West Bengal

South 24 Parganas

CC/88/2015

Mrs. Rita Das Sen Wife of Sri Ranjit Kumar Das. - Complainant(s)

Versus

1. The Oriental Insurance Co. Ltd. - Opp.Party(s)

Md. Meheraj.

15 Dec 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

SOUTH 24 – PARGANAS , AMANTRAN BAZAR, BARUIPUR, KOLKATA-700 0144

 

      C.C. CASE NO. _88_ OF ___2015_

 

DATE OF FILING : 18.2.2015                              DATE OF PASSING JUDGEMENT:  15/12/2016

 

Present                         :   President       :   Udayan Mukhopadhyay

 

                                        Member(s)    :     Sharmi Basu 

                                                                             

COMPLAINANT        :     Mrs. Rita Das (Sen), w/o Sri Ranjit Kumar Das of 1CII-2/2, Thakurpukur Co-operative Society, P.O R.C Thakurani, Kolkata – 104, P.S. Haridevpur, Dist. South 24-Parganas.

 

-VERSUS  -

 

O.P/O.Ps                            :    1.  The Oriental Insurance Co. ltd. A & B Block, 2^nd floor, 212, Rash Behari Avenue, Kolkata – 19, P.S. Gariahat, Dist. S-24PGs.

                                                2.    M/s Vipul Medcorp TPA Pvt. Ltd. 19, R.N Mukherjee Road, Main Building, 1^st floor, Kolkata – 1, P.S. Hare Street.

_______________________________________________________________________

                                                            J  U  D  G  E  M  E  N  T

Udayan Mukhopadhyay, President

This is an application under section 12 of the C.P Act, 1986 filed by the complainant on the allegation that complainant is the insurer to meet the untowards incidents ,if happened, in her life, which is commonly known as mediclaim. It has claimed that complainant entered into an agreement with the O.P-1 through mediclaim Insurance Policy (individual) on 7.5.2014 and has paid premium to the company in terms of the aforesaid policy. It has stated that O.P-2 being the TPA will meet up the expenses if any medical treatment or injury is faced by the complainant in terms of the policy and if TPA failed to provide , then O.P-1 will pay the insured person the said amount towards medical expenses. The mediclaim policy no. is 311604/48/2015/260 which has been commenced on and from 7.5.2014 till the mid-night of 6.5.2015. It has stated that complainant all on a sudden on 25^th June, 2014 had become seriously ill and admitted in the Nursing Home namely Apex Institute of Medical Science at Survey Park for her treatment and after treatment she was released from the Nursing Home and pay the entire amount of her treatment amounting to Rs. 53, 367/- as claimed by the Nursing Home on 4.7.2014 and thereafter complainant claimed the said amount placing all the medical treatment sheet issued by the Nursing Home to the O.P-2 for reimbursement. But the O.P-2 paid a sum of Rs.29000/- through cheque after deducting Rs.24,367/- ,out of the total amount of Rs.53,367/-, which is in contravention to the terms and conditions of the mediclaim insurance policy and complainant met with the O.P-1  stating all the facts , but they did not keep any satisfactory answer, on the contrary they suggested to meet the O.P-2 to solve the problem with them. The O.P-2 did not pay any heed to it,fo which complainant sent a legal notice on 6.9.2014 which was duly served with the O.Ps, but they did not pay any single farthing. Hence, this case for recovery of the remaining amount of Rs.24,367/- towards the medical treatment in terms of the mediclaim policy  and compensation of Rs.10,000/-, litigation cost Rs.5000/-.

 

 

 

 

It appears from the track report that inspite of sending summon the O.Ps did not turn up ,although chances were given .Thus the case is taken up for exparte hearing and heard the complainant who has filed BNA also.

Points for decision in this case is whether there is any deficiency in service or unfair trade practice on the part of the O.Ps or not.

                                                            Decision with reasons

At the very outset it must be stated that prima facie the O.Ps did not come to this bench as they have nothing to say regarding non-payment of remaining amount. We have perused the medical insurance policy and terms and conditions, wherefrom we find that in terms of the payment of claim 5.14A and B it has mentioned that payment of claim shall be made through TPA to the Nursing Home or Hospital in case policy is given through TPA. Clause no.B is not application herein because the policy was obtained through TPA by the complainant and if it was not through TPA ,then insured person will get the amount from the Insurance Company ,herein the O.P-1. In such  circumstances when admittedly out of Rs.53,367/- payment was made by the TPA ,O.P-2 amounting to Rs.29000/-, question of repudiation does not arise and reason for deduction as mentioned in the letter dated 6.8.2014 is that as per eligible PPN package Max. Payable Rs.29000/- with pre and post hospitalization expenses as per S.I for the year 2012-2013. From the individual mediclaim policy schedule it appears that some insured (overall liability ) is Rs.1,75000/-. So, overall sum assured is Rs.1,75,000/- and O.P-1 through TPA has collected premium for the period of 7.5.2014 to the mid-night of 6.5.2015 and complainant suffered within the stipulated period of coverage and the pretty amount of Rs.53,367/- is much less than Rs.1,75,000/- ,sum assured. So, we find no reason for deduction of Rs.24,367/- on the part of the O.Ps.  Moreover, O.Ps did not choose to contest this case voluntarily ,particularly when the notice was served. Chance of filing written version was given but all these opportunities they failed to avail which is the highhandedness of the O.Ps. Accordingly we find that O.Ps acted deficiency of service.

 

Hence,

                                                                        Ordered

 

That the complaint application is allowed  in exparte against all the O.Ps.

Both the O.Ps are directed jointly and/or severally to pay Rs.24,367/- , the remaining cost of medical expenses, to the complainant within 30 days from the date of this order .

Both the O.Ps are further directed jointly and/or severally to pay cost amount of Rs.5000/- to the complainant within 30 days from this date, failing which complainant will get compensation to the tune of Rs.5000/- from the O.Ps jointly and/or severally .

If the O.ps failed to pay the said within the stipulated period, then complainant is entitled to get entire decreetal amount ,cost and compensation and in that even further interest will carry @9% p.a on the total amounts from the date of this order till its realization.

 

 

 

Complainant is at liberty to execute the order through this Forum. 

Let a plain copy of this order be served upon the complainant free of cost and one copy be sent to the O.Ps through speed post.

                                                       Member                                                                President

 

Dictated and corrected by me  

 

                        President

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The judgment in separate sheet is ready and is delivered in open Forum. As it is ,

 

                                                           

Ordered

 

That the complaint application is allowed  in exparte against all the O.Ps.

Both the O.Ps are directed jointly and/or severally to pay Rs.24,367/- , the remaining cost of medical expenses, to the complainant within 30 days from the date of this order .

Both the O.Ps are further directed jointly and/or severally to pay cost amount of Rs.5000/- to the complainant within 30 days from this date, failing which complainant will get compensation to the tune of Rs.5000/- from the O.Ps jointly and/or severally .

If the O.ps failed to pay the said within the stipulated period, then complainant is entitled to get entire decreetal amount ,cost and compensation and in that even further interest will carry @9% p.a on the total amounts from the date of this order till its realization.

Complainant is at liberty to execute the order through this Forum. 

Let a plain copy of this order be served upon the complainant free of cost and one copy be sent to the O.Ps through speed post.

                                                       Member                                                                President