IN THE COURT OF THE LD. DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT S I L I G U R I.
CONSUMER CASE NO. : 81/S/2013. DATED :29.09.2016.
BEFORE PRESIDENT : SRI BISWANATH DE,
President, D.C.D.R.F., Siliguri.
MEMBERS : SMT. PTATITI BHATTACHARYYA &
SRI PABITRA MAZUMDAR.
COMPLAINANT : SRI BAPI DEY,
S/O Late Hiralal Dey,
Resident of C/O – M/s Maa Manaskamana,
Goshto Paul Sarani, Hakimpara,
P.O. & P.S- Siliguri, Dist.- Darjeeling,
PIN – 734 001.
O.Ps. 1. : ORIENTAL INSURANCE CO. LTD.,
CBO –I, Malhotra Tower,
Pradhan Nagar, Hill Cart Road, Siliguri – 734 003.
2. : THE BRANCH MANAGER,
Oriental Insurance Co. Ltd.,
CBO –I, Malhotra Tower,
Pradhan Nagar, Hill Cart Road, Siliguri – 734 003.
3. : MD INDIA HEALTHCARE SERVICES (TPA) PVT.
LTD.,
S.No.46/1, E-Space,
A2 Building, 3rd Floor,
Pune Nagar Rd., Vadgaonsheri,
Pune – 411 014, Maharashtra.
4. : MD INDIA HEALTHCARE SERVICES (TPA) PVT.
LTD.,
169, Sarat Bose Road, 3rd Floor,
Kolkata – 700 026.
FOR THE COMPLAINANT : Sri Milindo Paul, Advocate.
FOR THE OP Nos. 1 & 2 : Sri Bhaskar Maitra, Advocate.
J U D G E M E N T
Sri Biswanath De, Ld. President.
The complainant’s case in brief is that he took a mediclaim policy from OP No.1, which was valid for the period from 22.11.2010 to 21.11.2011, and the complainant paid the proper premium for the policy. In March, 2011 the complainant was afflicted with severe pain in the abdomen, and he consulted Dr. Amal Basak on 07.03.2011, and he was diagnosed as suffering from
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‘Slip-disc’, and he was advised to undergo surgery. The complainant informed the OP Nos.1 & 2 about the matter on 08.06.2011. Since the problem aggravated the complainant was admitted at a nursing home in Siliguri on 23.06.2011, and though he informed the OP Nos.1 & 2 about the matter yet, he was not given any cashless benefit. On 29.06.2011 the complainant again informed OP Nos.1 & 2, and prayed for cashless settlement of his treatment expenses, but the OP Nos.1 & 2 did not respond. The complainant underwent further hospitalization, but still he did not obtain any cashless settlement. He lodged reimbursement claim to OP No.1 with all the medical documents, but alas to no avail. At last in the month of December, 2011, the OP No.1 paid the complainant a much smaller sum than he was entitled to. The complainant protested about the matter to OP No.1, but to no avail, and even ld advocate’s notice to OP No.2 was fruitless. The complainant thus filed this case praying that the OPs be directed to pay him Rs.11,719/- being the amount that he is still entitled to from the OPs, and he prays for some other reliefs as well.
OP Nos.1 & 2 appeared and contested the case by filing written version denying inter-alia all the material allegations as raised by the complainant. It is positive case of the OP Nos.1 & 2 that claim of the complainant has been paid on 14.12.2011 vide para 13 of written version. The complainant took the A/C payee cheque on 20.12.2012 and also signed discharge voucher at the time of payment/claim. The complainant did not raise any objection or received the claim cheque without objection. The details amount deducted for the claim of the complainant has been clearly mentioned in the claim payment statement, complainant received a/c payee cheque on 20.12.2011 without objection. Xerox copy of claim payment statement has been annexed as annexure-A and Xerox copy of claim discharge voucher has been annexed as Annexure-B. So, the claim of complainant regarding non-settlement of Rs.11,719/- does not arise at all.
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. Copy of Mediclaim Insurance Policy.
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2. Copy of TPA Guide Book showing enlistment of Sunrise Nursing Home Pvt. Ltd.
3. Copy of Mediclaim Identity Card.
4. Copy of application dated 06.06.2011.
5. Copy of applications dated 17.06.2011, 29.06.2011, 07.07.2011 and 21.12.2011.
6. Copy of request letter issued by Sunrise Nursing Home Pvt. Ltd. along with prescriptions and Doctor’s certificate
7. Copy of denial letter.
8. Copy of Mediclaim policy claim form.
9. Copy of application dated 11.11.2011 sent to Grievance cell in regard to delay in settlement of claim.
10. Copy of notice dated 28.11.2011 along with postal receipt and acknowledgement.
11. Copy of reminder notice dated 16.12.2011 along with enclosure and postal receipts.
OP Nos.1 & 2 has filed two Xerox copy of Claims Payment Statement marked as Annexure-‘A’ & Annexure ‘B’.
Complainant has filed examination-in-chief by affidavit.
Complainant has filed written notes of Argument.
OP Nos.1 & 2 has filed evidence-in-chief.
OP Nos.1 & 2 has filed written notes of Argument.
Decision with reason.
All the issues are taken up together for the brevity and convenience of discussion.
From the complaint and the written version which is self explanatory shows that at first complainant claimed Rs.39,273/- before OP Nos.1 & 2 for incurring expenses for treatment in the Nursing Home. The OP Nos.1 & 2 after considering the claim paid the complainant a sum of Rs.27554/- after deducting Rs.11,719/-. Annexure A & B shows and supports the contention that complainant received the amount stated hereinbefore without any objection in spite of having less amount. Accordingly, as per case of complainant and point of dispute of OP Nos.1 & 2, it appears that claim has been settled by both sides. Complainant received an amount without any
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objection. So, he cannot be allowed to raise further claim as per complaint as the matter has been settled down. There is no chance of reopen the matter.
Accordingly, after considering the case of both side and documents therein, we are of opinion that the complainant has no case at this time. As such the case fails.
Hence, it is
O R D E R E D
that the Consumer Case No.81/S/2013 is dismissed on contest against the OP Nos.1 & 2 exparte dismissed against the OP Nos.3 & 4, but without any cost.
Copies of this judgment be supplied to the parties free of cost.
