West Bengal

Birbhum

CC/86/2020

Basudeb Kabiraj - Complainant(s)

Versus

Branch Manager, PNB OICL, Suri Branch - Opp.Party(s)

Samorpita Mukherjee

11 Aug 2023

ORDER

Shri Sudip Majumder- President-in-Charge.

            The complainant/petitioner files this case U/S 35 of Consumer Protection Act, 2019. The fact of the case in brief is that one Sri Basudeb Kabiraj aged about 67 years, permanent resident of ‘Suri Seharapara, P.O and P.S. Sure, District-Birbhum purchased a health insurance policy for himself and his family namely “PNB-ORIENTAL ROYAL MEDICLAIM  POLICY” from the OP No. 1/ PNB Oriental Ins. Co. Ltd. through its agent i.e. OP No. 2 on 14/03/2018 being policy No. 313102/48/2018/4180 by giving a premium of Rs. 7173.00/-. The policy was valid till midnight of 30/03/2019 and the said policy was commencing on and from 31/03/2015.

            It is the further case of the complainant that after insurance, the insured was ill and went to treat himself at Narayana  Netralaya, Bangalore and he was also admitted on 12/06/2018 and surgery in respect of his eyes was done on 12/06/2018 (right eye combined forms of age related cataract) and further another surgery was done on 14/06/2018 (left eye combined forms of age related cataract) and the said Hospital discharged the complainant on same date. The cost of surgery was Rs. 1,23,474/- (One lakh twenty three thousand four hundred seventy four only).

            It is the next case of the complainant that after treatment the complainant/insured returned to his house and thereafter the complainant/insured lodged his legitimate claim amounting to Rs. 1,23,474/- (One lakh twenty three thousand four hundred seventy four only). The claim bore No. 17709142 dated 14/08/2018 through its agent i.e. OP No. 3.

            It is the specific version of the complainant that the OP No. 3 on 10/07/2020 denied the claim of the complainant through email without any explanation/reason and wrote as “We regret to inform your that you claim is denied.”     

           Thus, the act of the OPs amounts to unfair trade practice.

            Hence, after finding no other alternative the complainant is compelled to file this complaint before this Forum/Commission for proper relief and prays for:

1. An order/direction to this opposite party to pay the claim amount i.e. Rs. 1,23,474/- (One lakh twenty three thousand four hundred seventy four only) to this petitioner along with interest.
2. An order/direction to this opposite party to pay Rs. 30,000/- (Thirty thousand only) as compensation to this petitioner.
3. An order/direction to this opposite party to pay Rs. 20,000/- (Twenty thousand only) as cost for harassment and mental agony to this petitioner.
4. An order/direction to this opposite party to pay Rs. 10,000/- (Ten thousand only) as litigation cost.
5. Any other relief/reliefs as this petitioner is entitled to.

It appears from case record that none appears from OPs before this District Commission after receiving the notice. OPs have not taken any steps. No written version has yet been filed by the OPs.  As a result of that vide order No. 22 dated 17/02/2023 this Commission stated for running of the instant case exparte against the OPs.

Complainant’s side submitted evidence-in-chief and written notes on argument. Some documents have also been filed by the complainant himself compared with original documents. Thereafter, Ld. Advocate for the complainant made oral argument in support of his case.

Points for determination/Issues

1.  Whether the complainant is a consumer as per definition of the term ‘Consumer’ of the C.P Act. ?
2. Whether this Commission has jurisdiction to try this case?
3. Whether there is any deficiency in service on the part of the O.Ps?
4. Whether the complainant is entitled to get any other relief or reliefs as prayed for?

Decision with reasons

Point No. 1:

            In this case, the complainant purchased a Mediclaim policy from the OP No. 1being Policy No. 313102/48/2018/4180 on payment of proper fees and this policy was valid till the midnight of 30/03/2019. Thus the complainant is a consumer under the OP No. 1/ PNB Oriental Ins. Co. Ltd. is the service provider. Hence, the complainant is a consumer as per Sec. 2(7)d(ii) of the Consumer Protection Act, 2019.

Point No. 2:

            In this case, the cause of action arose on and from 10/07/2020 and the case has been filed on 07/12/2020 and as such it can be said that the complainant has been filed this case within the statutory period of the C.P. Act, 2019 and as such the instant complaint is not barred U/S 69(1) of the C.P. Act, 2019.

            Pecuniary Jurisdiction of this District Commission as per Notification No. G.S.R. 892(E). dated 20^th December, 2022 by Consumer Affairs Department, Govt. of India, New Delhi is Rs. 50 lakh.

            That the complainant is a resident of Seharapara, P.O. and P.S. Suri, Dist. Birbhum, Pin-731101 which is under the Territorial Jurisdiction of this District Commission as per Sec. 34(2) of C.P. Act, 2019.

            Hence, this Commission has Pecuniary Jurisdiction as well as Territorial Jurisdiction.

Point No. 3:

It appears from the documentary evidence as available in the case record that the complainant was admitted in Narayan Nethralaya, NH Health City, Bangalore on 12/06/2018 and 14/06/2018 for his right and left eye cataract operation respectively. He was discharged on the same date and his legitimate claim was Rs. 1,23,474/- (One lakh twenty three thousand four hundred seventy four only). The complainant for reimbursement of the said medical expenses has filed an application (claim) being claim NO. 17709142 dated 14/08/2018 along with all the medical documents in original before the petitioner No. 1 through its agent i.e. opposite party No. 3/ Medi Assist Insurance TPA Pvt. Ltd. who repudiated the entire claim of the complainant without showing any explanation/reason.

It is necessary to mention that the said policy was commencing on and from 31/03/2015 and valid till the midnight of 30/03/2019 and operations were done on 12/06/2018 and 14/06/2018.

From the above discussion this Commission is of the view that the report made by the OP No. 3// Medi Assist Insurance TPA Pvt. Ltd. is completely baseless and vexatious one.

The OPs on several occasions harassed the complainant and did not return the consideration money i.e. Rs. 1,23,474/- (One lakh twenty three thousand four hundred seventy four only) to the complainant and opposite party No. 3/ Medi Assist Insurance TPA Pvt. Ltd. repudiated the entire claim of the complainant without showing any explanation/reason. It proved beyond all reasonable doubt that there is/was deficiency in service as per Sec. 2(11) of C.P. Act, 2019 as well as unfair trade practice as per Sec. 2(47) of C.P. Act, 2019 on the part of the OPs.

Hence, from the above discussion it is proved that the complainant could be able to prove his case beyond all reasonable doubts.

Point No. 4:

            As in this case, it is proved that there is deficiency in service on the part of the O.P. Hence, the complainant is entitled to get relief or compensation as prayed for.

• In Chengalrayan Cooperative Sugar Mills Vs. Oriental Insurance Co. Ltd. & Anr. (2000) 10 SCC 213 it was held that “Interest ought to have been awarded from the date on which the claim was filed before the Forum.”
• In Krishna Bhagya Jala Nigam Ltd. Vs. G. Harishchandra Reddy & Anr. (2007) 2 SCC 720 it was held that “Only 9% interest be awarded on refund matter.”

            In the instant case as per view of the Hon’ble Apex Court in several cases the interest will be given @ 9% p.a. from the date of filing of this case.

Hence, it is,

            O R D E R E D,

                                        that the instant C.F. Case No. 86/2020 be and same is allowed exparte against the OPs with cost.

            The OP Nos. 1 and 2 are jointly and severally directed to pay as insurance claim of Rs. 1,23,474/- (One lakh twenty three thousand four hundred seventy four only) to the complainant/petitioner along with interest thereon @ 9% per annum calculating on and from 07/12/2020 (i.e. from the date of filing of this case) till realization. The OP Nos. 1 and 2 are jointly and severally also directed to pay Rs. 5,000/- (Five thousand only) to the complainant/petitioner as cost of litigation.

The entire decree will be complied by the OPs within 45 (Forty five) days from this date of order, in default the complainant is at liberty to put this order in execution in accordance with law.

The instant case is thus disposed of.

Let a copy of this order be given/handed over to the parties to this case free of cost.

Dictated by me

 

President-in-Charge