Sri. Apurba Kr. Ghosh ……….President

The Complainant has filed this case u/s 12 of the Consumer Protection Act 1986 against the O.Ps. and praying for the following order / reliefs:-

1. Direction against the O.Ps. to pay the assured sum of Rs. 17,000/- only and additional sum of Rs. 50,000/- only as compensation for causing delay of disbursement of claim and on account of suffering of the complainant and also praying for a direction against the OPs to pay interest at the @ 12 % from the date of claim of sum assured till making payment.
2. Any other relief/reliefs to which the complainant is entitled.

      BRIEF FACT OF THE COMPLAINT

1. Complainant is residing within the jurisdiction under Siliguri P.S. in district Darjeeling since long and he purchased National Mediclaim Policy from the OP No. 1 being Agent Code No. 10577001 and the policy certificate was issued bearing policy No. 150610/48/15/8500000120 and the validity period of the insurance policy was from 19.05.2015 midnight of 08.05.2016 and subsequently he was renewed policy was valid from 19.05.2016 to 18.05.2017 and to that effect the OP No. 1 issued Policy Certificate bearing no. 150610/48/16/8500000128.
2. That, in the month of November 2016 the complainant feel high fever and headache first time, immediately went to Dr. Basu’s Nurshing Home at Siliguri and thereafter on 09.11.2016 as per Doctor’s advice he took admission in Basu’s Clinic on 09.11.2016.
3. That after admission in the said Nursing Home some examination was done including blood test and thereafter as per Doctor’s advice namely Sankha Sen the complainant was admitted in the said Nursing Home on 09.11.2016 as per blood report it was found that the complainant is a patient of Dengu.
4. Thereafter the Doctor Namely Sankha Sen started the treatment and the complainant took medicine as per prescription which was prepared by the Doctor namely Dr. Sankha Sen.
5. That the treatment was going on till 11.11.2016 and thereafter the complainant was discharged from the nursing home by his own risk on that day for better treatment.
6. That the complainant after admission of second time in the Sanjeevani Neuro Multi Specialty Hospital on 12.11.2016 discharge on 14.11.2016 that thereafter the complainant meet with the OP No. 1 several times for his rightful claim and deposited medical expenses bill and all documents before the Manager of the OP No. 1 but this day the OP No. 1 is avoiding to pay rightful claim of the complainant without any reason and lastly on 14.05.2017 the complainant met with the OP but no fruit full result made out. The OP No. 1 refused to give any receives copy to the complainant as because all are Xerox Copy of the Medical bill deposited by the complainant before the appropriate authority of the OP No. 1.
7. That on 19.07.2017 when the complainant was going to his house from Bidhan Market he lost all the original documents in respect of Basu’s Clinic and Sanjeevani thereafter he lodged a General Diary before The I.C., Siliguri Police Station on 23.11.2017.
8. That on 13.04.2018 the complainant send a notice to the OP no. 1 for his rightful claim and OP no. 1 received the same on 27.04.2018 but the OP no. 1 was avoiding and misleading the complainant for the payment of his medical benefit claim.
9. That the complainant has not violated any terms and conditions of the insurance policy by suppressing the material fact. The OP no. 1 most illegally repudiated the claim of the complainant by way of avoiding and in terms and conditions of insurance policy the OP no. 1 is bound to pay the sum assured of Rs. 17,000/- only of such policy to the complainant and the OPs are liable for deficiency in service in the matter of claim of the complainant and the OP intentionally and deliberately repudiated the claim of complainant without assigning proper reason with an ulterior motive to delay in settlement of the claim of complainant as a result of which the complainant is suffering lot of problem and inconvenience.
10. Cause of action of this case arose on 04.05.2017 and 23.11.2017 within the jurisdiction of this Commission.

In support of the complaint the complainant has filed the following documents:-

1. Xerox copy of admission and discharge certificate and medical bills of Basu’s Clinic and Sanjivani.
2. One Xerox Copy of FIR.
3. Two Xerox Copy of Policy Certificate.
4. One Xerox copy of notice dt. 13.04.2018 issued by complainant.
5. One Xerox Copy of reply letter dt. 23.04.2018 by OP No. 1.
6. One Original Discharge certificate on Risk Bond issued by Basu’s Clinic.
7. One Original Blood Report issued by Basu’s Clinic.
8. One Original Blood Report issued by Sanjivani Nursing Home.

Notice was sent from this Commission to the OPs. On receipt of notice, all the O.Ps. have appeared before this Commission through Vokalatnama, filed their written version separately, in the W/V the OP no. 1 has stated that the case is not maintainable either in law or fact/ there was no cause of action for filing this case/the case is barred by principle of waiver of estoppels and acquiescence/ the case is false and mala fide/ the case bad for misjonder and non joinder of parties.

In the W/V the OP no. 1 has further stated that the statement made in Para No. 1, 4, 5, 6, 7 & 8 of the complaint petition are matter of record and complainant is bound to prove the same. It is also stated in the W/V that the complainant did not file the claim form with original medical documents and he violated the clause 5.5 of the Insurance Policy which is mandatory to file original documents with claim form but for the suppressing of facts the complainant did not file any original documents along with claim form. The OP no. 1 has also stated in the W/V the statement in Paragraph No. 9, 10 11 & 12 are not correct and the complainant has falsely stated that he on several occasions met with the OP no. 1 and the complainant was discharged from the Nursing Home on 14.11.2016 but he did not file any original medical documents within 15 days from the date of discharge and in the petition of complaint he stated that when he was returning home from Bidhan Market, Siliguri he lost his original medical documents on 19.07.2017 where from it is clear that this 15 days from the date of discharge from the Hospital the complainant did not file the original medical documents to the Op no. 1.

The OP no.1 has further stated that there is no cause of action to file this instant case and to harass the OP no. 1 the complainant has file this case by suppressing material facts.

By filling W/V the OP no. 1 praying for dismissal of this case.

By filing separate W/V the OP no. 2 & 3 have stated that the complainant has filed this case against them without seeking any relief from them and the complainant has impleaded these OPs without having any cogent reasons. Both the OPs no. 2 & 3 have also stated that the complainant made no allegations against them and also made no claim form them that’s why this case is requires to be dismissed.

Having heard the Ld. Advocate of Complainant and Ld. advocate of OPs and on perusal of the complaint, written version of the OPs as well as documents filed by the parties the following points are taken to be considered/decided by this Commission.

POINTS FOR CONSIDERARTION   

1. Whether the Complainant is a consumer?
2. Whether the case is maintainable under the C.P. Act?
3. Whether there is any deficiency in service on the part of the O.P. as alleged by the Complainant?
4. Is the Complainant entitled to get any award and relief as prayed for as per the prayer of her Complaint?

Decision with Reasons

  All the points are taken up together for discussion to avoid unnecessary repetition and for sake of convenience and brevity of this case.

In order to prove the case complainant has adduced evidence by filing written deposition in the form of an affidavit. In the written deposition the complainant has specifically corroborated the contents of the complaint and has stated that he purchased one medicalim policy from the OP no. 1 being policy no. 150610/48/15/8500000120. He further stated in his evidence that subsequently he renewed policy and later on it was numbered as 150610/48/16/8500000128 and policy was valid till 18.05.2017 and in the midnight of 09.11.2016 he was compelled to admit to the Basu’s Clinic Nursing Home at Siliguri for treatment being a patient of Dengue and at his own risk he was discharged on 11.11.2016 form Basu’s Clinic Nursing Home. In the written deposition the complainant has further corroborated on 12.11.2016 he was compelled to admit for second time in the Sanjeevani Neuro Multi Specialty Hospital and he was discharged from there on 14.11.2016. The complainant has also corroborated his written evidence that he submitted the claim form along with medical documents to the OP no. 1. But the OP no. 1 has paid no heed to pay the medical reimbursement claim of the complainant. The complainant has also stated in his evidence that several occasions the complainant visited the office of the OP no. 1 but the Manager as well as other officials did not pay any attention to the complainant in disbursement of his claim. He further stated in his evidence that on 19.07.2017 while he was returning home from Bidhan Market, Siliguri he lost his medical documents and to that effect he lodged GDE with Siliguri PS. The complainant has further corroborated in his evidence that thereafter he sent notice on 13.04.2018 to the OP no. 1 asking for his rightful claim and that notice was duly received by the OP no. 1 on 27.04.2018 but no such medical expenses was given to the complainant till date.

At the time of hearing of argument Ld. advocate of the complainant argued that, the complainant has been able to prove the case against the OP’s not only by adducing evidence but also by producing documents before this Commission. He also argued that, the complainant has filed written notes of argument where he stated everything in support of his case. Ld. Advocate of the complainant further argued that, the complainant has been able to prove that there was deficiency of service on the part of the OP’s who deliberately did not pay the reimbursement of medical expenses though within the effective policy period the complainant was admitted in the Basu’s Nursing Home and Sanjeevani Neuro Multispecialty Hospital. He also argued that, the complainant after discharge from the hospital had submitted the Medical Discharge Summary, Medical Bills, Vouchers to the OP No. 1 within time but the OP No. 1 has neglected to pay the reimbursement amount to the complainant. Ld. Advocate of the complainant also argued that on several occasions the complainant has visited the office of the OP No. 1 asking for early settlement of his claim but the OP’s had paid no heed to him and despite receiving demand notice the OP No. 1 did not pay the medical expenses to the complainant which is deficiency of service and therefore the complainant is entitled to get the relief as prayed for. At the time of hearing of argument Ld. advocate of the complainant referring one decision passed in CWP No. 17694 of 2017 High Court of Punjab and Haryana and other documents in support of this case.

To falsify the case of the complainant the OPs were given liberty to file their evidence vide order no. 29 dated 04.04.2022. In view of the order no. 29 the OP no. 2 files an application stating that treating the W/V as their evidence and the prayer was allowed on 16.06.2022. The OP no. 3 to falsify the case of the complainant has filed written evidence in the form of an affidavit. But the OP No. 1 to falsify the case of the complainant did not adduced any evidence before this Commission though opportunity was given to him also. In the written evidence the OP no. 3 has corroborated the contents of their written version and has specifically stated that the complainant made no allegation in his written complaint as well as in his evidence against the OP no. 3. It is further stated in the evidence of the OP no. 3 that the complainant made no claim against the Op no. 3 or any action with this case and the OP no. 3 praying for dismissal of this case on the grounds that the complainant has no cause of action to implead the OP no. 3 as a party of this case.

At the time of argument Ld. Advocate of the OP No. 1 argued that the complainant has filed this case on some false allegation against the OP No. 1 as he suppressed the actual fact before this Commission. He further argued that he has already filed written notes of argument and stated everything. Ld. Advocate also argued that, the complainant has failed to prove the case against the said OP and he has violated the policy condition as mentioned in clause 5.5 of the medical insurance policy where lit is specifically disclosed that, the insured should file original medical documents, discharge summary, medical bills, vouchers along with the claim form within 15 days from the date of discharge from the Hospital/Nursing Home. It is also the argument of the Ld. Advocate of OP No. 1 that, in reply to the questionnaires the complainant replied that, he did not submit Original Medical Bills to the OP no. 1 and therefore there was no deficiency of service on the part of the OP No. 1. He also argued that, the OP No. 1 never repudiate the claim of the complainant as the complainant did not file the claim form with any medical documents in original. Ld. Advocate of the OP no. 1 praying for dismissal of this case.

Ld. Advocate of the OP No. 2 & 3 during their argument submits that, they have already filed their written notes of argument and stated everything there. They also argued that, the complainant has stated nothing against them and the complainant has not made any allegations against them either in his written complaint or in his written deposition and the complainant has not claimed any sort of relief from those OP No. 2 & 3. They further argued that, there is no allegations of medical negligence or deficiency of service against the OP No. 2 & 3 and therefore they have been unnecessarily made party of this case and they praying for dismissal of this case.

Having heard the Ld. advocate of the complainant and the OPs and on perusal of the written complaint, written version of the OPs documents filed by the complainant, evidence of the OPs, written notes of argument it reveals that the complainant has been able to prove its case to the effect that he purchased mediclaim policy from the OP no. 1 being policy no. 150610/48/8500000120 and for which the OP No. 1 had issued certificate being No. 150610/48/15/8500000128 and the policy was valid till midnight of 18.05.2017.

From the evidence of the complainant it appears that the complainant has been able to prove the fact he was firstly admitted in the Basu’s Nursing Home on 09.11.2016 as he was suffering from Dengue and when he was not satisfied with the treatment he had his own risk was discharged on 11.11.2016 for his better treatment. From the written evidence of the complainant it further reveals that the complainant has been able to prove the fact that secondly he was admitted in the Sanjeevani Neuro Multi Specialty Hospital on 12.11.2016 and discharge from there on 14.11.2016. It is not denied by the OP no. 2 & 3 i.e. Dr. Basu’s Clinick and Sanjeevani Neuro Multi Specialty Hospital but they specifically admits the evidence of the complainant who supported the evidence of the complainant and the OP no. 3 in his written evidence admits that the complainant was admitted in their hospitals for treatment and he paid the medical expenses there. In the written evidence of the OP no. 3 they stated that the medical documents were handed over to the complainant at the time of discharge from the Hospital. It is not denied by the OP No. 1 that the complainant was admitted in any hospital of Dr. Basu’s Clinic & Sanjeevani Neuro Multi Specialty Hospital. On the other hand the OP no. 1 has claimed that the complainant did not file the original medical documents to them which are very much necessary for the process of settlement of claim. But from the record it reveals that the complainant has not only sent the medical documents to the OP no. 1 but also sent legal notice to the OP no. 1 requesting them for early settlement of the reimbursement of claim as the complainant was admitted in those two hospitals within the effective validity period of insurance policy. It is needless to mention here that the complainant in his written complaint as well as in his evidence has stated he lost some of the medical documents in original while he was returning home from Bidhan Market, Siliguri but the complainant at the time of this case and during hearing of argument submitted several medical documents including testing reports, bills , vouchers before this Commission in support of his claim of Rs. 17,000/- which he paid in his medical treatment in this two hospitals. By referring the decisions Ld. Advocate of complainant argued that the Honble High Court of Punjab and Haryana in a decision of CPW No. 17694 of 2017 specifically where it was held that the OP-Insurance company cannot reject the medical reimbursement only on the ground of delay in filing medical documents and the insurance company cannot deny the medical reimbursement on the ground of delay only as the medical reimbursement is the right of the insurer which should have been granted immediately on receipt of the medical bills. In the instant case the complainant has filed medical documents including discharge summery as well as other test reports including bills and vouchers to substantiate its claim against the OP no. 1. It is needless to mention here that insurance company are refusing in many cases on flimsy grounds and thereby Hon’ble Apex Court observed that they should not too technical while settling claims and asking for with the insurer is not in a position to produce due to circumstance beyond his control. Hon’ble Apex Court has also observed that while allowing the appeal in a matter pertaining to the settlement of the claim under the insurance policy for Truck that was stolen in the year 2013. A bench of Hon’ble Justices Mr. Shah, Bvnagarathna said that the appellant was the owner of the Truck was wrongly denied the insurance claim and the insurance company had became too technical while settling the claim and had acted arbitrarily. In the instant case the OP no. 1 has not paid the reimbursement amount of the complainant mainly on the grounds that the complainant did not produce the original medical documents before them within time but from the record it clearly proves that the complainant has sufficient documents to substantiate his claim for reimbursement of the mediclaim as the complainant was suffering from Dengue and he was admitted in two separate hospitals within the effective validity period of the insurance policy. In the case in hand the complainant has also filed document to prove that he lost some of the original medical documents while he was returning home from Bidhan Market and to that effect he lodged GDE with the Siliguri P.S. and that is why it is safely presumed that when he was asked by the OP no. 1 to produce original medical documents it was beyond his control to procure and furnish the original medical documents before OP no. 1. It is admitted fact that there was a effective and validity mediclaim policy which the complainant had purchased from the OP no. 1 and the insurance company had not to have become too technical and refused to settle the claim of non submission of the original medical documents before them which the complainant could not produce due to circumstances beyond his control.

Considering the medical documents which are produced before this Commission at the time of filing of complaint and at the time of hearing of argument on the side of the complainant including the legal notice which was sent to the OP no. 1 on behalf of complainant and admission of the OP no. 2 & 3 regarding treatment of the complainant we are of the view that the complainant has been able to prove its case against the OP no. 1 and he was entitled to get medical imbursement which was incurred during the treatment by the Doctor of two separate hospitals.

The OP no. 1 in the case in hand did not challenge the evidence of the complainant by filing counter affidavit. Considering the unchallenged evidence of the complainant we are also of the view that the complainant has been able to prove his case against the OP no. 1 who did not file any counter affidavit against the evidence of the complainant.

Hence, it is therefore,

O R D E R E D

That the instant Consumer Case being No. 46/2018 is allowed on contest against the OP No. 1 and dismissed against the OP No. 2 & 3. The OP No. 1 is directed to pay a sum of Rs. 17,000/- (Rupees Seventeen Thousand) only to the complainant towards reimbursement of medical expenses. The OP no. 1 is directed to pay a sum of Rs. 30,000/- (Rupees Thirty Thousand) only to the complainant towards compensation for deficiency in service as well as causing mental pain and agony caused to the complainant by the OP No. 1 who deliberately did not settle the claim of the complainant despite receiving the legal notice of the complainant.

The OP No. 1 is also directed to pay a sum of Rs. 10,000/- (Rupees Ten Thousand) only to the complainant towards cost of legal proceedings and OP No. 1 is also directed to pay a sum of Rs. 10,000/- (Rupees Ten Thousand) only in the Consumer Legal Aid Account of this Commission.

The OP No. 1 is directed to pay interest at the rate of 7% per annum on the awarded amount to the complainant with effect from the date of filing of this case till making payment of entire amount.

The OP No. 1 is further directed to pay the awarded amount within 45 days from this day failing which the complainant will have liberty to take proper steps against the OP No. 1 as per law.

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