1. This is a petition filed U/S 12 of the consumer Protection Act, 1986 praying for recovery of money, compensation and other reliefs. The petition is filed by the one Naba Kr. Tamuli (hereinafter referred to as the petitioner/complainant) against National Insurance Company Limited and 2 (Two) Others ( hereinafter referred to as the opposite parties).
2. The petitioner’s case in brief is that the petitioner- Naba Kr. Tamuli is a policy holder of Mediclaim Policy bearing No.200203/48/12/8500000001 with card No.11308120000045 A with the National Insurance Company Limited which he started since 2009 and continued till his date of filing the petition. Further case of the complainant is that in the on last 04/02/2013 he had undergone CABG operation for his heart ailment at Narayana Hridayalay Hospital, Bangalore and prior to his operation, he had informed the same at E-Maditak, Gurgaon on 01.02.2013 and also registered his claim vide claim No.113021300005 before the opposite party No.3. He stated that after his discharge from the Hospital, he lodged his claim of Rs.2,09,894.00 which he spent for his medical treatment along with all relevant medical bills, vouchers, discharge certificate, investigation report etc. but even after elapse of one year from submitting his claim, the opposite parties neglected to settle his claim and on April offered a verbal proposal to the complainant /petitioner to settle his claim at Rs.43,500/-towards full and final settlement which is not acceptable to him. The complainant further submits that he has every right to treat him by a competent doctor and at proper hospital and the opposite parties have no right to force him to avail treatment at their choice. He submits that he being a heart patient and undergoing operation suffered much tension due to the negligent act of the opposite parties which is detrimental to his health and thus, the opposite parties committed deficiency in service. Hence, this claim petition is before this commission praying for reliefs.
3. The opposite parties filed written version denying all the allegation levelled against them by the petitioner/complainant. By their written version opposite parties took the pleas that the claim of the petitioner/complainant does not attract the provision of section 12 of the Consumer Protection Act, that the petition is bad for concealing material particulars and the opposite parties having offered Rs.43,500.00 to settle the claim of the petitioner/complainant, there was no deficiency of service on their part .towards the petitioner/complainant. The opposite parties stated that the petitioner/complainant is the policy holder of Mediclaim policy with the National Insurance Company Limited with effect from 06.04.2012 for 12 months i.e. up to 05.04.2013 and the sum assured was Rs.75,000.00. The opposite parties also stated that they entrusted E-Meditak TPA service Limited as their tie up with the company regarding assessment of Mediclaim and said agency after assessment of the relevant documents submitted by the complainant approved for payment of Rs.23,321.00 which was offered to the complainant but he was not satisfied with the offered amount, thereafter due to persistent insistent of the complainant, the offered amount was enhanced to Rs.43,500.00 and cheque for the amount was tendered to the complainant but he did not accept the same. The opposite parties stated that the earlier policy in question was for Rs.75,000.00 which was valid from 06.04.02012 to 05.04.2013 and complainant already received Rs.20,179.00 against his claim, and the present claim, for the same policy was settled at Rs.43,500.00. The opposite parties stated that the complainant had preferred two claims at two different time against the same policy within validity period of one year and hence, there cannot be any question of settlement of Mediclaim beyond the sum assured. The opposite parties further stated that as the complainant had already availed Rs.20,179.00 and the present offer is for Rs.43,500.00, the total amount comes to Rs.63,179.00 for the said policy and as per policy Clause No.7.1, 10% shall be reduced from claim insured, hence, claim of Rs.2,09,000.00 is quite absurd and beyond the policy under reference. Under the above premises, the opposite parties pray for dismissal of the claim petition.
4. Upon pleadings of parties the following points have been come out for discussion and decision.
1. Whether the opposite parties negligently refused to settle the Mediclaim of the petitioner/complainant by not offering Rs.2,09,894.00 which he incurred for his medical treatment from heart ailment and thus, the act of the opposite parties amounts to deficiency in service.
2. Whether the petitioner/complainant is entitled to the relief as prayed.
5. Both parties adduced evidence of one witness each and exhibited several documents in support of oral evidence. Witnesses were cross examined by the opponents.
- Written argument from both side filed and perused.
7. Findings and reasons thereof:-
For the sake of convenience both the points are taken together for discussion and decision.
The portioner/complainant claimed that he incurred Rs.2,09,894.00 for undergoing heart surgery at Narayan Hridalaya, Bangalore and when he submitted his claim before opposite parties with whom he opened a Mediclaim policy, they refused to pay him the cost of his medical treatment which he spent and offered him only Rs.43,500.00 as full and final settlement of his claim and such conduct on the part of opposite parties amount to deficiency in service. On the other hand, opposite parties claimed that there was no deficiency of service on their part as they already paid Rs.20,179.00 to the complainant and offered another amount of Rs.43,500.00 in as much as the assured same of the Mediclaim policy of the complainant was Rs.75,000.00 for the relevant year.
In support of his claim the petitioner/complainant as P.W.1 adduced evidence to the effect that he opened a Mediclaim policy with the National Insurance Company Limited since 2009 and continued till date of his evidence which was renewed yearly. His further evidence is that a last 04.02.2013 he had undergone CABG operation for his heart ailment at Narayan Hridalaya Hospital Bangalore and spent money of Rs.2,09,894.00 for his treatment. He deposed further that prior to the operation, he informed the matter to Meditak, Gurgaon on 01.02.2013 and after discharge from Hospital lodged his claim before the opposite parties along with all relevant medicals bills, vouchers, discharge certificate and investigation report along with details of his medical expenditure. Further evidence of the P.W.1 is that after elapsing one year from submitting his claim, the opposite parties neglected to settle his claim and on the month of April, 2014, they offered a verbal proposal to him intending to settle his claim at Rs.43,500.00 towards full and final settlement. The P.W1 also deposed that he has every right to treat by a competent doctor and at a proper Hospital and the opposite parties has no right to force him to treat at their choice. In support of his oral evidence the P.W.1 exhibited the Mediclaim policy as Ext.1, Insurance payment receipt from the year 2009 to 2013 as Ext.2 ,3, 4, 5 and 6.
The opposite parties examined one Sri Amritraj Baruah, Branch Manager, National Insurance Co Ltd. as D.W.1. This witness deposed that the complainant is a policy holder of a medical policy with the National Insurance Co Ltd. with effect from 06.04.2012 to 05.04.2013 and the sum assured was Rs.75,000.00 for that period. He further deposed that they entrusted Emiditak TPA Service Limited regarding assessment of Mediclaim policy of the petitioner/complainant and after assessment of the relevant documents submitted by him, the said agency approved payment of Rs.23,321.00 and thereafter, due to persistent insistent of the petitioner/complainant, the offered amount was enhanced up to Rs.43,500.00 but the petitioner/complainant not being satisfied with that amount did not accept the same. This witness also deposed that the earlier policy in question was for assured sum of Rs.75,000.00 which was valid from 06.04.2012 to 05.04.2013 and petitioner/complainant already received Rs.20,179.00 against his claim and the present claim, for the same policy was settled at Rs.43,000.00. This D.W. further adduced evidence that the petitioner/complainant preferred two claims for the same policy within a period of one year and hence, there cannot be any question of settlement of Mediclaim beyond the sum assured. The D.W.1 also adduced further evidence that as the petitioner/complainant had already availed Rs.20,179.00 and the present offer is for Rs.43,500.00, the total amount comes for the claim is Rs.63,179.00 and as per policy Clause No.7.1, 10% shall be reduced from claim insured, hence claim of Rs.2,09,000.00 is quite, absurd and beyond the policy under reference. This witness exhibited the relevant policy copy under Ext.A, claim possessing with Emeditak TPA service Ltd. under Ext.B, letter dated 09.01.2013 under Ext.C and Assessment by Emeditak as Ext.D.
The opposite parties by their written version and evidence claimed that the policy coverage of the petitioner/complainant was from 06-04-2012 to 05-04-2013 and the sum assured during that period was Rs.75,000/-. The complainant/petitioner side did not dispute such facts anywhere in the record. The claim of the petitioner/complainant is that he spend Rs.2,09,894.00 for his treatment and such fact is also not disputed by the opposite parties. The opposite parties in their written version and evidence claimed that the petitioner/complainant already received Rs.20,179/- for the said Mediclaim policy which the complainant/petitioner denied and the opposite parties failed to produce any document to prove such facts. Hence, we are unable to accept the contention of the opposite parties that the petitioner/complainant already received Rs.20,179/- for the said Mediclaim policy. The D.W.1 in his cross examination admitted the fact that the complainant/petitioner initiated the said Mediclaim policy since the year 2009 and continued till 2015 and if there was no claim in every year, then the policy holder is entitled to extended bonus of 5%. As there is no evidence that the petitioner/complainant has received any bonus since 2009 to 2012 for his Mediclaim policy, hence, he is entitled to bonus of 5% of the assured sum since 2009 to 2012. The opposite parties also pleaded and adduced evidence that as per policy clause7.1, 10% shall be reduced from the assured sum and such fact is not disputed by the petitioner/complainant. Thus, from the above discussion, it is found and held that the petitioner/complainant is entitled to receive 5% bonus from 2009 to 2012 on the assured sum together with the amount after deducting 10% of the assured sum for the period from 06-04-2012 to 05-04-2013 and the opposite parties by not offering the said amount to the petitioner/complainant against his claim had committed deficiency in service. In result both the points for discussion and decision are answered in affirmative and go in favour of the complainant.
O R D E R
9. In view of the above discussion, it is found that the complainant has succeeded to prove that there was a deficiency of service on the part of opposite parties.
Accordingly, the prayer made by the complainant U/S 12 of the Consumer protection is allowed on contest. Issue direction to the opposite parties to pay the complainant 5% bonus from 2009 to 2012 on the assured sum together with the amount after deducting 10% of the assured amount for the period from 06-04-2012 to 05-04-2013 along with compensation of Rs.30,000/-(Rupees Thirty Thousands) only with interest @ 12 per annum from the date of order till payment.
Inform all the parties concern.
Given under the hand and seal of this Commission, we signed and delivered this Judgment on this 4th Day of May 2021.
