Hon'ble Mr. Subhas Ch. Guin, Member.

The sum and substance of the Complaint petition is that the complainant, Sri Udayan Chowdhury, a resident of Sunity Road, P.S. Kotwali P.0.& DIST :- Coochbeher and an ex- employee of Punjub National Bank, took an IBA Group Medical. Insurance Policy for the period from 01-11-20 to 31-10-21 for which Rs. 29,442/= was deducted from his S/B Account No:- 024 0011075349 of PNB, Coochbehar Branch towards the premium for the same. That policy was under National Insurance Company Ltd. O.P-1 through PNB as proposer. The manager, Heritage Heath Insurance TPA Pvt. Ltd O.P-2 issued health card in favour of the Complainant having policy No :- 251100502010000329 and ID NO:- HHS10700295521. Unfortunately the complainant was attacked with covid-19 and was admitted in Subham Hospital and Diagnostic Centre Pvt. Limited, Coochbehar on 11-10-21 and discharged on 20-10-21. The Complainant paid total bill of nursing home in cash amounting to Rs 2,80,342/-by arranging fund from different sources as per advice of the O.P as the above said nursing home did not accept the cashless facility of the insurance company. Thereafter, he submitted claim form with annexure to the O.P-2 having claim No:- HH1172248839 on 01.11.21. On receipt of such claim form duly filled by the Insured, the OP-2 settled the claim to the tune of Rs. 1,40,360/- and transferred the same amount to the complainant's account on 27.12.21 without any intimation. Thus, the O.P-2 deducted Rs. 1,39,982/- from the claim amount Rs. 2,80,342/ illegally and issued claim settlement letter through e-mail. In the said letter of email, the OP-2 showed statement of deduction of Rs. 90,232/-only and rest amount of Rs 49,750/- was not shown. Therefore, the above activities of the OPs were illegal and tantamounts to deficiency in service. Afterward, he sent a letter dt.06-02-22 to the O.P-2 intending to know the details of deductions but the O.P-2 did not reply to that letter till date. The cause of action of present case arose on 11-10-21 when the petitioner was admitted in nursing home and again on 01-11-21 when he claimed the amount and on 27-12-20 when the O.P-1 disbursed less amount and lastly on 06-01-22 when the Complainant further wanted to know the reason behind the such deduction. He prayed for a direction to the OPs to pay Rs. 1,39,982/- which was deducted illegally and to pay Rs. 1,00,000/-for deficiency in service and mental pain and agony and Rs.20,000/- for litigation cost.

Summons were served upon the OP-1 and OP-2. The OP-1 contested the case by filing W.V, evidence on affidavit and other related documents. But the OP-2 did turn up to contest the case despite service of notice. So, the case is decided to be heard ex parte against the OP-2 vide order dt. 06-07-22

The OP-1 in his defence stated that the claim made by the complainant was not maintainable and as such it is not payable as cause of deduction was totally legal since it was done as per terms and Conditions of the policy. He also stated in his evidence on affidavit that a sum of Rs 1,40,360/-was disbursed to the complainant after deduction of Rs. 1,39,982/- as per terms and conditions of the policy. He further filed claim settlement Advice wherein details of deductions were given which are as follows.

1. Rs.10000/- on Bill No:- SS3626 dt 20-10-21 (Aaya charge) – Not Payable

2. Rs.48000/- on Bill No:- SS3626 dt 20-10-21 (Consultant )- Payable Rs .2000/- per day for Covid treatment in West Bengal.

3. Rs.19426/- on Bill No:- SS1966 dt. 12-10-21 (Medicine by shop)- Not  payable.

4. Rs.4206/-on Bill No:- SS1920 dt. 11-10-21 (Medicine by shop) – Not  payable

5. Rs.3800/- on Bill No:-SS3626 dt. 20-10-21 (Glucometer) – Report not enclosed.

6. Rs.2800/- on Bill No:- SS3626 dt 20-10-21 (Others) – Report not enclosed.

7. Rs.250/- on Bill No:- SS3626 dt 20-10-21 (Pathology) – Excess charge not payable for Covid test as per Govt. Rate.

8. Rs.28000/-On Bill No:- SS3626 dt 20-10-21 (Doctor / RMO/ duty doctor) - @ Rs 2000/+ per day payable for Covid treatment in West Bengal.

9. Rs.6000/-on Bill No:- SS3626 dt 20-10-21 (Room Rent) – Maximum payable Rs. 5000/- per day- Excess room rent deducted.

10. Rs.17500/- on Bill No:-SS3626 dt. 20-10-21 (ICU) -ICU charge maximum payable Rs. 7500/-per day – Excess ICU charge deducted.

Total deduction was Rs. 1,39,982/- after which a sum of Rs.1,40,360/- was transferred to the Complainant’s S/B A/C on 27-18-21 through NEFT. The O.P -1 stated that since there arises no cause of action to file this case as terms and conditions of the policy was followed strictly during deduction. So, the instant case is liable to be dismissed with cost.

Perused the pleadings, evidence and documents filled by both parties. Heard the arguments advanced by the Ld. Advocates of both parties. On doing so, it is imperative to discuss the following points on the basis of evidences available in the case record to adjudicate the case.

Points for Consideration

1. Whether there is any deficiency as alleged by the Complainant.
2.  Whether Complainant is entitled go to get any relief as prayed for in his complaint petition.                   

Decision with reasons

Point No.1 & 2.

Both points are taken up together for discussion as they are interlinked with each other and for brevity. The complainant was insured under IBA Group Medical Insurance Policy having No:- 251100502010000329 and ID No:-HHS10700295521 through PNB as proposed as he was  an ex-employee of PNB. The OP-2 issued health card (Annexure-A) and money receipt (Anex-A) for the same and the said policy was valid from 01-11-20 to 31-10-21. Owing to irony of fate, he was admitted in Subham Hospital on 11-10-21 due to COVID-19 and was discharged on 20-10-21 (Anex-B) and he had to pay the entire amount of hospital bill amounting to Rs. 280342/- by cash as (Annex-C and G) the said hospital was reluctant to accept cashless facility. Eventually, the Complainant submitted claims form having No:- HH172248839 on 01-11-21. with a claim of Rs. 2,80,342/- (Annex-D) which he paid to the Subham Hospital, Coochbehar.

On 27-12-21, the O.P-1settled the claim of Rs. 1,40,360/- and transferred the above said amount to the complainant’s account without any intimation. Thus the OP-1 deducted an of amount of Rs.1,39,982/- against the said claim (Annex-E) which was intimated to the complainant through e-mail. The Complainant claimed rest amount of his claim and intended to know the reason of such deduction by the letter dt. 06-01-22 but the OP-2 did not respond. In the said  policy sum insured was Rs. 7,00,000/- including top up.

The OP-1 submitted a prospectus of National Group Mediclaim Policy under their aegis in which coverage under the policy are stated in broad heads. In this case, three broad heads should be taken into Consideration e.g i) Room charges ii) Medical Practitioner's fees iii) Other expenses. In the first head i.e. Room charges which includes room rent, intensive care unit charges and associated charges (diet charge, nursing care, RMO charges, administration charge for IV field /blood transfusion/injection) should be 25% of sum issued. In this case Complainant claimed Rs. 1,29,500/- under this head but 25% of sum issued is Rs. 1,75,000/-. Thus, the claim amount is well below the admissible amount. In the second head i.e Medical Practitioner's Fee which includes fees for medical practitioners including treating medical Practitioners, surgeons, anaesthetist, consultant, specialist whose service has been utilized during hospitalisation should be 25% of sum insured, but the complainant claimed Rs 53,100/- under this head which is well below the admissible limit of Rs. 1,75,000/-. That the third one i.e. other expense which includes other expenses related to the hospitalisation  (Anaesthesia, blood, oxygen, OT charges and surgical applications, medicine and drug, diagnostic procedure, ambulance charge) should be 50% of sum Insured. Under this head, the complainant claimed Rs. 87,742/- which is well below the admissible limit of  Rs. 3,50,000/-. Therefore, the whole claim amount was within admissible limit except Aaya  charge which is Rs. 10,000/-.But in the said prospectus of the O.P-1 there is no such exclusion criterion which includes Aaya charge. On the other hand, the complainant who was 70 year old having attacked with COVID-19 pneumonia required an Aaya during hospitalisation as because no other patient parties were allowed at the time of pandemic in the hospital premises. Thus, the complainant was very much in need of an Aaya at the time of hospitalisation. Therefore the O.Ps deducted a sum of Rs. 1,39,982/- against the claim of Rs 2,80,342/- which  tantamounts to unfair trade practice. So, the complainant is entitled to get the relief. Thus, the points No-1&2 answered in affirmative and decided in favour of the Complainant.

In the result, the instant case succeeds on contest.

Hence it is,

Ordered

That the case No. CC/18/2022 be and the same is allowed on Contest with cost.

The O.Ps are directed to pay Rs.1,39,982/- towards rest of the claim amount and to pay Rs.50,000/- for deficiency in service and mental pain and to pay Rs.10,000/- for litigation cost Jointly and or severally. The O.Ps are further directed to pay the whole amount of Rs.1,99,982/-within (30) thirty days from the date of this order failing which the awarded sum shall carry an Interest @ 6% P.A from this date to till its realisation.

D.A to Note in the trail Registrar.

Let plain copy of this order be supplied to the parties concerned by hand/by post forthwith, free of cost for information and necessary action, if any.

The copy of the Final Order is also available on www.confonet.nic.in.

Dictated and corrected by me.