Ld. Advocate(s)
For Complainant: Subhasis Roy
For OP/OPs : Raj Kumar Mondal
Date of filing of the case :11.09.2018
Date of Disposal of the case :30.01.2023
Final Order / Judgment dtd.30.01.2023
Complainant Srikanta Das filed the present complainant against the aforesaid opposite parties under section 12 of the Consumer Protection Act, 1986 alleging deficiency in service and prayed for award amounting to Rs.1,72,000.00( Rupees One lakh Seventy two thousand), compensation amounting to Rs.1,00,000.00(Rupees One lakh) and cost of the case.
It is the allegation of the complainant that he had been covered by Insurance Policy which was known as West Bengal Police Medi-Claim Insurance Policy having TPA Id No.GINI0606148749 vide Policy No.100700/50/17/10006715. In the said Policy elder sister of the complainant namely Debjani Das was included.
Said Debjani Das was fallen ill and was treated at Charing Cross Nursing Home Pvt. Ltd. at Kolkata for the period from 10.01.2018 to 19.01.2018. Total charge was claimed by said Nursing Home amounting to Rs.3,69,200.00 (Rupees Three lakh sixty nine thousand two hundred). Complainant submitted Policy particulars to the said Nursing Home for availing cashless benefit but opposite parties issued one authorization letter to Nursing Home Authority by allowing medical expenses to the tune of Rs.53,000.00 (Rupees Fifty three thousand) vide their letter dated 19.01.2018. But as per the Policy document complainant was entitled to Rs.2,25,000.00 (Rupees Two lakh twenty five thousand). Hence the complainant filed this case praying for Rs.1,72,000.00 (Rupees One lakh seventy two thousand) as per aforesaid Policy and also claimed Rs.1,00,000.00(Rupees One lakh) as compensation and cost of the case.
(3)
After receipt of notice, OP No.1& 2 appeared in this case and filed W/V and denied the entire allegations and further stated that there is no deficiency in service on their part. They further stated that elder sister of the complainant namely Debjani Das was discharged from Charing Cross Nursing Home Pvt. Ltd. Said Hospital Authority charged total bill of Rs.78,350.00 (Rupees Seventy eight thousand three hundred fifty) and according to WBHS rate opposite parties took the liability of Rs.53,000.00(Rupees Fifty three thousand) for full and final settlement and opposite parties paid the said amount. But surprisingly complainant submitted another bill in later stage for the amount of Rs.3,69,200.00 (Rupees Three lakh sixty nine thousand two hundred) and same was absolutely contrary to the procedure of settlement of claim. Subsequently Charing Cross Nursing Home by their letter dated 12.03.2018 addressed to the Genins India TPA(P) Ltd. stating “in connection with above reference and had meeting with you at your office on 12.03.2018 we hereby withdrawn the bill for implant which was further sent to you after getting final authorization. In this regard we would like to inform you that our final claim for Rs.53,000.00 (Rupees Fifty three thousand) will be valid.”
They pray for dismissal of the case.
Trial
During trial complainant Srikanta Das did not file any evidence in the form of affidavit in chief. He only filed certain documents and also filed one affidavit dated 07.09.2022 in support of the aforesaid documents.
OP No. 1 & 2 not yet produced any evidence i.e. affidavit in chief. They also produced one document.
Documents
Following documents have been produced on behalf of the complainant viz :
- Receipt for payment to the West Bengal Police Medical Insurance Policy amounting to Rs.5500.00 dated 27.11.2017 paid by C/550 Srikanta Das......(One sheet).......(Original)
- Card No.GINI0603178571 in the name of Policy Holder Srikanta Das, Insured Srikanta Das issued by Genins India TPA Ltd.(West Bengal Police)(National Insurance Company Ltd.)...........(One sheet)..........(Original)
- Health Card in the name of Debjani Das issued by Genins India TPA Ltd. (Policy from 01.08.2014)...........(One sheet).........(Original)
OP No.1 & 2 produced following documents:-
- Letter issued by Charing Cross Nursing Home Pvt. Ltd. dated 12.03.2018 addressed to Genins India TPA(P) Ltd...........(One sheet)...........(Xerox)
(4)
Brief Notes of argument.
Complainant in support of his case did not file Brief Notes of Argument and OP NO.1 & 2 also did not file Brief Notes of Argument.
Decision With Reasons
Ld. Adv. for the complainant argued before this commission that complainant was covered with insurance policy under the OP No.1-2 and in the said policy name of his elder sister Debjani Das was included. In terms of the said policy he is entitled to medical expenditure in respect of medical treatment of Debjani Das upto Rs.2,25,000.00 (Rupees Two lakh twenty five thousand) but when Debjani Das was treated at Charing Cross Nursing Home Pvt. Ltd. at the cost of Rs.3,69,200.00(Rupees Three lakh sixty nine thousand two hundred) then OP No. 1 & 2 only allowed cashless facility of Rs.53,000.00 (Rupees Fifty three thousand). So the complainant is entitled to Rs.1,72,000.00 (Rupees One lakh seventy two thousand) relating to said treatment.
In reply Ld. Adv. for the OP No. 1 & 2 argued before this Commission that Charing Cross Nursing Home Pvt. Ltd. withdrew the bill for implant which was further sent to Genins India TPA(P) Ltd. and further stated that final claim of Rs.53,000.00 (Rupees Fifty three thousand) was valid. As the Charing Cross Nursing Home Pvt. Ltd. withdrew their claim complainant cannot make any claim subsequently. He prays for dismissal of the case.
It is admitted position that complainant Srikanta Das was covered with Policy which was known as West Bengal Policy Medi-claim Insurance Policy. Moreover, on perusal of documents filed by the complainant it is clear before this Commission that complainant was covered by Medical Insurance vide card no.GINI0603178571 issued by OP No.3. It is also admitted position that Health Card was issued in the name of Debjani Das, elder sister of the complainant vide no.GINI0603754302 with effect from 01.08.2014. It is clear before this Commission relating to the said Medi-Claim Policy that complainant paid Rs.5,500.00(Rupees Five thousand five hundred) as premium amount.
Complainant at the time of filing this complaint produced Xerox copy of final bill issued by Charing Cross Nursing Home Pvt. Ltd. amounting to Rs.3,93,715.00 (Rupees Three lakh ninety three thousand seven hundred fifteen). On perusal of letter dated 19.01.2018 issued by Genins India Insurance TPA(P) Ltd., we find that an amount of Rs.53,000.00 (Rupees fifty three thousand) was approved.
On perusal of letter dated 12.03.2018 issued by Charing Cross Nursing Home(P) Ltd. we find that they stated in their letter:-
“In connection with the above reference and had a meeting with you at your office on 12.03.2018, we hereby withdrew the bill for implant which was further sent to you after getting final authorization. In
(5)
this regard we would like to inform you that our final claim for Rs.53,000.00 (Rupees Fifty three thousand) will be valid.”
The genuineness and existence of the said letter has not been challenged from the side of the complainant. So we do not find any reason to disbelieve the said document. Moreover, complainant did not produce any document in support of the fact that he paid Rs.3,69,200.00 (Rupees Three lakh sixty nine thousand two hundred) as per his contention made in para 8 of the complaint. So it is clear before us that complainant did not pay any cash in favour of the Nursing Home namely Charing Cross Nursing Home Pvt. Ltd. relating to treatment of his elder sister namely Debjani Das. As the Nursing Home Authority namely Charing Cross Nursing Home Pvt. Ltd. by their letter dated 12.03.2018 withdrew their claim and admitted that claimed for Rs.53,000.00 (Rupees Fifty three thousand) will be treated as valid so it is clear before us that Charing Cross Nursing Home Pvt. Ltd. relinquished their claim amount which is excess of Rs.53,000.00 (Rupees Fifty three thousand) which was approved relating to treatment of Debjani Das.
Having regard to the aforesaid discussion we are of the firmed view that complainant has failed to establish his case in respect of his claim of Rs.1,72,000.00 (Rupees One lakh seventy two thousand) as cost of treatment of his elder sister Debjani Das, Rs.1,00,000.00 (Rupees One lakh) as compensation and cost of the case. Accordingly, we do not find any deficiency in service on the part of OP No.1-3.
In the result present case fails.
Hence,
It is
` Ordered
that the present case be and the same is dismissed on contest against the OP No.1 & 2 and dismissed ex-parte against OP No.3 but no order as to costs.
(6)
Let a copy of this Final Order be supplied to the complainant as free of cost.
Let another copy of this Final Order be supplied to OP No.1 & 2 as free of cost.
Dictated & corrected by me
............................................
PRESIDENT
(Shri DAMAN PROSAD BISWAS,) .................................................
PRESIDENT
(Shri DAMAN PROSAD BISWAS,)
I concur,
.............................................
MEMBER
(NIROD BARAN ROY CHOWDHURY)
