Date of Filing : 27/01/2021

Date of Judgement : 24/09/2024

Smt. Monihar Begum, Hon’ble President in-Charge

BRIEF FACTS

The petition of complaint is filed by the complainant Chandi Bhattacharjee alleging deficiency in service on the part of the opposite party namely National Insurance Company Limited.

Case of complainant in short is that complainant is a Mediclaim policy holder of National Insurance Company being Policy No.1010000/50/18/10000950, effective from 20.05.2018 to midnight of 19.05.2019. Complainant paid the premium of the policy on which the sum insured was Rs.1,00,000/- and cumulative bonus was Rs.50,000/-.

Complainant’s wife Mousumi Bhattacharjee had undergone an operation on 03.03.2019 in accordance with her Doctor’s advice. The sum insured was Rs.1,00,000/-(One lac) and cumulative bonus was Rs.50,000/-(Fifty thousands) and the claimed amount was Rs.1,10,789/- but Rs.77,813/- (Seventy seven thousand eight hundred thirteen) was approved and deposited in the Bank Account of the complainant.  The insurance company did not provide any copy of claim settlement details regarding the disapproval of amount of Rs.32,985/-. OP is liable to provide Mediclaim benefit to the petitioner of total sum assured.  There is deficiency in service on the part of the opposite party.  Complainant somehow downloaded the process sheet from the website of GENINS INDIA TPA LTD and found that the said process sheet was incomplete. Thereafter petitioner lodged a complaint to the Grievance Redressal Officer on 05.07.2019 and the Office of the Grievance Redressal Officer did not give any reply. Thereafter the case was registered before the Office of the Insurance Ombudsman on dated 30.07.2019 vide Complaint No.KOL-H-048-1920-0231 and Office of the Insurance Ombudsman gave a date of hearing on 12.11.2020. The Office of the Ombudsman failed to take notice of all the facts and gave justice to the complainant. Complainant again requested the OP to settle the claim but that too went in vein. Therefore, finding no other alternative, the complainant filed the instant consumer complaint and prayed for a direction upon the OP to pay claimed amount along with compensation and litigation cost.

Complainant annexed with the complaint petition, copy of relevant portion of Insurance Policy(National Insurance), process sheet of GENINS India Insurance TPA Ltd., copy of letter to Insurance Ombudsman, copy of complaint at Insurance Ombudsman dated 28.10.2020, Copy Final AWARD letter dated 27.11.2020 from Insurance Ombudsman to complainant Sri Chandi Bhattacharjee & National Insurance Company.

OP contested the case by filing a written version denying and disputing all the material allegations. According to that OP considered the claim of the complainant favourably and settled his claim by reimbursing the maximum amount of Rs.77,813/- under the terms and conditions of the Policy (as per PPN Hospital Package)  after deducting the inadmissible expenditure of Rs.32,985/-  from the claimed amount and credited the same Rs.77,813/- to the Bank Account of the complainant which was duly received and acknowledged. OP further stated that to determine the charges for this claim under Policy Condition 3.29 (reasonable charges),the TPA had taken in close vicinity to Ripon Nursing Home and settled the claim with the highest rates prevailing in that geographical area.

Both the parties adduced their evidences followed by cross examination in the form of questionnaire and reply thereto. 

During the course of argument, Ld. Advocate for complainant filed the brief notes of argument.

Ld. Advocate for the OP also filed BNA and he had argued that after going through the documents on record, it is observed that the settlement is in order.  Hence the complaint was dismissed without any relief to the complainant.

Ld advocate for the OP also argued that the instant complaint is not maintainable and the Hon’ble Insurance Ombudsman has also passed an AWARD on 27.11.2020 as “the complaint is dismissed without relief to the complainant.

The point of determination is whether the complainant is entitled to relief(s) as prayed for.

DECISION WITH REASON

Admittedly, the complainant along with his wife obtained a Health Insurance Policy being No.1010000/50/18/10000950 issued by the OP, Insurer.  Admittedly, the said policy has been renewed and in force. There is no dispute as to the statement that the complainant’s wife underwent operation and the complainant claimed to have obtained health insurance policy from the National Insurance Company.  In support of such contention filed photocopy of policy documents.

The complainant had stated that his wife was admitted at Ripon Nursing Home had undergone an operation on 03.03.2019, thereafter filed claim from the OP National Insurance Company for reimbursement of expenditure incurred by him for said operation. 

OP had stated that as per their rules the insurance company sent the claimed file to the TPA and as per recommendation, of the Doctor of the TPA, the claim was repudiated. 

To sum up, the complainant’s wife got admitted in Nursing Home for her treatment. After recovering, the complainant submitted his claim to the OP/Insurer for disbursement of the claim amount of  Rs.32,985/- which was disapproved without providing the complainant of any copy of the settlement details. But one self contained note was filed by OP (National Insurance Company) on 30.08.2019. As per the said note, deduction upon Doctor’s fees, Investigation without Money Receipts, Non-medical items and excess amount beyond reasonable and customary charges was made.

The complainant has prayed for direction upon the OP Insurer to settle the claim to refund the disapproved amount with interest and to pay damages by compensation of Rs.2,00,000/- along with litigation cost and mental pain and agony and distress suffered.

Insurance Company paid according to the terms and condition of the Health Insurance Policy after consultation with TPA. Insurance Ombudsman also dismissed the application of the complainant.  No deficiency in service can be attributed on the part of the insurance company.

The complainant is going to disentitle him from getting any relief in this case.

Therefore, on consideration of the materials of records, we find that the instant complaint is liable to be dismissed.

Accordingly it is

ORDERED

That the instant complaint stands dismissed.  No order as to cost.

Directed and corrected by me

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