Aloke Chakrabarti, President - (1.) COMPLAINANT through Mr. Jayanta Dasgupta, the learned Advocate and O.P. Nos. 1 and 2 through Mr. G.P. Dey, the learned Advocates are present. The complainant filed the complaint case contending that Complainant -Hospital, as welfare measure to extend medical support to its employees and to mitigate medical expenses, entered into contract with O.P. No. 1 -Insurance Company for having Mediclaim Policy for the employees of the complainant. From time -to -time Group Mediclaim Policy for one year on each occasion, had been renewed for the staff of Group 'D' category and such Policy is called Tailormade Group Mediclaim Policy. During the policy period 2007 -2008 from 28.2.2008 till 27.2.2009 in terms of memorandum of understanding met between the complainant and the Insurance Company, claim was submitted in respect of insured member within the scope of the same memorandum of understanding firstly on 18.7.2009 and thereafter on several dates for a claim totalling to Rs. 25,72,488. When the claim amount was not being released in spite of repeated follow -up by the complainant, correspondences were exchanged. Under the terms of Agreement the O.P. No. 3, appointed by the O.P. No. 1 as Third Party Administrator (TPA) was to settle the claim of the Policy Holder. The O.P. No. 3 being the TPA by its letter dated 28.8.2008 addressed to this Commission, disclosed that the claim had been lodged with them as mentioned by the complainant but it could not be processed as they did not receive the Policy copy from the insurer. The O.P. No. 3 explained the same as the only reason for delay. In the proceeding the O.P. No. 3 contested only by filing the said letter.
(2.) COMPLAINANT in its complaint stated in Paragraph 7 the relevant facts as follows: "Your petitioner hospital states that despite repeated follow up, persuasion by the management of the hospital opposite parties have failed and neglected to settle the claims and to make payment against such claims to your petitioner hospital as per the terms of understanding and have committed breach of condition of policy. It is further stated that at the time of execution of the said agreement the officers and agents of the opposite party company assured that comprehensive policy document would be furnished to the complainant upon payment of agreed amount of premium as a matter their system to enable to the petitioner to examine further the conditions and benefits under the policy, yet no such policy was at all furnished to the complainant though it hired the service of insurance coverage from the opposite party company."
(3.) O .P. No. 1 in its objection dealt with the same contention of the complainant in Paragraph 10 as follows "That with reference to paragraphs Nos. 6 and 7, it is stated that the allegations made thereto are not true picture and rather there exists several material suppression." O.P. No. 1 in Paragraph 11 of its Written Version stated as follows : "That with reference to paragraph No. 8, it is stated that the O.P. No. 3 by filing their W.S. on 16.9.2008 admitted that "...... But we cannot process any claim until and unless we receive the policy copy....." Thus it is apparent to settle the claim from the side of the complainant, there exists various lacunas on their own part and thus the answering opposite party No. 1 is not liable for the deficiency of service whatsoever and howsoever. The Annexure 'A' shall explicit on this point which bring a letter of Sr. Divisional Manager 11.11.2008." The complainant made prayer for direction upon the O.P. to release the claim amount of Rs. 25,72,488 in favour of the complainant, direction to O.Ps. to pay the complainant Rs. 50,000 as compensation and Rs. 3,00,000 towards interest. After the Written Version was filed by the O.P. No. 1 and letter dated 28.8.2008 was filed by the O.P. No. 3 and evidence on Affidavit, questionnaire and reply were filed by both parties and Brief Notes of Argument were also filed matter was taken up for hearing. Heard Mr. Dasgupta in support of the Complainant and Mr. Dey on behalf of O.P. Nos. 1 and 2.;