1. This case has been filed against the O.P. who illegally, improperly and arbitrarily did not settle the claim which amounts to denial of the claim causing loss and damages to the complainant to the tune of Rs 2,00,000.
2. The complainant’s case in brief is that the O.P. is a body corporate constituted under Company’s act which carries out General Insurance business as well as individual Mediclaim policy (Parivar Mediclaim Insurance business hospitalization benefit policy). It is further submitted that the complainant purchased the Mediclaim policy previously from Oriental Insurance Company Ltd. from 30.05.14 to 29.05.15 and the policy was renewed policy of the initially issued policy from Oriental Insurance Company for the period from 2012-2013 and 2013-2014.                                  
3. During the subsistence of the above stated policy for the period from 30.05.14 to 29.05.15 issued by the Oriental Insurance Co. Ltd. the complainant got its port to this O.P. National Insurance Company for which the complainant submitted the proposals form and the declaration on 27.05.15 and after considering the previously issued policy by the Oriental Insurance Co. Ltd. and after being fully satisfied the O.P. National Insurance Co. Ltd. received the insurance premium amounts on 28.05.15 and issued Parivar Mediclaim Policy bearing no. 171005/48/15/8500000048  valid from 30.05.15 to 29.05.16 in continuation of the policy of Oriental Insurance Co. Ltd. in favour of the complainant covering his wife also.  
4. It is further mentioned that the O.P. National Insurance Co. Ltd. did not provide the copy of proposals, terms and conditions of the policy rather provided only in three pages. No doubt, the said policy was meant to pay hospitalization expenses for medical/ surgical treatment at any Nursing Home/ Hospital in India. It is further submitted that the during the validity of the policy issued by the O.P. the complainant felt some problem in his body on 21.07.15 and the Doctor at Dumka advised to take appointment of cardiologist at Narayana Institute of Cardiac Sciences at Bangalore.
5.  After informing the O.P. on 05.08.15 the complainant went to the Narayana Institute of Cardiac Sciences at Bangalore for Medical treatment and the complainant got himself admitted on 05.08.15 at Narayana Institute of Cardiac Sciences at Bangalore for clinical examination where he was discharged on 06.08.15 and diagnosed with Rheumatic Heart Disease. Again the complainant was admitted on 10.08.15 at Narayana Institute of Cardiac Sciences for surgery where aortic valve replacement with St. Jude sortic valve prosthesis was done and after treatment he was discharged from the hospital on 25.08.15. After surgery and being discharged from the hospital the complainant informed the insurer O.P. on 04.09.15 and submitted the claim worth Rs 2,99,890 before the Insurance Company along with the relevant documents including the Medical claim treatment bill as required by the Insurance Company.
6. It is further submitted that as the sum insured in the said policy was Rs 2,00,000 only, hence the complainant is entitled to get Rs 2,00,000 from the O.P. It is further submitted that on demand of some documents by Genins India TPA Ltd. the complainant fulfilled all the requirements vide e-mail  dt. 30.12.15. Thereafter the complainant vide email     dt. 02.05.15, 07.12.15, 14.12.15 reminded the O.P. and requested to settle the claim but the matter was delayed to some pretext or others best known to the O.P. The complainant intimated the matter to IRDA on 16.06.16 and again sent a letter to the O.P. on 06.08.16 also and asked some query from O.P. and his agent Nirmal Kumar Das but till date the claim of the complainant has not been settled by the Insurance Co.
7. It is further submitted that the Insurance Co. wrongly and illegally hold the claim of the complainant in abeyance and in spite of the series of request and correspondence of the complainant did not settle the claim. The act of the O.P. is nothing but a patent and glaring deficiency in services rendered by the O.Ps and it is a patent negligent act of the O.Ps for which the complainant has suffered mental tension, agony, harassment to the tune of Rs 50,000. And due to willful act of the O.P. the complainant is deprived of Rs 2,00,000 and the O.P. has enjoyed the said amount and is also enjoying the same causing loss of interest to the complainant. The complainant claims the following amounts :-  i. Principal amount of Rs 2,00,000
   2. Compensation for mental tension, agony and harassment of Rs 50,000
   3. Cost of Litigation Rs 10,000

Total Rs 2,60,000 with interest 12 % p.a. from the date of loss till payment.

8. The complainant has claimed following reliefs :-

1. To direct the O.P to pay Rs 2,00,000 on account of incurred medical expenses.
2. To direct the O.P to pay Rs 50,000 as compensation on account of mental tension, agony and harassment.
3. To direct the O.P to pay the interest @ 12% p.a. from 04.09.15 till the date of payment and also direct the O.P. to pay the cost of litigation of  Rs 10,000.

9.  The O.P. National Insurance Co. appeared on 07.11.17 and filed his WS stating therein that the case of the complainant is not maintainable. It is further stated that this O.P. has not assured the complainant with Mediclaim policy which is continue from 30.05.14 to 29.05.15 of Oriental Insurance Co. and 30.05.15 to 29.05.16 of National Insurance Co. The complainant has admitted this fact that after surgery and discharge from the hospital the complainant informed the insurer O.P. on 04.09.15 and submitted the claim worth Rs 2,99,890 and before the Insurance Co. along with relevant documents including the medical treatment bill as required by the Insurance Company and it is essential to maintain that the sum assured of the said policy is Rs 2,00,000 only hence the complainant is entitled to get Rs 2,00,000 from the O.P.
10. It is further submitted that the claim of the complainant was closed due to non – submission of documents which is demanded by the O.P. and closed letter sent through the courier on 16.02.16 and under writing office on March 16 and final query letter sent to the insurer dt. 23.03.16. The statement of closed letter is mentioned below-

“The claim filed is deficient in desired documents which have not been submitted within the stipulated period after issuance of final reminder hence the claim has been closed.”

11. It is further submitted that the O.P. demanded following documents but the complainant has not filed the said documents to the O.P. which are as follows : -

1. The history of hypertension and RHO certified from treating doctor.
2. All previous medical records related to hypertension and RHD.
3. First consultation paper/ Doctor Prescription related to disease/ diagnosis.
4. All other co- morbidity record required for any previous hospitalization.

And the above mentioned document has not been submitted by the complainant and as such his claim has been closed.

12. It is further submitted that the O.P. Insurance Company is not liable to pay any amount to the complainant and the O.P. is also not liable to pay any compensation to the complainant and the complainant is not entitled to get any relief as mentioned in his complaint petition and the complaint of the complainant is liable to be dismissed.
13. The main point for the determination in this case is whether the complainant is entitled to get any relief or reliefs as claimed !

      Findings

The complainant in support of his case has filed oral and documentary evidence both. He has filed the affidavit as witness which is CW1 Gopal Prasad Aggrawal             

And has also filed the following documentary evidences which are as follows –

Exhibit 1 –  Photocopy of Insurance policy issued by   National Insurance Co. Ltd. which relates to scheduled printing for Parivar Mediclaim from the period 30.05.15 to 29.05.16.

    Exhibit 2 –   is the prescription of Doctor Ranjana of Dumka.

   Exhibit 3 – is the photocopy of case sheet of the complainant issued by Narayan Institute of Cardiac Sciences dt. 01.08.15.

   Exhibit 4 – is the letter of Gopal Aggrawal which was written to O.P. before going for the treatment.

   Exhibit 5 – is the surgical discharge summary issued by Narayan Institute of Cardiac Sciences.

  Exhibit 6 – is the operation note issued by National Institute of Cardiac Sciences.

  Exhibit 7 – is the finance clearance issued by Narayan Institute of Cardiac Sciences on 10.08.15 including bill- cum- receipt. Total                       9 sheets.

  Exhibit 8 – is the claim form submitted by the complainant to the O.P. on 4^th September 2015.

  Exhibit 9 – is the photocopy of medical policy issued by Oriental Bank for the period –

1. From 25.05.12 to 24.05.13.
2. From 25.05.13 to 24.05.14.
3. From 30.05.14 to 29.05.15.

Exhibit 10 – is the mail of the O.P. sent to the O.P. Co. dt. 02.12.15, 07.12.15, 14.12.15, 30.12.15 and 04.12.16.

14. The O.P. in support of his case and contention has not filed any oral evidence or affidavit of any person but he has filed following documents :-

Exhibit A – National Insurance Co. Ltd. Mediclaim policy

Exhibit B – provisions relating to portability of Health Insurance policy

Exhibit C – is the e-mail by National Insurance Co. to the complainant. Total 6 sheets.

Apart from that no other oral or documentary evidences has been adduced by the O.P.    

15. Heard the Learned Counsel of both the parties and also perused the case records evidences oral and documentary adduced on behalf of both the parties and after carefully scrutinizing the evidences of the parties it is admitted fact that the complainant          Gopal Prasad Aggrawal has taken Mediclaim policy from the O.P. i.e; Oriental Insurance Co. Ltd. which was renewed from time to time. Previously the complainant has taken Mediclaim policy from Oriental Insurance Co. Ltd. which was valid from 25.05.12 to 24.05.13 and thereafter same policy was renewed which was valid from 25.05.13 to 24.05.14 and thereafter the complainant port his policy from  Oriental Insurance Co. Ltd. to National Insurance Co. Ltd. and taken his policy which was valid from 30.05.14 to 29.05.15. It is also admitted fact that the claim of the complainant was not repudiated till 26.03.16. It is only closed by the O.P. the Mediclaim policy issued by National Insurance Co. Ltd. i.e; O.P. of the case which was valid from 25.05.14 to 29.05.14 is an admitted fact which is Exhibit 1.
16. The O.P. i.e; National Insurance Co. Ltd. in his show cause in Para 14 clearly mentioned that the complainant has not fulfilled and submitted the relevant documents to him and hence the claim has been closed and the following which was required was as  follows :-

1. The history of hypertension and RHO certified from treating doctor
2. All previous medical records related to hypertension and RHD.
3. First consultation paper/ Doctor Prescription related to disease/ diagnosis.
4. All other co- morbidity record required for any previous hospitalization.

17. Exhibit C is the e-mail sent by the O.P. National Insurance Co. Ltd. to the complainant dt. 25.09.16 which is total 6 pages. In this letter some query regarding treatment and Mediclaim was done by the Insurance Co. from the complainant and asked some documents :-

1. The history of hypertension and RHO certified from treating doctor
2. All previous medical records related to hypertension and RHD.
3. First consultation paper/ Doctor Prescription related to disease/ diagnosis.
4. All other co- morbidity record required for any previous hospitalization.

                              This Exhibit clearly supports the WS of the O.P. of Para 14 who in reply of that letter the complainant drew the attention of the court towards Exhibit 10 which is none other but the e-mail correspondence made by the complainant to the National Insurance Co. Ltd. which is related to dt. 02.12.15, 07.12.15, 14.12.15, 30.12.15 and 04.02.16. In the said e-mail letters the complainant has clearly stated that he has already submitted all the documents required by the Insurance Co.

18. In his reply dt. 14.12.15 he has clearly mentioned that documents regarding my above mentioned claim I have also visited the dumka Branch Office several times and met the Branch Manager for the settlement of my claim. I have also sent two e-mails regarding this for Dumka Branch but I am very disappointed that my claim has not been settled. In this e-mail letter dt. 30.15.15 he has clearly mentioned that as per query regarding my claim have been enclosed here with that -

                                    The history of hypertension and RHO certified from treating doctor. All previous medical records related to hypertension and RHD. First consultation paper/ Doctor Prescription related to disease/ diagnosis. I have no previous medical record related to hypertension and RHD and I am under not any medication.  I have no any co- morbidity for any previous hospitalization before.

19. The complainant has clearly mentioned in his reply dt. 30.12.15 that he did not had hypertension and RHD previously and so far as documents relating to previous medical record related to hypertension and RHD is concerned he has clearly mentioned that he was not in any previous medical record relating to hypertension and RHD and as such no question arises sending records relating to previous hypertension and RHD.
20. So far as his first consultation paper/ doctor prescription related to disease and diagnosis is concerned Exhibit 2 clearly shows that prescription shown by Dr. Ranjana on 21.07.15 he first consulted with this doctor and he has already sent this paper to the O.P. and so far as and other co- morbidity is concerned for previous hospitalization in this record the complainant in his e-mail letter dt. 30.12.15 has clearly mentioned that he does not have any morbidity record for any previous hospitalization as he was never hospitalized with the same. And as such this query made by the O.P. and already submitted the relevant documents to the O.P. within time in spite of the O.P. vide his letter dt. 25.09.16 closing the claim of the complainant.
21. The action of the O.P. closing the claim of the complainant is not on the bonafide and sufficient grounds. On the other hand the complainant has sent all the required documents and made all the query of the O.P. within time. From the perusal of case record it also appears that the complainant has got Mediclaim policy which sum assured was Rs 2,00,000 which is clearly apparent from Exhibit 1 which is schedule printing for parivar Mediclaim policy which was valid from 30.05.15 to 29.05.16 and the complainant has claimed the Mediclaim policy during the period of 10.08.15 to 25.08.15.
22. Apparently the Mediclaim policy is within the valid period of the Mediclaim policy of the O.P. Although the complainant has expanded worth Rs 2,99,890 in the medical treatment but as the assured amount was Rs 2,00,000 as such he has claimed only Rs 2,00,000 from the O.P. Exhibit 3 is the prescription and money receipt issued by Narayan Institute of Cardiac Sciences  and Exhibit 8 is the claim form which clearly indicates that the complainant has expanded on medical treatment of Rs 2,99,890 for which he has given the details but he simply claim assured amount of Rs 2,00,000 only from the O.P.
23. From the aforesaid discussion it is apparent that the act of the O.P. i.e; closing the claim of the complainant is totally wrong and illegal and it is clearly deficiency in services rendered by the O.P. to the complainant. From the aforesaid discussion we come to the conclusion that the O.P. National Insurance Co. Ltd. was negligent in providing the services to the complainant and it is clearly deficiency in services rendered by the O.P. It is therefore, we

Ordered

                                 That the O.P. i.e; National Insurance Co. Ltd. Dumka Branch, sunshine gali, main market, Dumka is hereby directed to pay Rs 2,00,000/- on account of incurred medical expenses to the complainant and also pay interest @ 12% upon the said amount from 04.09.15 till the payment. National Insurance Co. Ltd. Dumka Branch, sunshine gali, main market, Dumka is hereby directed to pay Rs 50,000/- as compensation on account of mental tension, agony and harassment to the complainant. The O.P. National Insurance Co. Ltd. Dumka Branch, sunshine gali, main market, Dumka is hereby directed to pay             Rs 10,000 as litigation cost to the complainant.

                          All the above payments to be made by the O.P. within 1 month from the date of the order failing which the complainant is at liberty to realize the said amount with due process of law.

Let a copy of this order be served to both the parties free of cost.

                       Let this document be deposited in the record room and also to be shown on the website of the commission.