Shri B. Mukhopadhyay, President.   

This is an application u/s.12 of the C.P. Act, 1986.

             On an indepth study from the bottom of the complaint and written version we have gathered that undisputed facts are as follows.

(1)  The present complainant Jayeeta Sen is covered by mediclaim policy under the OP New India Assurance Company Ltd. being Policy No.510300/334/11/00002040 from 2007 having family health plan as concerned TPA and that lady was admitted in Amri hospital at during the period from 21-08-2009 to 14-09-2009 under Dr. Sudip Chowdhury as she had been suffering from acute severe pancreatitis and tumor in her neck for which she was admitted in Amri (Salt Lake) Hospital.

(2)  It is undisputed fact that at the time of discharge of the complainant as patient of Amri Hospital, Hospital Authority sent final bill of Rs.3,61,638/- to the TPA against family health plan and TPA sanctioned a sum of Rs.2,03,625/- to the Amri Hospital but in respect of the balance amount Rs.1,32,388/- had been paid by the patient party for her release and as per family health plan TPA issued cheque No.660863 on 08-01-2011 to the Amri Hospital for Rs.2,03,625/-.

(3)  Fact remains that complainant submitted her mediclaim in respect of balance amount of Rs.1,32,388/- along with all papers in Xerox form on the ground she lost those papers and lodged diary at Burtolla P.S. but TPA insisted her to file original bill and invoices for settling the mediclaim as per their scheduled procedure but for not submitting the original bills and invoices the said claim was turned down and repudiated.

So, entire consumer dispute is related to Forum payment of balance amount of Rs.1,32,388/- what had not been paid by the OP Insurance Company.

Practically on proper consideration of the entire materials on records and the argument as advanced by the Ld. Lawyer of both the parties it is apparent that the OP Authority did not entertain the present claim of the complainant only on the ground that complainant failed to file original bills and invoices but there is no other allegation of the OP for dishonour of the claim of the complainant.

So, in the above situation we shall have to consider whether original bills and invoices in respect of the treatment of the complainant during her stay at Amri Hospital was received by the TPA or not and in this regard we have gone through the written version of the OP wherefrom (at page 4 of the written version) it is found that OP has admitted that Amri Hospital Authority at the time of discharge of the patient directly sent all original bills and reports to the concerned insurance company and its agent TPA, the Third Party Administrator (Family Health Plan, TPA) for settlement of the claim.  Then it is clear all the original bills invoices and medical reports are still in the custody of the insurance companies agent that is TPA then for what reason TPA had been insisting the complainant to file further original bills and invoices and moreover this TPA and this insurance company relying upon those bills in original received by the TPA and insurance company, settled the claim of the Amri Hospital against treatment cost of the present complainant and final bill was Rs.3,31,638/- and ultimately insurance company and TPA settled the matter but issued a cheque of Rs.2,03,625/- on 18-01-2011 in favour of the Amri Hospital.  Then it is clear original bills were submitted by the Amri Hospital along with all necessary papers in original and for which the part claim was allowed and that was sent to Amri Hospital.  But it is not clear to this Forum for what reason TPA insisted to file further original bills and original invoices and rightly complainant sent duplicate of the said bills after collecting it from the Amri Hospital but ultimately present claim was repudiated or rejected by the OPs only on that ground.  But we have already cleared this chapter after disclosing the admission of the OP insurance company about receipt of all original bills, invoices and doctor’s report from the Amri Hospital then what prompted the OPs to outright rejected the present claim when there is no other objection for releasing the present claim of the complainant in respect of Rs.1,32,388/-.  When truth is that this lady suffered pain, mental agony even after discharge from, her hospital for getting this amount of Rs.1,32,388/- from the OPs and no doubt OPs have their no moral and social approach in this regard and fact remains in the present case the present OPs illegally without any foundation rejected the present claim of the complainant for some naked reason best known to the OPs because complainant complied everything as per law and insurance rules and fact remains that still original bills are in their custody of the OPs but they are not tagging the same for considering the present claim of the complainant which is no doubt an unfair trade practice on the part of the OP insurance company.  On overall evaluation of the above materials and finding we are convinced that complainant has been harassed illegal, harassing by the OP insurance company without any valid reasons and there was no good ground to reject the prayer of the complainant for getting the present claim of Rs.1,32,388/- from the OPs when no other objection regarding the bill is raised by the OIP before this Forum or the complainant at any point of time. 

In view of the above situation and position and materials we are to hold that the complainant has been able to prove any manner of doubt that she is entitled to get the entire claim amount of Rs.1,32,388/- from the OP insurance company and rejection of the claim of the OP is completely invalid, uncalled for and unwarranted and entire approach of the OPs is virtually immoral and without any legal foundation.

In the light of the above observation we are allowing this complaint by directing the OP insurance company to pay to the complainant who has paid the said sum to Amri Hospital at the time of her discharge.

But considering the unfair trade practice adopting the OPs Insurance Company to refuse the claim of the complainant though it was or is legal and valid, OPs insurance company are directed to pay a sum of Rs.20,000/- as penal damages for adopting such unfair trade practice which is being followed in so many cases by the OP and only to check this habit of the OP insurance company this penal damages is imposed and OP insurance company shall have to deposit the said amount to the Forum against the head of State Consumer Welfare Fund.

Hence,

Ordered

That complaint be and the same is allowed with cost with a cost of Rs.5,000/- (Rupees Five thousand only) against the OP1 but same is dismissed against without any cost against OPs 2 and 3 and finally the case is disposed of with final order what shall be complied by the OP within one month from the date of this order as per sprit of the body of the judgment failing which for each days delay interest @100/-(Rupees one hundred only) shall be assessed for disobedience and non-compliance of this order and till full satisfaction of the decretal amount and if it is collected same shall be deposited to State Consumer Welfare Fund.