Date of filing: 21.06.2017                                                                           Date of disposal: 16.08.2018

Complainant:              Sri Dibbyendu Dan, Resident of 14, Pubali, Bidhannagar, Durgapur-12, Dist-Paschim Barddhaman.

                                                                         - V E R S U S -

Opposite Party:   1.     Branch Manager, The New India Assurance Co. Ltd., R.G. Bhaban, 1^st Floor, Parbirhata, P.O.-Sripally, Dist.-Purba Barddhaman.

                            2.     Medi Assist India TPA Pvt. Ltd., Executive(CRM) “Premier Court” 4^th Floor, 4, Chandni Chowk Street, Beside Sabirs Hotel, Kolkata- 700 072.

                            3.   Life Insurance Corporation of India, Asansol Divisional Office, 1^st Floor, “Jeevan Prakash” West End, G.T. Road, Asansol-713 304, Dist.-Paschim Barddhaman.

Present:

                                    Hon’ble President: Smt. Jayanti Maitra (Ray).

 Hon’ble Member: Smt. Nivedita Ghosh.

 Hon’ble Member: Dr. Tapan Kumar Tripathy.

Appeared for the Complainant:                      Ld. Advocate, Tapan Kumar Jash.

Appeared for the Opposite Party No.1&2:  Ld. Advocate, Shyamal Kr. Ganguli.

Appeared for the Opposite Party No.3:       Ld. Advocate, Saurabh Dey.

J U D G E M E N T

          This is a case u/S. 12 of the C.P. Act 1986 alleging deficiency in service and directing an award of Rs.99, 578=00 towards the reimbursement of Hospitalization charges, Rs.50, 000=00 towards mental pain, agony and harassment and Rs.10, 000=00 towards litigation cost.

            The complainant’s case in short is that he joined a Mediclaim Policy for Club Member Agents of L.I.C.I. for the year 2014-2015 and was insured with a health policy with O.P. No.1 and the O.P. No.1 issued the policy for the period from 01.09.2014 to 31.08.2015. On 14.07.2015, the complainant was admitted to Apollo Gleneagles Hospitals Kolkata for some abdominal problem and was diagnosed with multiple ulcers in I/C valve and was treated there. He was discharged with improvement on 21.07.2015 and a sum of Rs. 99,578=00 was spent for this treatment. After that the complainant submitted claim application for reimbursement of Medical Bills to the O.P. No.2 on 09.09.2015. After submitting the original pre-numbered bill paid receipt and consultation papers, the O.P.2 informed that all those had been submitted to O.P. No.3 who forwarded the same to O.P. No.2 on 09.09.2015. When the documents were sent to O.P. No.1 for opinion and advice, they repudiated on 12.09.2015. After that the complainant filed a complaint before the Assistant Director, Consumer Affairs and Fair Business Practices at Kolkata and Assistant Director issued notice to the O.P.No.2 but they did not appear. Then the Assistant Director dropped the complaint to avoid further delay and advised the complainant to approach appropriate legal forum for redressal grievance.

            That the O.Ps. here have filed their written version by claiming the complaint false and baseless. They have mentioned the Clause - 4.10 under which they repudiated the claim, where it is stated -“Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/ Nursing Home”.

                                                            Points for consideration

1. Is the complainant a consumer as per Section 2(1) (d) (ii) of the C.P. Act 1986?
2. Has this Forum jurisdiction to entertain the instant complaint?  
3. Have the O.Ps any deficiency in service?
4. Whether the complaint is entitled to get relief/ reliefs as prayed for?

Decision with Reasons

We have gone through the records very carefully, perused the entire documents in the records and also heard the argument at length advanced by both the parties.

Point No.1:-

Undisputedly, the complainant is a valuable customer as well as a consumer accordingly to the provision of Section 2(1) (d) (ii) of the C.P. Act 1986.

Point No.2:-

The office and place of business of the O.P. Nos. 1 & 3 is within the district Burdwan, i.e., within the territorial jurisdiction of this Forum. The value of the case is within the limit of Rs.20, 000, 00=00. So, this forum has territorial as well as pecuniary jurisdiction to entertain and try the instant case.

Point Nos. 3 & 4:-

Undisputedly, the complainant had policy under the O.Ps which he had claimed. But as per the clause No. 4.10, which is very precise to be stated that without any operative activity the O.Ps could not be liable of accepting the policy coverage. The complainant, also, did not deposit any document to prove that he had undergone any surgical treatment. Hence, the O.Ps. succeed to contest the case.

Hence, it is   

O r d e r e d

that the Consumer Complaint being No. 103/2017 be and the same is dismissed on contest against the Ops without any cost.

Let plain copies of this order be supplied to the parties free of cost as per provisions of law.

Dictated & Corrected by me:                                                          (Jayanti Maitra (Ray)

                   President

 (Tapan Kumar Tripathy)                                                                    DCDRF, Burdwan

    Member

        DCDRF, Burdwan

                                         (Tapan Kumar Tripathy)                                  (Nivedita Ghosh)

                                                       Member                                                       Member

                                              DCDRF, Burdwan                                         DCDRF, Burdwan