory/diagnostics tests, X ray and other expenses related to the treatment.
E. Hospitalization expenses (excluding cost of organ) incurred on donor in respect of organ transplant to the insured.
Note: 1. The amount payable under 1.2 C & D above shall be at the rate applicable to the entitled room category. In case the Insured person opts for a room with rent higher than the entitled category as in 1.2 A above, the charges payable under 1.2 C & D shall be limited to the charges applicable to the entitled category. This will not be applicable in respect of medicines & drugs and implants.
The OP No.2 i.e. TPA settled the claim amounting to Rs.45,221.00 in full & final settlement. But failed to state the heads in which they allowed claim of what extent. The letter dated 05.04.2014 of OP No.2 stated the details of deductions which transpires that a sum of Rs.2,12,289.00 has deducted from the expenditure amounting to Rs.2,57,510.00 and lastly he settled the claim amounting to Rs.45,221.00.
From the above discussion it is crystal clear that the OP No.2 did not show good gesture upon the complainant by settling the claim of the complainant as consumer friendly but caused impediment for getting the claim of an insured person. Nowhere the OP No.2 showed bonafide by paying the fees incurred for the treatment. On the other hand he deducted in 16 heads, the major portion of expenditure. In an insurance agreement the rule is framed by the Insurer so he knows everything regarding the pros & cons of the policy but the insured knows only where to put signature and when the premium have to be paid. The insured ought to face problem while getting his/her claim.
As the complainant failed to follow the terms and conditions in respect of his claim regarding the entitlement of getting admission charge, medical record charge and CD charge then these charges are liable to be excluded. Perusing the 1.2 clause of the policy; Room, Boarding and Nursing expenses as provided by the Hospital/ Nursing home not exceeding 1% of the sum insured per day or the actual amount whichever is less so the accommodation charge is reduced to 1% of the sum insured.
From the above discussion we are in a considered opinion that the OP No.1&2 followed the terms & conditions as envisaged in the Individual Health Insurance Policy-2010 to reduce the claim of the complainant as Insurer &TPA but the claim of the complainant is not settled properly as a result they are deficient in providing service towards the claim of the complainant.
4. Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to him?
The discussion made herein before, we have no hesitation to come in a conclusion that the Complainant proved his case, so the Opposite Party could not avoid his responsibility of paying the claim of the complainant in part including interest thereon as ascertained by this Forum.
ORDER
Hence, it is ordered that the complaint case being No.96/2014 be and the same is allowed in part against the Opposite Party No.1.
The Opposite party 1 is directed to pay a sum of Rs.1,80,000/- to this complainant including interest @8% p.a since the date of filing this complaint case till the payment within 45 days from the date of final order.
No other reliefs are awarded to the complainant for harassment and mental agony.
At the event of failure to comply with the order the Opposite Party shall pay fine @Rs.50/- for each day’s delay, if caused, on expiry of the aforesaid 45 days by depositing the accrued amount, if any, in the Consumer Legal Aid Account.
Let a plain copy of this Order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/ sent by ordinary Post for information & necessary action.
Dictated and corrected by me.
Member, Member, President,
