BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM.
KAMRUP
C.C.No.86/2015
Present: I) Shri A.F.A.Bora, M.Sc.,L.L.B., A.J.S -President
II) Smti Archana Deka Lahkar,B.Sc.,L.L.B. -Member
III) Sri Jamatul Islam,B.Sc,Former Dy
Director, FCS & CA - Member
Sri Joydeep Bora - Complainant
S/0 Sri Tulan Ch.Bora
Basostha Chariali, Guwhati-29,
District –Kamrup (M), Assam.
-vs-
I) The oriental Insurance Co.Ltd. - Opposite parties
Represented by its Divisional Manager,
City Division Office,
Mani Ram Dewan Road,
Chandmari, Guwahati,Assam.
II) Raksh TPA Pvt.Ltd.
Represented by its Managing Director,
Escorts Corporate Centre
15/5 Mathura Road, Faridabad , Haryana-1
Pin-121003
III) Raksh TPA Pvt.Ltd.
Represented by its Managing Director,
Prag Plaza Super Market
G.S.Road, Bhangagorh, Guwahati-7
Appearance
Learned advocate Sri Dilip Dey, Sri Tandra Nandi for the complainant .
Learned advocate Ms.Swarnali Shyam Choudhury for the opposite party .
Date of filing written argument:- 5.2.2019
Date of oral argument:- 10.12.2020
Date of judgment: - 29 .12.2020
JUDGMENT
1) This is a complaint petition filed by Sri Joydeep Bora u/s 12 of the Consumer Protection Act, 1986. The brief of the case is that complainant entered into an insurance policy on 20.3.2014 vide policy No. 321300/48/2014/ 3369 for a period from 20.3.2014 to 19.3.2015 on payment of Rs.3,580/- as premium for covering the risk of Rs.2,50,000/- under Oriental Insurance Company Ltd. and renew payment on 19.3.2015 vide policy No. 311300/48/2015/3188 for the period from 19.3.2015 to 19.3.2016 and paid Rs. 4022/- for personal risk cover along with his wife Smti Jahnobi Bhattacharjyya .
2) The fact narrated by the complainant is that his wife Jahnobi Bhattacharjyya suddenly became ill during the month of July, 2015 and was medically check –up at Gauhati Medical College Hospital at Guwahati , but she was taken to Down Town Hospital where her medical examination and treatment were done. The complainant has submitted all the medical papers and bills to the opp.party No.2 for payment, but no payment was made , asking for some more documents on 19.1.2015 in original. That time the wife of the complainant was not cured in Assam and she was taken up to Apollo Hospital, Chennai on 1.9.15 and on the same day she was admitted there and operation was done on 3.9.2015. She was later released from said hospital on 7.9.2015. During the period of treatment at Apollo Hospital the total expenditure was Rs.4,58,694.56/- and as per policy it was reported to the opp.party No. 2 in time along with all relevant documents and claim form in original for payment.
3) It is submitted in the complaint petition that wife of the complainant was examined by Dr. Navaladi Shankar of Apollo Hospital, Chennai and opined that she has no previous record of tuberculosis, but detected spinal tuberculosis.
4) It is alleged in the complaint petition that the complainant made several correspondence for payment against expenditure occurred in Apollo Hospital, but no payment was made by the opp.party No. 1 with the above. The present complaint was filed for passing an order directing the opp.party to make payment to expenditure amounting to Rs. 4,58,694.56/- with an interest @ 18% till realization with the awarded amount.
5) The opp.party No. 1 appeared and contested the proceeding by filing written statement and case proceeded exparte against opp.party No. 2 & 3.
6) The opp. party no-1 contested the proceeding by filing written statement and case proceeded exparte against opp. party no-2 & 3 . The opp. party no-1 stated that the claim is unsustainable and liable to be dismissed U/S-26 of the Consumer Protection Act,1986 . The contesting opp. party further submit that there was a deficiency of service on the part of the opp. party no-2 & 3 . When complainant filed a mediclaim for expenditure of his wife’s treatment and hence it is submitted that complainant have not file any power of attorney and hence complainant has no locus standi in this proceeding.
7) The opp. party have alleged that opp. party no-2 had raised some queries as under on 28/08/2015 from the patient:
a) Treating doctors certificate mentioning history of patients ailment with detail past history clearly specifying durating.
b) Copy of indoor case papers and vital charting
c) Break up of Rs462 / charge on account of refund medicine to hospital dtd 18/08/2015
d) Kindly send cross checked blank cheque and bank details for NEFT.
8) It is alleged that the patient has not given any reply against the query raised except NEFT details. Further in respect of claim no- 556181516137184under policy no- 321300/48/2015/3188 for treatment of Mrs Jahnobi Bhattacharyya at Down Town Hospital, Guwahati from 13/08/2015 to 18/08/2015 opp. party no-2 & 3 received the reimbursement claim on 20/08/2015 and after scrutiny some query was raised and asked for following queries from the patient as indicated above.
9) The contesting opp. party alleged that opp. party no-2 & 3 did not received any reply other than NEFT details and issued reminder on 25/09/2015 & 13/10/2015 & thereafter on 28/10/2015 the file was closed due to non-submission of documents by the patient / complaint.
10) It is again raised by the contesting opp. party that there was a request from the hospital for cashless payment on 03/09/2015 but the opp. party stated that as the diagnosis was not clear and supported by investigation reports queries were raised with the hospital but the reply from the hospital were not confirmative and supported by investigation / evidence and mention the diagnosis as TB/ Spondylodiscitis. Based on the scenario cashless facility was denied by the opp. party no-2 & 3 .On 26/09/2015 opp. party no-2 & 3 received the reimbursement claim for the said treatment but al the documents were in photocopies. As Mr Joydeep Bora , husband of the patient refused to give the originals on 01/10/2015 the opp. party no-2 and 3 raised the following and sent to the complainant:
a) Copy of indoor case papers and vital charting
b) Original discharge summary
c) Original investigation reports of ALL INVESTIGATION DONE DURING HOSPITALIZATION PERIOD FROM dtd.01/09/2015 to dtd. 07/09/2015
d) Original pre-numbered , pre-printed duly signed and stamped final bill of the hospital
e) Original breakup of main hospital bill
f) Photo identity proof for the proposer(passport/pan card/voter identity card/ driving licence/ letter from recognized public authority /letter issued by unique identification authority of india containing details of name , address and aadhaar name.
g) Proof of residence for the proposer: Current passbook with details of residence address/ letter from recognized public authority/ electricity bill/ ration card/ telephone bill/ valid lease agreement along with rent receipt /employer certificate as a proof of residence (please ensure that address proof has same address as mentioned in your policy document)
11) It has been admitted by the opp. party no-1 that opp. party no-2 & 3 received reply from the insured but copy of indoor case paper & vital charting was not received . Thereafter, the opp. party sent two reminder to the complainant but no reply was received from the complainant and finally the claim was closed on 20/11/2015 .
12) After placing on record the above pleadings the opp. party no-1 through his W/S submits that the claim of the patient was never rejected by opp. party no-2 & 3 and still both the claim are closed for non- submission of documents by the claimant inspite of repeated reminder and finally it is claimed by the contesting opp. party that claim couldnot be settled due to non- submission of documents by the claimant.
Reasons for decision:
13) After due consideration of pleadings of the parties in the earlier paragraph we are of the view that following issues are raised and need to be determined.
I) Whether claimant have submitted the claim form along with required documents ?
II) Whether the rejection of the cashless benefit application by the opp.party No. 2 & 3 are justified ?
III) Whether the claim is put on hold for want of original documents if so whether such act is justified ?
IV) Whether claimant is entitled for the claim if so to what extent ?
14) The issues are interrelated and as such issue No. I and II are taken jointly for consideration. We have caredully taken note of Ext. 1 Oriental insurance policy documents. clause 3(13) refers below-
Cashless Facility: The TPA may authorize upon the request of the insured for direct settlement of admissible claim as per agreed charges between Network Hospitals and the TPA/Company. In such cases, the TPA SHALL directly settle all bills of admissible amounts with the Network Hospitals and the insured person may not have to pay such admissible amounts to the Hospital to the extent the claim is covered under the policy.
15) Having regards to the above policy clause we have found from the argument of the parties that opp.party No.1 admitted the fact that opp.party No. 2 & 3 received documents from claimant except one and finally the claim was closed on 20.11.2015. It is further found that opp.party being insurance company adduced evidence of D.W.1 who have exhibited Ext.A and Ext.B which reveals the fact that there is no dispute about illness and treatment of the claimant’s wife and admittedly the claim was not settled for want of documents and was not rejected.
16) In such a situation if we look at clause 3 (13) of the policy and we have found that the TPA shall directly settle all bills of admissible amount with the network hospitals which has not been done in the present case of the complainant i.e. Apollo Hospital of Chennai. The ground on which cashless benefit was rejected is not properly explained and justified as because the witness examined as D.W.1 & D.W.2 has failed to narrate why the claim was rejected by opp.party No. 2 & 3. By submitting appropriate documents in support of such claim made by her in evidence. D.W.1 on behalf of the insurance company however admitted that opp.party No.2 & 3 have not communicated regarding non furnishing of documents by the complainant. That being so we cannot hold any view that the required and important documents were not furnished to the opp.party No.2 & 3 by the complainant .
17) It is further admitted by O.P.W. 1 that they have not directly communicated the complainant about closure of the claim by the company if it is a ground between the claimant and the insurance company then in our considered view that there ought to have direct communication between the insurance company and the claimant about such closure of the claims made by the complainant during the period of his wife’s ailment.
18) Having such evidence of the contesting opp.party we are of the view that if there was a direct communication between opp.party No. 2 & 3 with the complainant then they ought have come forward to contest the proceeding. The Opp.party No. 1 have adduced their evidence to substantiate the fact as alleged by them at the time of closing the mediclaim, but have not examined the opp.party No.2 & 3 for the purpose of corroborating the fact as alleged.
19) On the other side the evidence adduced by the complainant is considered and found that complainant have testified as many as 12 no.s of documents which are in respect of the claim including Ext.1 the original policy cover. The documents on record however found undisputed and there were certain documents from Apollo Hospital , Chennai in the form of discharge summary testified as Ext.5. Ext. 6 is the medical report from Apollo Hospital and Ext.7 testified by the complainant are medical in patient bill which we do not like to go in details as there is no point of disagreement from the parties contesting the proceeding.
20) Here, complainant have filed Ex.8 a confidential letter issued to Apollo Hospital. Ext. 8, Ext.9, Ext.10, Ext.11 are letter issued to the Apollo Hospital, Chennai by the RAksha TPA i.e. op.party No.2.
21) We have also look on Ext.12 the photo copy of medical opinion in respect of the wife of the complainant issued by Apollo Hospital, Chennai. The above documents are not contradicted on any cogent ground. The documents are sufficient proof of having treatment of the wife of the complainant and the network hospital have definitely submitted these documents to the opp.party No. 2 . As such the evidence of the complainant is found in favour of the fact that after submission of sufficient documents including bills the insurance company have not taken due care and their services is deficient in respect of a mediclaim made by the insured at the critical time of ailment and treatment.
22) In our opinion it is the responsibility and duty of the insurance company to make enquiry if any from their side and directly settle all their bills of admissible amount with cashless facility as per clause 3 (13) of the policy which has not been done by the contesting opp.party. In such a situation it is held that issue No. I and II are decided in favour of the complainant .
23) So far issue No. III is concerned we found from the evidence of the claimant that the claim was put on hold by opp.party No. 2 which has not been properly informed to the contesting opp.party No.1 as admitted in the evidence of O.P.W.1, Madhu Chandra Dhar. If such documents were not furnished the non-contesting op.party No. 2 & 3 ought have came forward to substantiate their allegation and to explain what type of documents they required further. This has not been done and as such this issue is decided in negative and in favour of the complainant.
24) If we look into the entire evidence and documents placed on record where from it is found that opp.party No.1 testified Ext.A & B i.e. Ext.A is the copy of the policy and Ext. B is the policy schedule which are not in supporting of any fact to hold a view that ground is not entitled for mediclaim.
25) So far Ext.C , Ext.D , Ext.E, Ext.F, Ext.G, Ext.H, Ext.I, Ext.J are the same set of documents which were testified by the claimant. However , we have not found any deficiency or irregularity in making a mediclaim by the complainant in respect of his policy which was duly renewed by the complainant.
26) As such after going through Ext. A the policy letter at clause 4.1 it is found that there is a clause of condition if the disease was pre-existing , but in our present case opp.party have failed to establish the fact that the claimant had any pre-existing disease. On the contrary complainant have produce a documents i.e. Ext.12 which shows that there was no pre-existing spinal tuberculosis. Hence we do not found any reason to put on hold the claim of the complainant.
27) As such our considered view is that complainant having a party on good faith with the opp.party made his genuine claim along with bill and prescription from Apollo Hospital, Chennai and also claim that he had submitted his claim of hospitalization from Down Town Hospital, Guwahati, but his claim was kept on hold without explaining the reason properly by the opp.party No. 1 .
28) We have look at clause 3.16 of the policy of opp.party No.1 where it has been noted that the amount stated in schedule if entitle for the policy holder the maximum amount of coverage of the complainant was Rs.2,50,000/- and same is payable to the complainant for his insured wife Smti Jahnabi Bhattacharjyya.
29) In the result the issue No. III & IV are decided in favour of the complainant and case is ultimately decreed accordingly.
ORDER
30) The claim is decreed in favour of the claimant Sri Joydeep Bora directing the opp.parties to make the payment of the maximum limit of the policy which is amounting to Rs.2,50,000/-(Rupees two lakhs fifty thousand)only. The complainant is further entitled for compensation for mental agony and trouble during hard days of his wife’s ailment. For the negligence and deficiency of service of the opp.parties compensation is awarded amounting Rs.50,000/- (Rupees fifty thousand) only along with Rs.20,000/-(Rupees twenty thousand) only as cost of proceeding .The entire awarded amount need to pay by the opp.aprties within 45 days from the date of judgement , failing which the opp.parties have to pay an interest @ 12% per annum from the date of judgment till realization. All the opp.parties are jointly and severally liable to make the payment as indicated above.
Given under our hand and seal of the District Forum, Kamrup, this the 29st day of December/2020.
Member Member President
Smt A.D.Lahkar Md J.Islam Shri AFA Bora
