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

          Complainant by filing this complaint has submitted that he took cashless mediclaim policy from the OP for the period from 02-12-2011 to 01-12-2012 and complainant renewed the said mediclaim policy being no.311500/48/2012/6474 for a sum insured of Rs.2 lakh and OP1 is the decision taking authority and the OP2 is working under the authority and control of OP1.

          OP2 after receiving premium of Rs.10,560/- issued a policy certificate in favour of the complainant for availing cashless hospitalization benefits in Network Hospitals.

          On or about 18-04-2012 complainant became seriously ill due to abdomen pain and admitted in Narayana Hridayala Hospitals at 124, Mukundapur, E.M. Bypass, Kolkata – 700 099 under V.K. Gupta and he was discharged from the said hospital on 19-04-2012 after payment of Final Bill of Rs.16,359-00 to th`e said Hospital.  No cashless benefit was provided to the complainant at the time of admission at the said Hospital.

          After discharge from the hospital complainant submitted mediclaim policy claim form along with all relevant documents in original OPs 1 to 3 and on receipt of the same claim form was allotted to the complainant being NO.102041200083 and on receipt of the claim form complainant submitted all original papers along with duly filled in form but OP did not agree to settle the same though OP by a letter dated 25-08-2012 requested the complainant to provide bank details for facilitation of claims payment through Electronic Fund Transfer and also requested the complainant to provide copy of Bank Pass Book etc. which was also submitted by the complainant.

          But most surprisingly factor is that OP even after receipt of the same did not solve the matter though complainant forwarded a Demand Justice dated 15-05-2013 to all the OPs but OP did not respond for the same for which for negligent and deficiency manner of service this complaint was filed for redressal.

          On the contrary OP by filing written statement submitted the present complaint is liable to be dismissed on the ground instant case is not maintainable stating that policy holder Benoy Shankar Sinha Roy of Jadavpur, is not the same and identical person who filed the complaint having address Millennium Apartment, Flat No.B-4, 23, Kalibari Lane, Kolkata – 700 032,P.S. Jadavpur, and further submitted that no supporting document has been produced by the complainant along with said claim and further for non-submission of the same the claim could not be disposed of though claim application was received by the OP on 13-07-2012 and the queries as made by the OP was not necessary for which it was decided though several letters were sent to the complainant by post but it was not answered by the OP for which the present complaint should be dismissed.

Decision with Reasons

Heard Ld. Lawyer for both the parties and also considered the application and the written version including home address of the complainant which is found 87/C, Ibrahimpur Road, Kolkata – 700 032.  Fact remains OP received the claim application and it is a fact that along with claim application complainant did not file the reason for hospitalization, no doctor’s advice before hospitalization was also filed by the complainant and fact remains for mere hospitalization without any reason only for check up claim cannot be considered by the Insurance Company.  It is also proved that on so many occasions the OP sent letters to the complainant for filing certain documents but complainant did not follow the same.  So, the claim could not be disposed of.  Practically complainant has not produced the copy of the discharge certificate and treatments sheets and reasons for admission which are not in the record and at the same time cause of his admission is also not proved.  No doctor’s certificate is filed for what reason he was hospitalized but from the argument of the Ld. Lawyer of the complainant we have gathered that complainant got a CAG package from 18-04-2012 to 19-04-2012 and it is for only health check up what complainant availed of it and net bill was for Rs.15,933/- but the complainant claimed for Rs.16,350/-.  Practically, the complainant is a barrister by profession so, he is well aware of terms and condition of the policy.  But anyhow after considering the argument of the Ld. Lawyer for the complainant and also defence of the OP it is clear that OP sent letters by post on 26/7, 11/8, 25/8, 2/9, 10/9, 21/9, 2/10, 31/12 of 2012 and also on 16-01-2013 and 01-02-2013 but against that letter complainant did not respond because complainant was asked to submit some necessary papers to M/s. E-Meditek (TPA) Service Ltd. acting as an agent of original insurance company.  So, considering the above fact we are convinced that mere filing of the claim by any insured does not give any right to the insured to get the entire mediclaim amount.  But it is the duty of the insured to submit all bills as per requirement of the TPA but in this case complainant has failed to produce any such paper to show that he submitted such papers and moreover complainant is not entitled to Rs.16,350/- against the bill when same  is in respect of Rs.15,933/-.  Another factor is that complainant did not try to meet the queries of the OPs and so we are sure that for non-submission of the papers to the TPA same had not been properly disposed of and so we find there was no negligence or deficiency on the part of the OP.  but what we have gathered that the present complaint is filed by the complainant praying for getting the said amount as of right but fact remains the insured and insurer are guided by the terms and condition of the policy so policy condition must be followed by the parties of the agreement and there is no question of giving any exception or relaxation on the ground of equity under any circumstances even if it is found that insured is a man of status and in this regard ruling reported in 2013(4) CPR(165) NC is followed for coming to a conclusion that parties of this case are strictly governed by the policy condition and no explanation or relaxation will be made on the ground of equity and relying upon that principle we are convinced to hold that complainant must have to send all information and documents as per queries made by the OP and truth is that many letters were sent but that was unanswered by the complainant for which the claim could not be disposed of.  So, apparently we have failed to search out any negligence or deficiency on the part of the OP for non-settlement of the said claim when OPs authority sent several letters to the complainant but complainant did not respond.  In the above circumstances we are of opinion that present complaint is not entertainable in view of the fact that complainant has failed to prove the deficiency and negligence on the part of the OP.

          But invariably the complainant’s claim should be decided by the OP and we have gathered that OPs are very much ready to decide it and sent so many letters but complainant did not comply it so complainant is requested to send all materials as required by the OP and on request of the same as their requirement OP shall have to dispose of the settlement matter but we are unable to allow the complaint when no negligence or deficiency on the part of the is proved.

Hence,

Ordered

That the case be and the same is dismissed on contest but without cost.

          OPs are requested to dispose of claim application after receipt of all required documents as per requirement of the OP and if complainant complies the same in that case invariably matter can easily be settled but what we have gathered that in this case complainant did not act properly as insured when it is the duty of the insured to supply all the materials as per requirement of the OP for settlement of the claim in any case.