THE PRESIDENT

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA : AGARTALA

 

 

CASE No. CC- 87  of  2018

 

Smti. Namita Paul,

W/O- Sri Swapan Kumar Paul,

Banamalipur, Agartala, West Tripura. …...................Complainant.

 

 

-VERSUS-

 

1. Apollo Munich Health Insurance,

Represented by its authorized 

Signatory,/Representative,

Ground Floor Srinilaya,

Cyber Spazio Road No.2,

Banzara Hills, Hyderabad-500034,

Telengana,

 

2. Authorized Signatory/ Representative,

Apollo Munich Health Insurance, 

Ground Floor Srinilaya,

Cyber Spazio Road No.2,

Banzara Hills, Hyderabad- 500034, 

Telengana.

 

3. Authorized Signatory/ Representative,

Apollo Munich Health Insurance,

Agartala Branch, Canara Bank,

B.K.Road, Banamalipur,

Agartala, P.O.- Agartala,

P.S. East Agartala,

District- West Tripura,

Pin-799001.

 

4. Mr. Sayantan Das,

In-charge,

Apollo Munich Health Insurance,

Agartala Branch,

Canara Bank, B. K. Road,

Banamalipur, Agartala, 

P.O.- Agartala, P.S. East Agartala.

District- West Tripura,

Pin-799001.

 

5. Canara Bank, Head office,

112, J.C. Road,

Bangalore-560002,

Represented by its Chairman,

 

6. The Chief Manager,

Canara Bank, Agartala Branch, 

B.K. Road, Banamalipur, 

Agartala, West Tripura,

Pin-799001.

 

7. Mr. Arunabhoy,

Canara Bank, Agartala Branch, 

B.K. Road, Banamalipur, Agartala, 

West Tripura, Pin-799001.

 

8. Marketing Officer,

Canara Bank,

Agartala Branch, B.K. Road,

Banamalipur, Agartala,

West Tripura, Pin- 799001.

 

9. HDFC ERGO Health Insurance Company Limited, 

1st Floor, HDFC House, Backbay Reclamation, 

H.T. Perekh Marg Churchgate, Mumbai-240020, 

Represented by its authorized person,

 

10. HDFC ERGO Health Insurance Company Limited,

Agartala Branch, B.K. Road, 

Banamalipur, Agartala, P.O. Agartala,

P.S. East Agartala, West Tripura,

Represented by its authorized representative. ..................Opposite Parties.

 

 

     __________PRESENT__________

 

 SRI RUHIDAS PAL

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION

      WEST TRIPURA, AGARTALA. 

 

Dr (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.

 

SRI SAMIR GUPTA,

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.

 

 

C O U N S E L

 

For the Complainant : Sri Raju Datta,

  Learned Advocate.

    

For the O.P. No. 1 to 4 : Sri Sampad Choudhury,

  Smt. Rinku Shil,

  Learned Advocates.

 

For the O.P. No. 5, 6, 7 & 8 : Ranjan Bhattacharjee,

  Learned Advocate.

 

 

For the O.P. No. 9 & 10 : Exparte.

 

 

 

 

JUDGMENT  DELIVERED  ON  :  22.10.2021

 

 

J U D G M E N T

The Complainant's case in short is that the complainant is a citizen of India and permanent resident of Tripura and she is a renowned businessmen. The O.P. No.1 sales different kinds of health insurance polices and O.P. No.1 started a business in the state of Tripura through O.P. No.6.  On 28.03.2017 complainant purchased one health insurance policy namely Easy Health Group Insurance vide policy no- 120100/ 12001/ 2018/ A007068/ PE00518069 from Apollo Munich Health Insurance through O.P. No.6. Sum assured was Rs.10,00,000/- and optional critical sum insured was Rs.50,000/- w.e.f., 28.03.2017 to 27.03.2018. Complainant had paid Rs.8,697.61/- towards the premium for Canara Bank Group Health Insurance no-A007068 for the period of 28.03.2017 to 27.03.2018. On 07.11.2017 suddenly complainant felt chest pain and immediately met with Dr. Chayan Bhattacharjee in his chamber at Agartala, West Tripura. And Dr. Bhattacharjee prescribed some medicines and advised her for admission in any specialty hospital. Then the complainant admitted in ILS Hospital, Agartala and was admitted in ICU. Due to insufficient medical facilities complainant left from ILS hospital on 08.11.2017 and admitted in AMRI Hospital, Mukundapur, Kolkata. Dr. Uttam Kumar Saha, Chief Interventional Cardiologist and his team started for examination and conducted Coronary Angiogram and Angiopastry. She was treated in the said hospital upto 11.11.2017 and total expenditure was Rs.1,71,840/-. At that point O.P. No.1 rejected the cashless claim of the complainant. Complainant informed the matter to the O.P. No.6. After arriving at Agartala complainant met with the O.P. No.6 for settling her claim. Complainant submitted the claim along with all the documents on 07.12.2017. but the claim was returned on 09.02.2018.stating that all the documents need to be submitted in original copies. Accordingly on 08.03.2018 she submitted all the original documents as per requirement of the O.Ps. on 22.03.2018 O.P. no.1 issued a query letter asking some additional documents for making their decision regarding payment of the medical claim to the complainant. In reply the complainant issued a letter to the O.Ps requesting them to release the claim amount of Rs.1,71,804/-. On 11.04.2018 O.P. No.5 issued a letter to the husband of the complainant to furnish the following documents:

a. Treating doctor's Certificate Regarding Duration of Seizure Disorder with First consultation letter,

b. Treating Doctor's Certificate regarding duration of Seizure Disorder with first consultation letter. 

In reply complainant issued a letter to the O.Ps that Dr. U.K.Saha at the time of admission of the complainant at Amri Hospital, Kolkata on 08.11.2017 speculated it as seizure disorder. Complainant issued several reminders including emails to the O.Ps for releasing the said amount. Till today the O.Ps did not release amount of the complainant. Complainant stated that she suffered huge mental depression and agony and as a result she failed to concentrate in her business and suffered huge loss in her business also. Finding no other alternative complainant filed this complaint before this Commission claiming the medical expenditure of Rs.1,71,804/- along with 12% interest and Rs.3,00,000/- for mental agony and suffering  and Rs.5,00,000/- for loss of business. 

 

2. On the other hand O.P. No.1 to 4 appeared and submitted their written objection. O.P. No.6 also submitted their separate written objection. At the stage of argument complaint was amended and O.P. No.9 and 10 namely HDFC ERGO Health Insurance Co. Ltd. and HDFC ERGO Health Insurance Co. Ltd., Agartala Branch was added as necessary party. Notice was issued upon them and after receiving notice they did not turned up. Accordingly, it was ordered to proceed exparte against them.

In the written objection submitted by O.P. no.6, it is stated that the instant complaint is not maintainable in law as well as factual aspects. The answering O.P. No.6 being agent of Apollo Munich Health Insurance sold the policy collected the premium and hence they are not necessary party. The O.P. No.6 has no obligation to settle the claim and hence the complaint is not maintainable against the answering O.P. No.6. 

O.P. No.1 to 4 in their common written objection stated that they are the registered company and the complaint filed by the complainant is in entirety vague, false, vexatious and frivolous, without merits and the same ought to to be dismissed. It is further stated that this commission has no jurisdiction to entertain the present complaint. It is further stated that the complaint is liable to be dismissed as not maintainable. 

 

3. EVIDENCE ADDUCED BY THE PARTIES:-

The complainant submitted her examination in chief on affidavit as P.W.1 and examination chief of Sri Suvajit Paul, son of the complainant as P.W.2. and some documents(12 Nos.)  which are marked as Exhibit- 1 Series. 

 

On the other hand, one Supriyo Chakraborty, Agent of Apollo Munich Health Insurance also submitted examination in chief  on affidavit on behalf of the O.P. No.6. 

 

4. POINTS TO BE DETERMINED: - 

(i) Whether there is deficiency of service on the part of the O.Ps?

  (ii) Whether the complainant is entitled to get compensation/ relief as prayed for?

 

5. ARGUMENTS: - 

  At the time of argument Learned counsel Mr. Raju Datta appearing for the complainant submitted that complainant purchased one Health Insurance policy namely Easy Health Proof Insurance from the Apollo Munich Health Insurance through O.P. No.6. As per the said policy the complainant had paid Rs.8697/- towards premium for the period of 28.03.2017 to 27.03.2018. During that period complainant suddenly felt chest pain on 07.11.2017 and she was admitted to ILS Hospital Agartala as per advise of Dr. Chayan Bhattacharjee  and Dr. Arup Deb but due to insufficient medical facilities at Agartala on 18.11.2017 she was admitted in Amri Hospital Mukundapur, Kolkata and stayed in the hospital up to 11.11.2017 and she was under treatment of Dr. Uttam Kumar Saha, chief interventional Cardiologist. The total expenditure was Rs.1,71,840/- and the O.P. No.1 rejected the cashless claim of the complainant. The complainant after coming to Agartala submitted her claim along with documents but O.Ps rejected the claim. It is their deficiency in service and complainant has been able to prove her case by adducing sufficient evidence and she is entitled to get her medical expenditure as well as compensations as sought for. 

 

On the other hand, Learned Counsel Mr. Sampad Choudhury appearing for the O.P. No.1 to 4 submitted that the claim is not maintainable and this commission has no jurisdiction to settle the dispute as because it can not be decided in summary trial. Civil Court is the proper Forum to decide the dispute. He further submitted that the complaint involves complicated and complex question which requires elaborate evidence and the dispute is not adjudicable in summary trial. Therefore, the complaint is not maintainable in Consumer Protection Act. 

 

6. FINDINGS  AND  REASONS  FOR  DECISION:-

                   All the points are taken up together for convenience.  We have perused the pleadings as well as the evidences adduced by the parties. Complainant was examined as P.W.1 in her examination in chief on affidavit she stated that she felt chest pain on 07.11.2017 and immediately she met with Dr. Chayan Bhattacaharjee  in his chamber at Agartala and he advised for admission in a specialty hospital. Accordingly she was admitted in ICU at ILS Hospital and she left the hospital on 08.11.2017 and was admitted in Amri Hospital, Kolkata under Dr. Uttam Kumar Saha chief Interventional Cardiologist and he started for examination and conducted Coronary Angiogram and Angiopastry. As per suggestion of Dr. Saha she stayed at Hospital up to 11.11.2017. Her total treatment expenditure was Rs.1,71,840/-. She deposited the amount through cheque as O.P. No.1 rejected her cashless claim. After coming to Agartala she submitted her claim to the O.Ps for making payment but it was denied. At Para-6 she deposed that on 11.04.2018 O.P. No.5 issued a letter to her husband to furnish the following documents:

a. Treating Doctor's Certificate Regarding Duration of Seizure Disorder with First consultation letter,

b. Treating Doctor's Certificate regarding duration of Seizure Disorder with first consultation letter.  

In reply she issued a letter to the O.P. stating that Dr. U.K. Saha of Amri Hospital, Kolkata who speculated her disease as seizure disorder. At Para -6 she further deposed that at the time of discharge the said doctor Saha certified that she is not having any active seizure disorder. At para-7 she admitted that O.P. No.1 issued a letter on 18.04.2018 for submitting some vital documents and she gave her reply. In cross examination complainant admitted that her documents speaks that she was suffering from seizure disorder. A suggestion was given from the side of the O.P. that she has suppressed the fact about seizure disorder at the time of purchasing the insurance policy. She is not entitled to claim any compensation. 

On appreciation of the evidences adduced from the side of the complainant we found that that there are contrary evidences in respect of disease. We also found that the complainant failed to submit the necessary documents which were asked from the side of the insurance company to submit for settlement. 

 

7. It is the duty of the claimant to submit the necessary medical report/documents which are required for the settlement of the medical reimbursement to the Insurance Company/O.Ps. In the instant case we found that the Complainant did not cooperate with the O.Ps and due to non-cooperation from the side of the Complainant her claim was repudiated and it is justifiable. 

On over all appreciation of entire facts and circumstances as well as the evidence adduced by the parties we are in the opinion that the Complainant has failed to prove her complaint U/S 12 of the Consumer Protection Act, 1986. 

Accordingly, the complaint is dismissed and no costs. 

  Supply a certified copy of the judgment to both the parties free of cost. 

 

 

Announced.

 

 

SRI R. PAL

PRESIDENT, 

DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA. 

 

 

 

Dr (SMT) B. PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

  WEST TRIPURA,  AGARTALA.

 

 

SRI SAMIR GUPTA,

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.