1. The complainant has filed this case for non- payment of medi claims of the complainant by the Opposite parties and withholding the amount illegally and also not providing the services proposal.
2.                                        The complainant’s case in brief is that the complainant along with his wife Sapna Modi insured with Medical policy- Cum- Life- Insurance- Policy bearing Policy No./ Contract No. 51859264 which commenced on 22.10.14 for 12 years that is from 22.10.14 to 22.10.26. Sum assured Rs 2,00,000 plan -“Reliance care for your Advantage” which was accompanied with Reliance Health Insurance proposed for covering family members under same proposal. The nominee Sapna Modi got problem in her both eyes. Doctor suggested for operation which was operated by Doctors of Disha Eye Hospital on 16.05.17 and 25.07.17, expenses were Rs 35,000 only. It is further submitted that O.Ps insurer convinced the complainant and his wife Sapna Modi for a health insurance/ Medicare Insurance with assurance that insurers/ O.Ps providing cashless facilities by issuing card for Medicare TPA Services saying that the card will provide all facilities in hospital in which sum assured is Rs 2,00,000 for the yearly premium of Rs 5,722 for 12 years. The complainant seeing the facilities and easy process agreed for the policy and signed the proposal form on 11.10.14 which was verified by O.P, accepted the proposal and issued policy bond on 22.10.14 which is date of commencement of policy and the proposal form was filled by the agent of O.P No. – 4.
3.                                          It is further submitted that the complainant continued the policy and in the mean time in the year 2017 the wife of the complainant got problem in her both eyes who ran to an eye hospital                      “Disha Eye Hospital” at Barrackpore, Kolkata  for check up. The doctor checked the eyes and suggested for operation and the complainant admitted his wife for check up on 20.04.17 and which was operated on 16.05.17 and second eye operated on 25.07.17 and expenses occurred in the operation of both the eyes of Rs 35000. Thereafter the complainant gave the information for the operation to the O.P regarding operation. The O.P issued the claim form asked to attach all slips and documents, copy of policy bond which was submitted to the O.P twice. One set of forms and slips for one eye which was operated on 16.05.17 and another set of forms and slips for another eye which was operated on 25.05.17 and waited for amount which the complainant had paid to the hospital. The O.P after taking the documents send letter on 27.07.17 asking clearly for the following –

1. Detail break up of procedure charges for amount of Rs 12600/-
2. Since when the patient was suffering from dimness of vision, doctor’s certificate
3. Cause of cataract and just on 31.07.15 for the non- submission of the documents.

It is further submitted that the O.Ps had been provided all necessary documents with claim form in their legal office at Dumka who took the documents, verified and said that they are going to send the documents to the higher office for quick payment and then there were no requirements.    

4.                                    The O.Ps are intentionally trying to slip up from the payment of Medicare policy, the assurances of the O.P to provide cashless facility by such card became fruitless and after submission of claim, O.Ps started demanding baseless documents not only to send a claim closing letter on 31.07.17  but to close the chapter. These are nothing but unfair trade practices, fake promises, bluff to the public, deficiency of services, neglizency and violation of contract for which the O.Ps are liable to pay a heavy compensation for not less than Rs 1,25,000 with 12% interest over the expense amount.
5.                             The cause of action of the complaint arose on 10.11.14 when O.Ps convinced the complainant and his wife in their house at Dharamashala road, Dumka on 22.10.14 when the policy commenced, on 20.04.17 when the doctor suggested for operation, on 16.05.17 when one eye was operated on 25.07.17 when another eye was operated, on 24.04.17 when information for operation was given to the O.Ps in their local office, Dumka, on 27.07.17 when O.Ps demanded further document, on 31.07.17 when the O.Ps closed the claim and same is in continuation on 19.09.17 and 29.11.17 when pleader notice was sent to the O.Ps.
5. The complainant claim following reliefs :–

1. Principal amount Rs 35,000/-
2. Compensation amount of Rs 1,00,000/-
3. Cost of Litigation Rs 25,000/-

Total Rs 1,60,000 and 12% interest over principal since the date of filing till realization. And also prayed that the O.P be directed to pay the Principal amount of Rs 35,000, compensation of Rs 100000 for such unfair trade practices and deficiency in services and for violation of contract for harassment and mental agony and also cost of litigation of Rs 25000 and therefore be directed to pay 12% interest over the principal amount from the date of filing till realization.

6.                                          O.P No. 1 & 2 appeared and filed hisso cause/written statement on 23.03.18 and has stated that O.P No. 1 & 2 Reliance Nippon Life Insurance Co. Ltd. formerly known as Reliance Life Insurance Co. Ltd. registered u/s 3 of Insurance Act 1938 having its registered office at 22^nd floor, A Wing, Marathon Futurex, Mafatlal Mills Compound, N M Joshi Marg, Lower Parel(E), Mumbai, carrying inter – alia business of life insurance. It is further stated that these answering opposite parties denies each and every statement or contention which is inconsistent with or contradictory to whatever is stated in this written statement and no statement or contention not specifically denied by the Answering Opposite Parties shall be deemed to have been admitted merely for want of a specific transverse. The answering opposite parties has preliminary objection and has stated that complaint is false, frivolous and vexatious as no cause of action lies against the answering opposite parties and the claim of the complainant was not processed due to failure of complainant to submit requisite documents for processing the same and therefore as there has been no deficiency of service or negligence on the part of the Answering Opposite Parties.
7.                                          The present complaint does not raise any Consumer Dispute as defined under the Consumer Protection Act, 1986 and there is no cause of action. The complainant has no privity of contract with the Chairman of Reliance Life Insurance Co. Ltd. The cause of action, if any, lies only against the Life Insurance Co. Ltd. and not against Chairman in person. The Company has been provided with the documentation on original or copy attested by any other insurer information as asked for from time to time and the Company or the TPA Services has requested the policy holder to establish the circumstances of the claim, its quantum or company’s liability for it and if the insured person has complied with his obligations under this policy and in the present case the complainant failed to submit the documents by the TPA Services despite repeated reminders and hence conducted clear breach of policy terms and conditions and therefore the Answering Opposite Parties have rightfully closed the claim of the complainant on his failure to comply with the above mentioned clause. 
8.                                          It is further submitted that in spite of repeated request by the O.P to the complainant to submit the requisite documents by his letter dated 30.06.17, 20.07.17, 27.07.17 and 21.07.17 and thus the present complaint is liable to be dismissed on this ground alone and the Answering Opposite Parties in his final reminder on 27.07.17 has clearly issued that on failure of the complainant to submit the requisite documents the said claim will be closed and no further claims will be entertained with respect to the policy in question. Since the complainant failed and neglected to act in accordance with the policy terms and conditions therefore the present complaint is liable to be dismissed.
9.                                                    The complainant has not approached the Hon. Forum with clean hands and has suppressed his negligence and fault on his part just to misguide the Hon. Forum. The present complaint is wholly misconceived, groundless and unsustainable in law as the complainant has no locus standi to initiate the present proceedings and is only to harass, put undue pressure and to obtain unlawful gains from the Answering Opposite Parties. There is no deficiency on the part of the O.Ps in providing the services to the complainant and as such the complainant is not entitled for any relief
10.                              In Para ‘L’(A) the O.P has submitted this fact that proposal forum believing the sum to be true and correct in all aspects and as per the underwriting norms of the company the said proposal was accepted by the Company and Life Insurance policy bearing a no. 51859264 on 22.10.14 in the name of Pankaj Kumar Modi, details are given below and the proposals form  is also attached with the written statement as Annexure ‘A’. and further stated that in Para B, the O.P has admitted this fact that the proposals of the complainant was accepted by the company and Life Insurance Policy bearing no. 51859264 was issued on 22.10.14 and the detailed document is also attached with the written statement as Annexure B. In Para C this answering O.Ps has admitted that this O.P No. 3 Medicare Insurance TPA Services Pvt. Ltd. is the vendor of answering opposite parties and it processes the health claims of RNLIC Health policy holders of all over India except the policy holders of South states.                          The Medicare TPA Services Pvt. Ltd. is a company incorporated under the Companies Act 1956 having it registered office at 6, Bishop Lefroy road, Kolkata, West Bengal and holds the license as a third party administrator under the Third Party Administrator Health Services Regulation, 2001 and as per the agreement between the Answering Opposite Parties and TPA Services dt. 26.04.14 the TPA Services processed all the health insurance and claims of the Answering Opposite Parties. The copy of agreement is also annexed as Annexure C.
11.                       And in the light of above stated agreement between the Answering Opposite Parties and the TPA Services that the claim submitted by the complainant on 20.06.17 with respect to reimbursement of expenses for the surgery of cataract of the nominee namely Sapna Modi was duly processed by the TPA Services. The claim dt. 20.06.17 is also annexed and marked as Annexure D. It is further submitted that on receipt of claim from the complainant, the TPA Services issued the requirement letter dt. 30.06.17 demanding for breakup of procedure charges and attending doctor to certify that since when was the insured suffering from illness. It is to be noted that on failure of the insurer to submit the requisite documents the Answering Opposite Parties further issued another reminder letter dt. 20^th July 2017 reminding the insured to submit the documents required to process the claim. And both the reminder letter dt. 30.06.17 and 20.07.17 is also annexed and marked as Annexure E & F. Final reminder letter was also send on 27.07.17 and 31.07.17 which is also annexed as Annexure G & H.
12.                                                 It is further submitted that the claim is paid by the Insurance Company out of the common pool of funds belonging to all policy holders of the company and Insurance Co. has to check the genuineness of a claim before honoring it and the Insurance Co. cannot do injustice to genuine policy holders by allowing ingenious and false claims.  And the             modus operandi of the Answering Opposite Parties are different from any insurance sectors and earnestly follows the rules and regulations passed by the IRDA and further functions is carried in accordance with the settled principles of law.
13.                                          The Answering Opposite Parties admitted this fact that complaint petition is true only to the extent that on the information declared contained in the proposal form and believing the same to be true and also upon receipt of the duly filled form on 11.10.14 the Answering Opposite Parties issued policy in the name of Pankaj Kumar Modi, complainant. He has also given the details of the policy in his so cause. It is further submitted that Answering Opposite Parties has issued various reminder letters demanding for the required documents from the complainant but the same was neglected by the complainant. Hence on failure and negligence of the complainant to submit requisite documents the answering opposite parties rightfully closed the claim after intimating the same to the complainant. Hence the present complaint is liable to be dismissed as there has been no deficiency of service or negligence on the part of Answering O.Ps. And further prayed that present complaint may be dismissed with exemplary case in favour of the Answering O.Ps.

The main point for the determination in this case that whether the complainant is entitled for the relief or reliefs as claimed !

14.                                    Findings

The complainant in support of his case filed certain documents which are as follows :-

Exhibit 1 – is the card issued by Reliance Insurance Co. and photocopy of the policy issued by Reliance Life Insurance.

Exhibit 2 – is the photocopy of Eye Vision report issued by   Disha Eye Hospital along with money receipts.

Exhibit 3 – is the photocopy of vision reported.

Exhibit 4 – is also report of vision of both the eyes of Disha Eye Hospital.

Exhibit 5 – is the 6 detail of operation charges issued by Disha Hospital of Sapna Modi.

Exhibit 6 – is report of dimness of vision

Exhibit 7 – is cash memo issued by Disha Hospital dt. 25.07.17

Exhibit 8 – is the money receipts issued by Disha Eye hospital

Exhibit 9 – is the certificate of Sapna Modi issued by Dr. Ayan Mohanty of Disha Hospital.

Exhibit 10 – is the card issued by Medicare TPA services Pvt. Ltd.

Exhibit 11 – is the photocopy of doctor card of Pankaj Kumar Modi.

Exhibit 11(i) – is the photocopy of doctor card of Sapna Modi.

Exhibit 12 – is the letter issued by Medicare to Pankaj Kumar Modi dt. 27.07.17 and 31.07.17.

Exhibit 13 – is the pleader notice dt. 19.09.17 and also dt. 29.11.17.

Apart from that the complainant himself produced as a witness as CW1 Pankaj Kumar Modi filed as affidavit.

15.                                       The opposite party has filed some documents in support of his defence which are as follows :-

Annexure A – is the proposal form of the complainant for insurance policy

Annexure B – is the policy documents issued by O.P

Annexure C – is the agreement dt. 26.04.14 that O.P No. 3 that is Medicare Insurance TPA Services Pvt. Ltd.

Annexure D – is the claim of the claimant dt. 20.06.17

Annexure E & F – is the reminder by O.P No. 3 that is TPA Co. to claimant dt. 30.06.17 and 20.07.17 respectively.

Annexure G & H – is the final reminder dt. 27.07.17 and 31.07.17 issued by O.P No. 3 to complainant.

Apart from that the O.Ps filed the affidavit of Rajnish Kumar as evidence on behalf of the O.P 1 & 2. Apart from that the O.P 1 & 2 has not filed any oral or documentary evidence in support of his case.

16.                                                 Heard the Learned Counsel on behalf of both the parties and also perused the documents and evidence adduced of both the parties and gone through the case record thoroughly.
17.                                       It is admitted fact by the O.P in his written statement Para wise reply in Para A that complainant Pankaj Kumar Modi is the policy holder of his company and he admitted this fact that                          Policy Contract No. 51859264 and date of issue is 22.10.14 and policy terms is 12 years premium payment is 12 years frequently maturity sum assured is Rs 200,000 and premium paid Rs 5722. This fact is also corroborated by O.P witness, Rajnish Kumar in Para 4 also.
18.                                       Admittedly the complainant and his wife is bonafide insured persons of O.P no. 1 & 2. It is also admitted fact by the O.P in Annexure C that O.P no. 3 Medicare TPA Services Pvt. Ltd. is none other but the vendor of Answering Opposite Parties, issued duty, processed the insurance claim of RNLIC Health policy holders of all over India. The O.P No. 3 has not appeared in this case and against whom the proceeding is going Exparte. Duty of the O.P No. 3 Medicare TPA Services is only to process the Health claims on behalf of O.P No. 1 & 2, it is between O.P No. 1 & O.P No. 3.
19.                                       It is also admitted fact that the wife of the complainant Sapna Modi got operated her both the eyes in Disha Eye Hospital, Barrackpore, Kolkata and the documents produced by the complainant before Medicare TPA Services were produced and found true and genuine but from the perusal of Annexure E, F, G & H which is also Exhibit 12. This is the letter issued by Medicare to Pankaj Kumar Modi regarding some points. That are :-

1. Please provide detail breakup of the procedure charges for amount of Rs 12600/-
2. Attending Doctor to verify when the patient is suffering from dimness of vision
3. Attending doctor to certify the cause of contract in this patient.

This information was called from the complainant by his letter dt. 27.07.17.

20. In this regard the complainant has submitted that he has already given all the documents relating to the claim and also relating to the objection raised by Medicare TPA Services Pvt. Ltd. vide his letter dt. 27.07.17 and he has also drawn the attention of the court towards Exhibit 9 which is the report of the Doctor Ayan Mohanty of Disha Eye Hospital. He has clearly written that patient was suffering for 4 months dimness of vision and so far as second information regarding breakup of amount of  Rs 12600/- is concerned he has stated that no receipts of     Rs 12600 was submitted by him before the              Medicare TPA Services Pvt. Ltd. that is O.P No. 4. He further draws the attention of the court towards         Exhibit No. 5 which is the Cash Memo receipts clearly shows that cost of lens is Rs 3000 and procedural charges including medicine, operation fees is Rs 12600, total         Rs 15600/-
21. Apparently Exhibit 5 clearly states about the breakup of the amount of Rs 12600 as demanded by Medicare by his letter which is Exhibit 12 corresponding to Annexure E,F,G & H. Simply information producing of about details of the breakup amount and dimness of the vision report the O.P on the report of the O.P no. 3 that is Annexure E,F,G & H which is dt. 30.06.17 20.07.17 27.07.17 and 30.07.17 closed the claim of the complainant and considering the date of the reminders letter which is only around 1 week it  is highly containable and the act of the O.Ps are not justified in any way because much before his demand regarding his confusion to the documents the complainant prior much to their demand has already filed the entire documents and certificates of the Dr. regarding the element without going through the records and its genuineness on the report of O.P No. 3 which is Medicare TPA services who is simply vendor of O.P No. 1 closed the claim of the claimant. The act of the O.P is totally arbitrary and it shows the deficiency in his services. The complainant has successfully established his case with the conduct of the O.P was irresponsible arbitrary and without considering the claim of the claimant refused to pay the claim. Apparently the complainant has not claimed any huge amount rather he claimed simply the expenses of Medicare charges and expenses of the hospital which was Rs 35000/- only. This amount is not very huge one and the policy issued by the O.P covers the amount of Rs 2,00,000.
22.                                                 Due to act of the O.Ps the complainant suffered harassment, mental agony apart from other monetary loss. It is admitted fact that O.P No. 2 is the Chairman of Reliance Life Insurance Company Pvt. Ltd. He will not be made responsible as he is simply chairman in his legal personal capacity and cannot be held liable or responsible for grievances relating to the complain and so far as O.P No. 4 is concerned he is simply agent and he cannot be held liable when the policy was also admitted issued by O.P No. 1. So far as O.P no. 3 is concerned Medicare TPA Services it is also admitted by O.P No. 1 that he is simply vendor of his company as it is admitted in Annexure C. As such only O.P No.1 is solely responsible for whole loss caused to the complainant. As such the O.P No. 2, 3 & 4 are hereby exempted from their liabilities in this case.
23. From the aforesaid discussion we come to the conclusion that O.P No. 1 Reliance Life Insurance Company Pvt. Ltd. is solely responsible for whole loss suffered by complainant. We therefore,      

      Ordered

         That the O.P No. 1 is hereby directed to pay Principal amount of Rs 35,000/- to the complainant and Rs 1,00,000/- for compensation for unfair trade practices, deficiency and violation of the contract and for harassment and mental agony and cost of litigation of Rs 25,000/-. And it is also further directed to pay 12% interest over the principal amount from the date of filing the case till realization of the money.

                     Thus, this case is disposed off on contest with cost.

                    Office is directed to supply the copy of this order to both the parties free of cost.