The present complainant by filing this complaint has alleged that he purchased an Individual Mediclaim Policy at first in the year 1998 from National Insurance Company Limited having policy No. 102000/48/10/8500003632 and purchasing the said policy he had been paying premium in each year and then time complying all requisites as required under the said policy.

          During existence of the valid mediclaim policy  since 2006/2007 he was suffering from severe pain in both legs and was advised by the Orthopedic surgeon for knee replacement of right leg immediately and accordingly he was admitted to Pearless General Hospital Kolkata for knee replacement in the month of August 2008 and operation was done by Dr. P.K. Banerjee and thereafter he went back to his home after replacement from the hospital.  Again he was admitted to same hospital with severe infection in the right knee on emergent basis with critical condition under intimation to the insurance company and he was in complete bed rest.  But subsequently after more than three months remaining on the bed he received a call from hospital authority for immediate admission on 03.03.2011 and accordingly he was admitted for immediately for removal of temporary fixing a new implant of steel plate, rod and other orthopedic accessories which were inserted in his right leg and was released from hospital.  At that time hospital charged Rs.6,38,607/- for the treatment cost and complainant paid it and being admitted on November-24.01.2010 his operation was done on 26.11.2010 and insurance authority paid certain amount.  After operation on 26.11.2010 he was totally bed ridden and not in a position to move and his old wife was completely perplexed and finally discharged on 04.03.2011 and subsequently complainant submitted his mediclaim but claim was rejected by insurance authority on the ground that informing of the final admission within the time as fixed by the policy condition was not reported.

          But fact remains he had already spent more than Rs.14,00,000/- to 15,00,000/- but as per policy he is entitled to get Rs. 1,50,000/- only but that had not been disbursed.  In the circumstances, for negligent manner and service and deficient manner of service this complaint was filed for redressal.

          On the other hand op by filing written version has submitted that the instant complaint has been filed against the insurance company challenging the letter dated 29.09.2011 issued by Heritage Health TPA Private Limited for non consideration of the claim and repudiation of the claim of the complainant due non submission of intimation as per norms within 7 days of hospitalization and the claim was repudiated in respect of the mediclaim policy in question within the stipulated period as prescribed in the contract and such intimation violates the conditions of the contract and hence the claim was repudiated.

           Further it was submitted that the complainant for reimbursement of the same has relied upon earlier mediclaim policies from the said op and so it can be presumed that the complainant is well aware about the terms and conditions of the policy and also about the stipulated period of intimation as prescribed in the policy condition and in the above circumstances, the entire claim is not maintainable and there is no latches on the part of the op for which the complaint should be dismissed.

                                              Decision with reasons

          On maturity of the entire case after hearing the Ld. Lawyers of both the parties and considering the particular letter of the Heritage Health TPA Pvt. Ltd. dated 08.06.2011 it is found that the claim of the complainant was turned down only on the ground that patient did not inform neither the insurance company nor the TPA within 7 days from the date of his admission in the hospital.  But there was no other ground for rejection of the claim of the complainant.  Then it is clear that the Heritage Health TPA Pvt. Ltd. practically repudiated the claim but Heritage Health TPA Pvt. Ltd. has no legal authority to repudiate the claim but the claim may only be repudiated by the insurance company.  But now insurance company also by a letter dated 11.08.2011 reported the complainant that no further change has been taken in place of earlier decision as we consider the delay as per condition exclusive Clause 5.3 stipulated in the said policy.  So, considering that fact it is found that there was no latches on the part of the complainant not to report the fact of admission in the hospital within 7 days from the date of his admission.  But other hand such sort of repudiation on the technical ground is completely illegal, uncalled for.  But it is fact that the claim was made by the complainant in respect of huge amount but the op insurance company ought to have considered the insured sum of Rs.1,50,000/- as per insurance policy but that was also turned down but it is unfortunate.  In view of the above fact all the insurance companies particularly the Government undertaking insurance company are regularly rejection of claim of the insured through TPA without considering the social aspect of the consumers but that aspect has been denied and no doubt it is not at all accepted in the eye of law.  But it is proved that the complainant is a bonafide consumer of insurance company since 1998 and his policy since 1988 till today are valid and continuously he showed his bonafideness what is well proved and when the complainant’s claim is bonafide insurance claim it ought to have been settled by the insurance company.  And no doubt the claim of the complainant is genuine in respect of range of Rs.1,50,000/- because insured amount is Rs.1,50,000/-.  The most interesting factor is that this op without considering the total aspect with casual approach and merely relying upon the decision of the TPA rejected the claim.  But it should be taught by the op insurance company that the op insurance company ought to have considered the uncontrolled situation of the complainant to report it and ought to have taken a liberal view in settlement of the claim but that had not been done and considering that fact we are convinced to hold that approach of the insurance company was uncalled for, unwanted and no at all justified and in fact it has become an immoral approach of the insurance company in all the cases to accept the decision of the TPA but we are aware of the fact that TPA was borne with such right to make the end of both of claim of complainant and for that purpose TPAs are appointed by the insurance company and their approach are always invariably immoral and unwanted.

          And in this case the approach as taken by the TPA is casual and then normal approach as they are not ready to give the relief to consumers who have their valid insurance policy.  But they are appointed by the insurance company only for rejecting and repudiating the claim of the complainant.  In the light of the above observation we are convinced to hold that there is no other alternative  but to allow this complaint by directing the insurance company to release Rs.1,50,000/- and bonus amount if any within one month from the date of this order and without creating any further complication in favour of the complainant.

          In the result, the complaint succeeds.

          Hence, it is

                                                     ORDERED      

          That the complaint be and the same is allowed on contest with cost of Rs.2,000/- in favour of the complainant against op nos.1 to 3 and same is dismissed against op no.4 without any cost.

          Op nos. 1 to 3 jointly and severally are directed to pay a sum of Rs.1,50,000/- for insured sum and bonus amount if any to the complainant and the complainant is entitled to get it within one month from the date of this order without facing any further complication and trouble.

          For causing certain harassment to the complainant, the op nos. 1 to 3 are also directed to pay a sum of Rs.5,000/- as compensation and same shall also be paid by issuing a cheque within one month from the date of this order.

          Op nos.1 to 3 are directed to comply the order within one month that is within the stipulate period from the date of this order very strictly failing which for each day’s delay @ Rs.200/- pending shall be assessed as punitive damages till full satisfaction of the decree and if the said amount is collected same shall be deposited to the Head of the State Consumer Welfare Fund.

          For any sort of disobeyance and non compliance of the Forum’s order the op nos. 1 to 3 shall be looked for further penal action against them and in that case also they may be sent to the jail for non-compliance of Forum’s order u/s 27 of C.P. Act 1986.