The case of the complainant in a nutshell is that he has availed the Floater Mediclaim policy of The New India Assurance Company Limited bearing No. 51280034212800000102 for the period from 13.05.2021 to 12.06.2022 in continuation from earlier period. It is the further case of the complainant that he had been hospitalized as per medical advice on 17.09.2020 at Woodlands Hospital, Kolkata. After completion of treatment he submitted a claim bearing No. 201200189368 for the cost of treatment and admissible charges along with all relevant documents with the opposite parties. Thereafter, the complainant’s wife furnished all queries raised by the opposite parties vide her letter dated 11.12.2020 and submitted all documents as asked for but the opposite parties did not settle the claim of the complainant. After lapse of four months on 08.06.2021 the complainant seek information under Right to Information Act, 2005 regarding his claim and obtained reply from the opposite parties on 08.09.2021. The opposite parties stated that no queries is pending and the claim has not been concluded. Thereafter on 04.10.2021 the complainant sent an email to the opposite parties settling his claim but to no effect. According to the complainant the opposite parties is negligent and liable for deficiency of service for which the complainant had to suffer immensely.
By filing Written Version the opposite parties denies and dispute the allegation made in the complaint. The opposite parties state that the complainant has not submitted the required documents which were essential for settlement of the claim. The claim of the complainant was with regard to policy being No. 512800342028000000 availed from 08.05.2020 to 07.05.2021 for hospitalization of the complainant who was admitted on 17.09.2020 and discharged on 20.09.2020 from Woodlands Hospital, Kolkata. It is further stated that the TPA is an independent statutory party to settle the mediclaim policy in accordance with the provisions of Regulation 33 of Insurance Regulatory and Development Authority of India (Health Insurance) Regulations 2016. The TPA calculated the payable amount of Rs.48,850/- (Rupees Forty Eight Thousand Eight Hundred Fifty) only but there has been an inadvertent mistake on the part of TPA while calculating the claim amount under ICU bed charges etc., for which the complainant is entitled to get Rs.2,000/- (Rupees Two Thousand) only more. In the mean time on 21.12.2021 the opposite parties disbursed a sum of Rs.48,850/- (Rupees Forty Eight Thousand Eight Hundred Fifty) only in favour of the complainant by NEFT. Therefore, Rs.2,000/- (Rupees Two Thousand) only is payable by the opposite parties.
Points for decision:
- Is the case maintainable in law and in its present form?
- Has the complainant any cause of action to file the case?
- Is the complainant entitled to any relief as prayed for?
- To what other relief or relieves the complainant is entitled to?
Decision with reasons:
Point Nos. 1 & 2
For the sake of brevity and convenience both the points are taken up together for consideration and discussion. At the time of argument the Ld. Advocate for the opposite parties did not utter a single sentence against the above two points.
On scrutiny of material on record and evidence of the complainant, we find that the complainant is a consumer and the opposite parties are service provider in terms of the Consumer Protection Act, 2019. Moreover, it appears that in spite of all the queries of the opposite parties were met by the complainant, the opposite parties have not settled the claim till filing of the case.
Therefore, we are of the opinion that the case is maintainable in law and in its present form.
Thus point nos. 1 & 2 are decided in favour of the complainant.
Point Nos. 3 & 4
For the sake of brevity and convenience both the points are taken up together for consideration and discussion.
It is admitted fact that the complainant had mediclaim policy during the period of his admission in Woodlands Hospital on 17.09.2020 and discharged on 20.09.2020. It also admitted fact that the complainant has submitted his claim along with documents with the opposite parties and also answered the queries raised by the TPA. It is further admitted fact that in reply to the questions of the complainant under Right to Information Act, the opposite parties disclosed that all the queries were addressed by the complainant and still the claim was pending. During pendency of the instant case a sum of Rs.48,850/- (Rupees Forty Eight Thousand Eight Hundred Fifty) only was paid by the opposite parties to the complainant.
The detail computation of the claim amount has been disclosed by the opposite parties in affidavit in chief which remained unchallenged and un-rebutted by the complainant. In course of argument Ld. Advocate for the opposite parties admitted that Rs.2,000/- (Rupees Two Thousand) only is still payable by the opposite parties in favour of the complainant.
From the evidence of opposite parties, it is crystal clear that though the complainant answered all the queries of the opposite parties and TPA and submitted all relevant documents but the opposite parties have not settled the claim of the complainant. The complainant being harassed, was compelled to file the case against the opposite parties for settlement of the claim which is certainly deficiency in service by the opposite parties which caused harassment to the complainant.
Therefore, the complainant is entitled to compensation in this case.
In light of the observation made above, we are of the opinion that both point nos. 3 & 4 are decided in favour of the complainant.
Thus the complaint case succeeds.
Hence, it is
O R D E R E D
- that the opposite party shall pay an amount of Rs.2,000/- (Rupees two thousand) only along with simple interest of 8% from the date of filing of the complaint case till the date of payment.
- the opposite party shall pay a sum of Rs.10,000/- (Rupees ten thousand) only to the complainant for mental agony, harassment and compensation and shall pay a sum of Rs.2,000/- (Rupees two thousand) only as litigation cost within one month from this day i.d. to pay simple interest @18% per annum on the total amount from the date of filing of the case till payment.
