Date of filing:16.05.2016 Date of disposal:07.06.2018
Complainant: Dharam Das Mondal, S/o.Lt. Badal Mondal, residence of Vill.-Jote Janki, P.O.-
Topsi, P.S.-Jamuria, Dist.-Burdwan, Pin-713362.
-VERSUS-
Opposite Party: 1. The National Insurance Co. Ltd., Durgapur Division, represented through its
Divisional Manager, having its office at Ajit Banerjee Building, Nachan
Road, Benachity, Durgapur-13, Dist.-Burdwan, Pin-713213.
2. The Medi Assist India Pvt. Ltd., represented through its Manager, having
its office at ‘ # 4, Premier Court’, 4th floor, Chandni Chowk Street, Kolkata-72.
Present: Hon’ble President: Smt.Jayanti Maitra(Ray).
Hon’ble Member: Miss Nivedita Ghosh.
Hon’ble Member : Dr. Tapan Kr. Tripathy.
Appeared for the Complainant: Ld. Advocate, Suvro Chakraborty.
Appeared for the Opposite Party No.1: Ld. Advocate, Shyamal Kumar Ganguli.
Appeared for the Opposite Party No.2: None.
JUDGEMENT
This is a case u/S. 12 of the C.P. Act for an award directing the O.Ps. to pay a sum of Rs.79,667/- towards refund of treatment expenses, to pay Rs.50,000/- as compensation for mental pain, agony and harassment and to pay Rs.20,000/- towards litigation cost to the complainant.
The complainants’ case in short is that he incepted a Mediclaim Policy in the year 2010 from the O.P. No.1. The O.P. No.2 is the TPA and they have been incorporated in the instant case. After receiving premium the O.P. No.1 issued a policy in the year 2010. The complainant renewed the policy every year and in the year 2015-2016 complainant’s policy number was 150403/48/15/8500000618. The said policy valid from 9.6.2015 to 8.6.2016. It is pertinent to mention here that the policy was covered the risk of health of complainant, his wife and his two daughters namely Prity Mondal and Riya Mondal.
During continuation of the policy the wife of the complainant namely Banita Mondal begun to suffer with her teeth. The complainant consulted with Dr. Vinod Gupta at Rabindranath Tagore International Institute of Cardiac Sciences as outdoor patient on 15.7.2015. As per advice of the said doctor the complainant and his wife again visited the said doctor on 20.7.2015. The doctor of the said hospital advice the wife of the complainant to take admission in the hospital. The wife of the complainant admitted in the R.N. Tagore International Institute of Cardiac Science on 29.7.2015 for surgical removal of upper and lower molar teeth of both sides under anesthesia. Surgery was done on 30.7.2015 and patient was discharge there from on 4.8.2015. In this treatment the complainant incurred expenses of Rs.79,667/-.
After discharge from the hospital the complainant intimated the said fact to the O.Ps. vide his letter dated 12.8.2015. After getting intimation the O.P. No.1 issued claim form in favour of the complainant. After filling up the claim form, the complainant submitted the same before the O.P. No.1 on 19.8.2015 along with all required documents. But very surprisingly, the O.Ps. inspite of getting claim form, kept themselves mum instead of settling the claim. The complainant several times visited the office of the O.Ps. and requested to settle the claim. But O.P. only assured the complainant that they will consider his claim and as soon as possible they will settle the claim. At last the complainant by a letter requested the O.Ps. to settle the claim but O.P. No.1 refused to do the same. The O.Ps. neither repudiated the claim nor settled the legitimate claim of the complainant. Finding no other alternative the complainant filed this case before this Forum for relief as prayed for.
The O.P. No.1 contested this case by filing written version stating inter-alia all the material facts. This O.P. submits that the O.P. No.2 is the agent of O.P. No.1, insurance company. The Medi Assist India Pvt. Ltd. entered into a memorandum of understating with the National Insurance Company Ltd. as insurer wherein it was agreed that the Medi Assist IndiaPvt. Ltd would take mediclaim Insurance Policy under this O.P. and extend the coverage of the mediclaim policy to the members. By virtue of memorandum of understanding, the O.P. No.2 approached the public at large for mediclaim policy and in that view the O.P. No.2 usually collected fees as well as premium to grant Mediclaim Policy to different persons time to time to extend the coverage of the Health Insurance. In fact the O.P. No.2 should be instrumental as per settling the claim with its approval whenever a claim has been filed before him or to the insurer by such policy holder. The Insurance Company after getting approval and or opinion finding regarding the settlement of claim, this O.P. will consider/act on the basis of the finding and opinion of the O.P. No.2, TPA regarding the claim keeping in view the opinion and finding of the O.P. No.2 TPA and also the terms and conditions and exception of the policy.
This O.P. further submits that the complainant submitted his claim before this O.P. on 19.8.2015 along with the documents and this O.P. after receiving the claim form and documents sent the claim file before the O.P. No.2. The O.P. No.2 after considering the claim paper and medical documents and discharge summery & prescription and also terms and conditions and exclusion of that policy, submitted his opinion/findings about the claim to this O.P. vide letter dated 1.9.2015 to the effect that the company shall not be liable to make any payment under the policy in respect of any expenses incurred in connection with or in respect of the following deceases/treatment for dental treatment unless arising due to an accident. As per clause-4.16 of the policy the claim merits repudiation and seek opinion of this O.P. On getting the opinion of the O.P. No.2, TPA this O.P. perused the claim file and documents and the terms and condition and exclusion of the policy and also the opinion of the O.P. No.2 and found that surgical removal of impacted all third molars unless arising due to an accident was not covered in the policy in clause 4.16 as such the claim of the complainant could not be honoured. In the circumstances this O.P. has/had no obligation to allow the claimant’s claim and accordingly had no other alternative but to repudiate the claim of the complainant on 1.9.2015 as the said treatment was not covered under clause 4.16 of Mediclaim Policy and as such repudiation was made on application of judicial mind and as such cannot be called as deficiency and this O.P. informed the said fact to the insurer by letter dated 1.9.2015.
That this O.P. has no latches, negligence or deficiency or unfair trade practice rendering proper service to the complainants as such the complainant claim is not sustainable against this O.P. That complainant was aware of the repudiation of his claim but suppressing the fact of repudiation, he filed this instant case.
DECISION WITH RESONS
To prove the case the complainant has prayed to treat his petition of complaint which is supported by affidavit, as his evidence. It was accepted by this Forum. So, also Ld. Lawyer for O.P. prayed for treating his written version as evidence of O.P. and the same was allowed. Thereafter the O.P. was asked to file questionnaire. But O.P. did not file any questionnaire. The complainant did not file any questionnaire to the same. Therefore, argument is heard in full from Ld. Lawyer of both sides. From the petition of complaint as well as written version filed by the O.P. and be it mentioned that the O.P. No.2, TPA did not contest this case and therefore, the case against O.P. No.2 is heard exparte.
The complainant has been able to prove that he purchased the policy (Mediclaim) which was started from in the year 2010 and in the year 2015-2016 the number of the policy is 150403/48/15/8500000618, which was valid from 9.6.2015 to 8.6.2016. There is no denial in this regard from O.P. No.1.
It is also proved from the documents filed by the complainant. His wife was admitted in the R.N. Tagore Hospital for surgical removal of upper and lower molar teeth of both sides under anesthesia on 29.7.2015. Surgery was done on 30.7.2015. The hospital authority discharged his wife on 4.8.2015 and total expenses of Rs.79,667/-was incurred by the complainant and in this regard he has filed the documents showing such expenses. Actually there was no specific challenge regarding such surgery and expenditure. But the question remains that whether the O.P. Insurance Company is liable for payment of such expenses under the policy. The O.P. cited the letter dated 1.9.2016 stating the fact that repudiating the claim as it heeds the policy terms and conditions. Before that complainant asked for claim form on 12.8.2015 and the claim from was filled up and deposited to the O.P. No.1 on 19.8.2015. However, complainant denied that he received any repudiation letter dated 1.9.2016 and it is a manufactured documents. But to this extent there is no specific evidence. From the policy papers filed by the O.P. No.1 it is clear to this Forum that O.P. pointed out that as per clause No.4.16 of the policy the company shall not be liable to make any payment under the policy in respect of any expenses incurred in treatment for dental ailment unless such ailment is resulted from any accident. Admittedly, the ailment of the wife of the complainant is not a result of any accident. She was suffering from dental disease and it requires surgical removal. So, if the claim of the petitioner is repudiated after consideration of the TPA, on whole observation of the medical documents and discharge summary and prescription that it contradicts the terms and conditions of the policy and as per the exclusion terms of the policy clause -4.16. TPA also opined for repudiation and after getting approval and opinion of TPA regarding the settlement of the claim and on the basis of the finding and opinion, company rightly repudiated the claim. The company has no obligation to allow the claim as the said term was not covered under clause No.4.16 of the policy. We do not find any deficiency on the part of this O.P. Therefore, complainant is not entitled to get any relief as prayed for. Hence, complaint case fails. C.F. paid is correct. Hence, it is
Ordered
that the case be and the same is dismissed on contest without any cost.
Let the copy of this order be supplied to the parties free of cost.
Jayanti Maitra (Ray)
Dictated and corrected by me. President
D.C.D.R.F., Burdwan
Jayanti Maitra (Ray)
President
D.C.D.R.F., Burdwan
(Nivedita Ghosh) (Dr. Tapan Kr. Tripathy)
Member Member
D.C.D.R.F., Burdwan D.C.D.R.F., Burdwan
