Judgment : Dt.21.3.2017
Mrs. Balaka Chatterjee, Member
This petition of complaint is filed under Sec. 12& C P Act by Shri Chandan Ghosh alleging deficiency in providing service on the part of the New India Assurance Comp. Ltd. And M/S Modicare TPA Services(1) Pvt. Ltd.
In the petition of complaint the Complainant stated that with intention to cover himself and his wife under a mediclaim policy with overall limit of Rs. 100000/- he has himself along with his wife insured under scheme of mediclaim vide policy no 510600/34/15/25/00000424 issued in favour of him and his wife on payment of premium for a period of 1 year commencing on and from 8.5.2015 till 7.5.2016 and the same was renewable. It is stated by the complainant that he fell seriously ill and had been to Christian Medical College, Vellore for treatment in March 2016. Subsequently on 20th April 2016 the Complainant was admitted to the said Medical College and was diagnosed to have Chronic Budd Chiari Syndrome with History of Variccal Bleed. The Complainant has paid Rs. 50000/- to the Hospital on 20.04.2016 that is the day on which he was admitted to the said Hospital and having been treated there.He was discharged on 30.04.2016
The Complainant claimed that he had to spent Rs. 138000/- for the treatment. The complainant therefore , duly filled up claim form along with all supporting documents and deposited the same with the office of the OP No-1 i.e. the Insurance Company for settlement of the claim. But, the OP no-1 did not sanction the same on contrary the OP no-2 being the TPA of OP no-1 demanded repeatedly the original receipts. The complainant, however , being disgusted with the policy adopted by The OP no 1 & 2 sent a letter dt 22.8.2016 through hi Ld Advocate to the OP no 1 & 2 demanding payment of the said amount of Rs. 138297 /- within 15 days from the receipt of the letter but Ops did not pay heed to that. Hence the complainant has filed the petition of complainant praying for a direction upon the Ops to pay Rs. 138297/- to the petitioner, to pay interest 18% p.a. till the date of payment of ligimate claim, to pay Rs. 10000/- as cost and to pay Rs. 50000/- as compensation and demand for the harassment and mental agony.
The OP No.1 has filed written statement stating, inter alia, that the Complainant is insured under Health Policy No.5106034152500000424 which was in force on and from 8.5.2015 to 7.5.2016 and he was admitted at CMC Vellore on 20.4.2016 for his treatment and according to discharge summary he was diagnosed to have suffered from chronic Liver Disease – NAFLP related body syndrome, Diabetes Mellitus type II, Hypertension, Ischemic Heart Disease, suspected AKI on CKD. The OP No.1 has further stated that the Complainant submitted the claim documents along with claim form on 4.5.2016 for settlement of his claim of Rs.1,38,297/- and while processing of the claim settlement was on the T.P.A (OP No.2 herein) informed the Complainant to submit some documents, vide his letter dt.19.5.2016, i.e. (i) head-wise detailed break up of opening balance for Rs.34,386/- in the CMC bill dt.30.4.2016 and (ii) original advance money receipt for Rs.50,000/- against Hospital Bill. Subsequently, the TPA had repeatedly requested vide letters dt.28.5.2016 and 3.6.2016 and through e-mail dt.14.6.2016. The Complainant to submit the said required documents but the Complainant paid no heed to that. The OP insurer specifically stated that the Complainant had got ample opportunity to submit the original receipts but failed to do so for which the TPA sent a letter dt.20.6.2016 to the insured intimating their inability to process the claim for non-submission of said document mentioning that closing of the claim does not restrict the insured to submit the original documents, to enable the TPA to reopen the case and to proceed further but the said documents have not been submitted so far. According to the OP insurer the Complainant has no cause of action and therefore, prayed for dismissal of petition of complaint in limini under Sec.26 of C.P.Act.
The Complainant adopted the petition of complaint as affidavit-in-chief. The Complainant annexed Photostat copies of medical report issued by CMC, Vellore, page No.1 of the policy document, payment receipt of Rs.50,000/- dt.20.4.2016 issued by CMC, Discharge summary issued by CMC, in patient discharge bill, claim form, letter dt.19.5.2016 from medicare TPA Services (I) Pvt. Ltd., Reminder dt.282.5.2016 of the said letter, application to the TPA dt.1.6.2016 by the Complainant, etc.
The OP insurer adopted their written version as affidavit-in-chief and annexed photocopy of the discharge summary of the patient issued by CMC. Both parties cross examined each other followed by reply.
The OP No.2 in spite of service of notice upon them did not turn up and, therefore, vide order No.4 dt.16.11.2016, the case was proceeded ex-parte against OP No.2.
Both sides submitted brief notes on argument.
Now, the points to be determined whether (i) the OPs have deficiency in providing service to the Complainants, whether (ii) the Complainant is entitled to get relief as prayed for.
Decision with reasons
Both the points are being taken into consideration for the same of brevity and comprehensive decision. Admittedly the Complainant is insured under the medi claim policy issued by the OP No.1. Admittedly, the Complainant got admitted to the CMC, Vellore, when the policy was still in force. The Complainant claimed to have paid Rs.1,38,297/- towards expenditure of his treatment and accordingly forwarded claim for disbursement of the sum assured to him which remained due in reality/ has not been done by the OP so far.
On the other hand the OP insurer has alleged that in spite of request on repeated occasions for filing the original documents, in respect of (i) headwise detailed break up of opening balance for Rs.34,386/- in the CMC bill dt.30.4.2016 and (ii) Original advance money receipt for Rs.50,000/- against Hospital bill has not been filed by the Complainant.
The moot point is whether the Complainant submitted the required documents in original.
In course of hearing Ld. Advocate has submitted that the Complainant submitted the required documents in original enclosing with the claim form. On the contrary, Ld. Advocate for the OP insurance company has submitted that they did not receive the required documents in original from the Complainant. However, it appears from the letters issued by the TPA that they repeatedly asked the Complainant to file the original documents towards the claim. However, in spite of receiving such letter no step such as G.D. with the local P.S.etc. has not been taken by the Complainant. Prolonged silence on the part of the Complainant cause failure to substantiate documents in original, although a duplicate cash receipt dt.27.12.2016 and break up for Rs.34,385.95 having annexed to the affidavit-in-reply filed by the Complainant.
However, the letter dt.3.6.2015 (20.6.2015) from the end of TPA reveals that the break up for Rs.34,386/- has been submitted with them by the Complainant and the remaining part i.e. the receipt of advance payment was asked to be submitted. The Complainant sent a letter dt.30.5.2016 intimating that the original receipt of advance payment of Rs.50,000/- is lying with the CMC authority and the same is acknowledged in the In-Patient Discharge Bill, for the period from 20.4.2016 to 30.4.2016. Therefore, it is evident therefrom that all the directions from the end of OPs all are complied by the Complainant.
Under such state of affairs we are of opinion that the Complainant is entitled to get relief as prayed for under prayer (a) that is a direction upon OP No.1 & 2 to settle the claim of Rs.1,38,297/- to the Complainant. Since the OPs compelled the Complainant liable to pay Rs.10,000/- towards cost.
Accordingly, both points are decided. In the result the petition of complaint succeeded in part.
Hence,
ordered
That CC/441/2016 and the same is allowed in part on contest against OP No.1 and ex-parte against OP No.2. OPs are directed to pay Rs.1,38,297/- to the Complainant within two months of this order. OPs are also directed to pay Rs.10,000/- as cost within this period in default the amount shall carry interest @ 10% p.a.
