IN THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, MURSHIDABAD AT BERHAMPORE.
CASE No. CC/85/2017.
Date of Filing: Date of Admission Date of Disposal:
01.06.17 08.06.17 06.06.23
Complainant:Jaba Ghosh
14/4, Natunpara, PO- Khagra,
PS- Berhampore, Pin- 742103
-Vs-
Opposite Party:Branch Manager, L.I.C.I. ,
Berhampore Branch
K.N.Road, PO & PS- Berhampore,
Pin- 742101
Agent/Advocate for the Complainant : Sampa Ray
Agent/Advocate for the Opposite Party No.1 :Subhash Saha.
Present: Sri Ajay Kumar Das………………………….......President.
Smt. Aloka Bandyopadhyay……………………..Member.
Sri. Nityananda Roy……………………………….Member.
FINAL ORDER
Sri Ajay Kumar Das, Presiding Member.
This is a complaint under section 12 of the CP Act, 1986.
One Jaba Ghosh(here in after referred to as the Complainant) filed the case against Branch Manager, Life Insurance Corporation of India(here in after referred to as the OP) praying for compensation alleging deficiency in service.
The material facts giving rise to file the complaint are that:-
The Complainant is a permanent resident of Berhampore, PS-Berhampore, Dist-Murshidabad within the jurisdiction of this Forum. The Complainant lodged hospitalization claim under policy No. 429173110. The Complainant has been paying premium of the said policy. The Complainant was hospitalized for a period of 15.04.16 and was discharged on 15.04.16 for fracture of leg and for plasters a leg and the bill amount of Rs. 5,000/- was made that after the Complainant was admitted on 22.04.16 to 24.04.16 for operation of her leg and a bill of Rs. 50,695/- was made. The Complainant was paid a sum of Rs. 12,000/-. Thereafter the Complainant was admitted on 26.04.16 and discharged on 27.04.16 on account of fracture and an amount of Rs. 8,000/- was again charged. The Complainant has informed all the dates in the claim form. The total amount was (Rs. 5,000/-+ Rs. 50,695/- + Rs.8,000/-) out of which Rs. 12,000/- was paid and no reason has been assigned for short payment of Rs. 51,195/-. The Complainant claimed the said amount but the said amount has been rejected by the OP. It appears from the policy that the risk period is 10.12.11 to 10.12.2032 within which is the claim period or in other word which covers the claim period. The Complainant was also admitted to Rabindranath Tagore Diagnostic & Medical Care Centre on account of afore said fracture. The OP rejected the claim of the Complainant as account of her age of 63 years. The OP accepted proposal of Jeevan Arogya Policy knowing the date of birth of the Complainant. The Complainant asked the OP several time by writing and over phone to consider the claim and also the Complainant asked the OP to consider the claim of the Complainant and there has been negligence and deficiency of service on the part of the OP for not settling the claim of the Complainant.
Finding no other alternative the Complainant filed this instant case for appropriate relief and prayed with a direction for a sum of Rs. 51,195/- which was short payment and a sum of Rs. 1,50,000/- only for mental agony, harassment and Rs. 25,000/- for litigation cost from the OPs.
The OP No. 1, Branch Manager, Life Insurance Corporation of India, Berhampore Branch is contesting the case by filing W/V contending inter alia that the instant case is not maintainable particularly when there is no deficiency of service on the part of the OP No.1.
The sum and substance of the defence case is that:
- The Complainant was first admitted in R. N. Tagore Diagnostic and Medical Care Centre, Berhampore for fracture of leg on 15.04.16 at 01.15 AM and discharged at 3.30 PM. Total stay in Hospital was 14 Hrs 15 Minutes and Bill amount was Rs. 5,163/-. As stay in Hospital is less that (24+4) 28 hours nothing is payable for this admission and treatment.
- Second time Complainant was admitted in the same Hospital for operation of her leg on 22.04.16 at 11.00 AM and discharged on 24.04.16 at 11.00 AM. Total duration in Hospital was 48 hours and claimed Rs. 50,695/- Complainant opted initial Daily Benefit for Rs. 2,000/- and completed 4 years from commencement of policy. Hence there will be a escalation of initial daily benefit (HCB) by 5% for 4 years i.e. for duration of policy there is a increase of 20% of initial benefit. Again there is a 5% increase on Initial Benefit for no claim Benefit. Now total increase comes to 25% of initial benefit of Rs. 2,000/-. After 4 years total daily benefit comes eligible for Other Surgical Benefit for double the amount of Applicable Daily benefit for two days i.e. Rs. 2500*2*2 days= 10,000/-. Total payable Rs. 2,500+10,000=12,500/- TPA paid the claim amount correctly though she spent Rs. 50,695/-.
- Third time she was admitted on 26.04.16 at 12.30 PM and discharged on 27.04.
- 2016 at 9.30 AM. Total duration was less than 28 hours. Hence claim was rejected due to duration of stay in Hospital is less than 28 hours and not due to her age.
- As per policy condition claims were settled correctly as per condition and privileges of the policy. Hence, question of negligence and deficiency of service does not arise on the part of the OP.
The point to be noted is that the name of OP No.2, Manager, CRM, Life Insurance Corporation of India, KSDO, Jeevan Arogya Office, Sector 4, Salt lake city, Kol-64 was expunged vide order dated 29.01.18.
On the basis of the complaint and the written versions the following points are framed for proper adjudication of the case:
Points for decision
- Is the Complainant a consumer under the provision of the CP Act, 1986?
2. Has the OP any deficiency in service, as alleged?
3. Is the Complainant entitled to get any relief, as prayed for?
Decision with Reasons:
Point nos.1,2&3
All the points are taken up together for the sake of convenience and brevity of discussion. As per petition of complaint, the Complainant is a consumer to the OP No.1 and this point was not challenged by the OP No.1. Such being the position Point No. 1 is thus decided in favour of the Complainant.
The date of hearing of argument was fixed on 31.05.23 as another special chance but the Complainant was found absent on call. The record further shows that the Complainant has not been taking steps for long period. Such being the position, argument was heard on behalf of the OP No.1 on 31.05.23 and fixed 06.06.23 for passing final order.
On perusing the petition of complaint, we find that the complaint was not boldly drafted, and as such the petition of complaint is quoted within the inverted comas. ‘’ The Complainant is a permanent resident of Berhampore, PS-Berhampore, Dist-Murshidabad within the jurisdiction of this Forum. The Complainant lodged hospitalization claim under policy No. 429173110. The Complainant has been paying premium of the said policy. The Complainant was hospitalized for a period of 15.04.16 and was discharged on 15.04.16 for fracture of leg and for plasters a leg and the bill amount of Rs. 5,000/- was made that after the Complainant was admitted on 22.04.16 to 24.04.16 for operation of her leg and a bill of Rs. 50,695/- was made. The Complainant was paid a sum of Rs. 12,000/-. Thereafter the Complainant was admitted on 26.04.16 and discharged on 27.04.16 on account of fracture and an amount of Rs. 8,000/- was again charged. The Complainant has informed all the dates in the claim form. The total amount was (Rs. 5,000/-+ Rs. 50,695/- + Rs.8,000/-) out of which Rs. 12,000/- was paid and no reason has been assigned for short payment of Rs. 51,195/-. The Complainant claimed the said amount but the said amount has been rejected by the OP. It appears from the policy that the risk period is 10.12.11 to 10.12.2032 within which is the claim period or in other word which covers the claim period. The Complainant was also admitted to Rabindranath Tagore Diagnostic & Medical Care Centre on account of afore said fracture. The OP rejected the claim of the Complainant as account of her age of 63 years. The OP accepted proposal of Jeevan Arogya Policy knowing the date of birth of the Complainant. The Complainant asked the OP several time by writing and over phone to consider the claim and also the Complainant asked the OP to consider the claim of the Complainant and there has been negligence and deficiency of service on the part of the OP for not settling the claim of the Complainant.
Finding no other alternative the Complainant filed this instant case for appropriate relief and prayed with a direction for a sum of Rs. 51,195/- which was short payment and a sum of Rs. 1,50,000/- only for mental agony, harassment and Rs. 25,000/- for litigation cost from the OPs.’’
From the materials on record we find that the Complainant has filed the copy of insurance policy but no other document regarding her treatment and the expenses regarding medical treatment have been filed by the Complainant.
Ld. Advocate for the OP submitted before this District Commission that :
- The Complainant was first admitted in R. N. Tagore Diagnostic and Medical Care Centre, Berhampore for fracture of leg on 15.04.16 at 01.15 AM and discharged at 3.30 PM. Total stay in Hospital was 14 Hrs 15 Minutes and Bill amount was Rs. 5,163/-. As stay in Hospital is less that (24+4) 28 hours nothing is payable for this admission and treatment.
- Second time Complainant was admitted in the same Hospital for operation of her leg on 22.04.16 at 11.00 AM and discharged on 24.04.16 at 11.00 AM. Total duration in Hospital was 48 hours and claimed Rs. 50,695/- Complainant opted initial Daily Benefit for Rs. 2,000/- and completed 4 years from commencement of policy. Hence there will be a escalation of initial daily benefit (HCB) by 5% for 4 years i.e. for duration of policy there is a increase of 20% of initial benefit. Again there is a 5% increase on Initial Benefit for no claim Benefit. Now total increase comes to 25% of initial benefit of Rs. 2,000/-. After 4 years total daily benefit comes eligible for Other Surgical Benefit for double the amount of Applicable Daily benefit for two days i.e. Rs. 2500*2*2 days= 10,000/-. Total payable Rs. 2,500+10,000=12,500/- TPA paid the claim amount correctly though she spent Rs. 50,695/-.
- Third time she was admitted on 26.04.16 at 12.30 PM and discharged on 27.04.
- 2016 at 9.30 AM. Total duration was less than 28 hours. Hence claim was rejected due to duration of stay in Hospital is less than 28 hours and not due to her age.
- As per policy condition claims were settled correctly as per condition and privileges of the policy. Hence, question of negligence and deficiency of service does not arise on the part of the OP.
Considering the facts and circumstances of the case and the submissions made by the Ld. Advocate for the OP, we are of the view that the submissions made by the Ld. Advocate for the OP appears to be justified particularly when the Complainant is less interested in the instant case and as such the instant case is liable to be dismissed without any order as to costs.
Reasons for delay
The Case was filed on 01.06.17 and admitted on 08.06.17. This Commission tried its level best to dispose of the case as expeditiously as possible in terms of the provision under section 13(3A) of the CP Act,1986. Delay in disposal of the case has also been explained in the day to day orders.
In the result, the Consumer case fails.
Fees paid are correct. Hence, it is
Ordered
that the complaint Case No. CC/85/2017 be and the same is dismissed on merit but without any order as to costs.
Let plain copy of this order be supplied free of cost, to each of the parties / Ld. Advocate/Agent on record, by hand /by post under proper acknowledgment as per rules, for information and necessary action.
The Final Order will also be available in the following Website:
confonet.nic.in
Dictated & corrected by me.
President
Member Member President.
