IN THE COURT OF THE LD. DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT S I L I G U R I.
CONSUMER CASE NO. : 69/S/2012. DATED : 18.01.2016.
BEFORE PRESIDENT : SRI BISWANATH DE,
President, D.C.D.R.F., Siliguri.
MEMBERS : SMT. PRATITI BHATTACHARYYA AND
SRI PABITRA MAJUMDAR.
COMPLAINANT : MRS. PIYA CHAKRABORTY,
W/O Sri Arun Kumar Chakraborty,
R/O Stalin Nagar - 2,
Panighata Road, Upper Bagdogra,
P.O. & P.S.- Bagdogra, Dist.- Darjeeling.
O.Ps. 1. : BAJAJ ALLIANZ LIFE INSURANCE CO. LTD.,
A Company registered under the Companies Act,
1956, having its Registered office at GE Plaza,
Airport Road, Yerawada, Pune – 411 006 and
Having its Branch office at ‘Kulsum Complex’,
1st Floor, Station More, Bagdogra,
P.O. & P.S.- Bagdogra, Dist.- Darjeeling.
2. : THE BRANCH MANAGER,
Bajaj Allianz Life Insurance Co. Ltd.,
having his office at ‘Kulsum Complex’,
1st Floor, Station More, Bagdogra,
P.O. & P.S.- Bagdogra, Dist.- Darjeeling.
3. : MEDICA NORTH BENGAL CLINIC,
North Bengal Clinic Pvt. Ltd.,
A company registered under the Companies Act,
1956, having its office at Meghnath Saha Sarani,
P.O. & P.S.- Pradhan Nagar, Dist.- Darjeeling.
FOR THE COMPLAINANT : Sri Rathin Sarkar, Advocate.
FOR THE OP Nos. 1 & 2 : Sri Minindo Paul, advocate.
J U D G E M E N T
Sri Biswanath De, Ld. President.
The complainant’s case is that the complainant insured herself with the OP No.1 under the brand name of Bajaj Allianz Care Fast Policy being Policy
Contd…….P/2
-:2:-
No.0165111828. After making payment of Rs.3,585/- only as premium, as per terms & conditions of Bajaj Allianz Policy. The policy commenced on 14.04.2010 and covered the risk insured from 14.04.10 to 14.04.2013. Total sum assured is Rs.1,50,000/-. The OP Nos. 1 & 2 hereinafter will be mentioned as OP and issued policy schedule cum policy certificate along with the terms & conditions to the complainant. Regular premium has been paid under renewal premium receipt. There was one talking of cashless service facility from some specified hospitals for cashless benefit being ID Card No.BAL016511828. On 11.05.2012 complainant felt abdomen pain and she was treated in Siliguri Hospital. The matter was intimated to the OPs. The doctor treated the patient as per treatment protocol with laparoscopic operation for removing gall bladder stone. The complainant was admitted till 20.05.2012. The complainant found total bill was calculated at Rs.68,189.90/- out of which only a sum of Rs.23,783/- has been adjusted by the OP Nos.1 & 2 and rests sum of Rs.44,407/- has been demanded from the complainant (vide para-10). As the complainant is entitled to get absolutely cashless benefit for the said operation, which was denied by the OPs, accordingly, complainant paid Rs.44,407/- for her release. But as per policy OP Nos.1 & 2 are bound to pay that sum to OP No.3 which has been demanded from the complainant. The complainant thereafter issued legal notice to the OP No.1 & 2, but the same was not paid. Accordingly, finding no alternative, the complainant woman has approached before this Forum for redress as per provision of Consumer Protection Act, 1986, Section 14. The complainant has also prayed other reliefs for mental pain, agony and harassment for some punitive damages, for some litigation cost.
OP No.3 filed written version denying inter-alia all the material allegations as raised by the complainant. The positive version of OPs is that complainant was treated by OP No.3 and there was a policy. It is admitted that total cost was Rs.68,189/-. But OP Nos.1 & 2 paid Rs.23,783/- only. On enquiry it appeared that balance amount of Rs.44,407/- would be paid by the patient party. The complainant therefore prayed the balance sum of Rs.44,407/-. There is no illegal demand by the OP No.3. The OP No.3 prays for dismissal of the case against OP No.3.
Contd…….P/3
-:3:-
OP Nos.1 & 2 filed written version denying inter-alia all the material allegations as raised by the complainant. The OP Nos.1 & 2 admitted that total bill was Rs.68,190/-. But The OP Nos.1 & 2 did not consider some amount of bill as per page 4 of 9. After computation as stated by OP Nos.1 & 2 the total admitted cost is stands at Rs.49,585/-.
The OP Nos.1 & 2 further stated that total liability have been fixed at Rs.44,627/- because Rs.4,958.58/- has been deducted showing calculation in para-E at page 5. It is again stated that for the first time the Company OP Nos.1 & 2 paid Rs.23,783/- and rest of Rs.20,864/- has been paid to the complainant Piya Chakraborty by two cheques of Rs.5,437/- and Rs.15,424/- vide cheque no.181081 dated 21.12.2012 and cheque no.182062 dated 16.01.2013. As such the Respondent Company has no liability to pay towards the complainant. But the said cheque has been paid after filing this case and said two cheques submitted by OP Nos.1 & 2 has not been encashed and placed in record.
Points for decision
1. Whether there is deficiency in service on the part of the OPs ?
2. Whether the complainant is entitled to get the relief as prayed for ?
Complainant has filed the following documents :-
1. Original copy of the Policy along with terms & conditions.
2. Original copy of the two cheques being dated 21.12.2012 being No.181081 411211003 073495 29, other dated no.16.01.2013 being No.182067 411211003 073495 29.
Complainant has filed examination-in-chief by affidavit.
Complainant has filed written notes of Argument.
OPs have filed evidence-in-chief.
OPs have filed written notes of Argument.
Decision with reason.
All the issues are taken up together for the brevity and convenience of discussion.
Contd…….P/4
-:4:-
The treatment of the complainant is admitted by the OPs.
The existence of Health Insurance Policy is also admitted.
The total cost as calculated as Rs.68,189.90/-.
OP Nos.1 & 2 paid Rs.23,783/- and rest Rs.44,407/- has been paid by the complainant to the OP No.3.
The complainant filed this case to recovery this amount along with other compensation.
The OP Nos.1 & 2 in fact made part payment. But reason of not payment on earlier occasion has not been explained, rather during the continuation of case, the OP Nos.1 & 2 have sent two cheques of Rs.5,437/- and Rs.15,427/-. The complainant did not encash those cheques. The OP NOs.1 & 2 has stated some reasons for less amount of payment. In page 6 the OP Nos.1 & 2 has stated the reason. But those reasons find no place in the terms and conditions of Insurance Policy, which have been placed by this complainant before this Forum for observation. Moreover, in the Policy Book addressed to Mrs. Piya Chakraborty, W/o Arun Kumar Chakraborty, Stalin Nagar 2, Bagdogra, Panighata Road, Dist.- Darjeeling, State – West Bengal, Pincode – 734 014, INDIA, Tel. No.- 99337 66159. This Policy document had been issued by Bajaj Life Insurance Co. Ltd. All the terms and conditions regarding payment of maturity benefit, basic sum assured, date of commencement of risk, death of birth of policy holder, other information has been embodied in the second page of the policy. This policy is construed itself. No outside element should be brought for giving interpretation of this self contained Insurance Book. Page 9 of 20 caption 4) runs follows :- “In a Policy Year, Our total liability under this Policy is limited to the Sum Assured, without making any reference to what We reimbursed or are liable to reimburse for the claims made in the previous Policy Year.”
The reason of less deduction as argued by the ld advocate of the OP No.1 & 2 finds no place in this self contained Bajaj Allianz Insurance Book. In absence of written embodiment of less amount as argued by the OPs is not acceptable. The OP Nos.1 & 2 is bound to give full amount as per expressed provision in the Insurance Policy. The total cost bourn by the complainant
Contd…….P/5
-:5:-
Piya Chakraborty shall be paid the OP Nos.1 & 2. Of course, the OP Nos.1 & 2 shall be bound to make payment of rest amount i.e. Rs.(68,189.90 – 23,783.00) = 44,407/- (rounded off) to the complainant. As OP Nos.1 & 2 has paid Rs.23,783/- to the OP No.3 for cost of treatment of complainant.
Therefore, after going through the claim of the complainant, and averment of OPs, this Forum is of opinion that complainant is entitled to get the cost of treatment from OP Nos.1 & 2, which has not been paid by the OP No.1 & 2 and amount that Rs.44,407/-.
The complainant along with the claim of cost, has also prayed for compensation for mental pain, agony, harassment and punitive damages.
The complainant ought to have been paid by OP No.1 & 2 as soon as the complainant had been discharged from the hospital, but the OP Nos.1 & 2 with the help of self interpretation of policy, did not pay the total cost for treatment in spite of contract in the Insurance Policy.
The complainant has come before the Forum on 23.07.2012.
The OP Nos.1 & 2 appeared, but did not solve the legal claim of complainant, resulting mental pain, agony and harassment of complainant. The self contained Insurance Policy itself shows that OP Nos.1 & 2 is liable for deficiency in service. The act and conduct of OP Nos.1 & 2 is itself a proof of deficiency in service i.e., res ipsa liquitor which means that the act is sufficient proof of negligence and deficiency in service. Section 14 of the C.P. Act, empower this Forum to make adequate compensation to the aggrieved consumers.
On the premise above, the material on record, in inspires confidence in the mind of Forum that the lady complainant is entitled to get Rs.20,000/- for compensation towards mental, pain, agony and harassment.
The complainant is further entitled to get Rs.10,000/- towards punitive damages.
The complainant is further entitled to get Rs.10,000/- for cost of litigation.
The complainant is further entitled to get 9 % interest on the awarded sum from the date of filing of this case till full payment.
In the result, the case succeeds.
Contd…….P/6
-:6:-
Hence, it is
O R D E R E D
that the Consumer Case No. 69/S/2012 is allowed on contest against the OP Nos.1 & 2 and dismissed ex-parte against the OP No.3.
The complainant is entitled to get Rs.44,407/- for the rest amount of her treatment from the OP Nos.1 & 2/Bajaj Allianz Life Insurance Co. Ltd.
The complainant is further entitled to get Rs.10,000/- towards compensation for mental pain, agony and harassment caused by the OP Nos.1 & 2/ Bajaj Allianz Life Insurance Co. Ltd.
The complainant is further entitled to get Rs.10,000/- on account of her punitive damages from OP No.1 & 2.
The complainant is further entitled to get Rs.10,000/- towards litigation cost from the OP Nos.1 & 2.
The complainant is further entitled to get 9 % interest on the awarded sum of Rs.64,407/- from the OP Nos.1 & 2 from the date of filing of this case till full payment.
The OP Nos.1 & 2, who are jointly and severally liable, are directed to pay Rs.44,407/- for the rest amount of treatment by issuing an account payee cheque in the name of the complainant within 45 days of this order.
The OP Nos.1 & 2, who are jointly and severally liable, are directed to pay Rs.10,000/- by issuing an account payee cheque in the name of the complainant for mental pain, agony and harassment within 45 days of this order.
OP Nos.1 & 2, who are jointly and severally liable, are further directed to pay Rs.10,000/- by issuing an account payee cheque in the name of the complainant towards her punitive damages within 45 days of this order.
OP Nos.1 & 2, who are jointly and severally liable, are further directed to pay Rs.10,000/- by issuing an account payee cheque in the name of the complainant towards litigation cost within 45 days of this order.
OP Nos.1 & 2, who are jointly and severally liable, are further directed to pay 9 % interest on the awarded sum of Rs.64,407/- to the complainant from the date of filing of this case till full payment.
Contd…….P/7
-:7:-
In case of default of payment, the complainant is entitled to get interest @ 9% per annum on the awarded sum of Rs.64,407/- from the date of filing of this case till full realization.
In case of default, the complainant is at liberty to execute this order through this Forum as per law.
Copies of this judgment be supplied to the parties free of cost.
-Member- -Member- -President-
