Ld. Advocate(s)
For Complainant: Makbul Rahaman
For OP/OPs : Manas Kanjilal
(2)
Date of filing of the case :01.02.2019
Date of Disposal of the case : 01.06.2023
Final Order / Judgment dtd.01.06.2023
Complainant above named filed this complaint against the aforesaid opposite parties u/s 12 of the Consumer Protection Act, 1986 praying for Rs.50,000/- as cost of the bill, interest @ 10% over the aforesaid amount, compensation amounting to Rs.50,000/- and cost of the case.
He alleged that husband of the complainant purchased one Medi-claim Policy on 01.11.2013 and said policy was continued from 01.11.2017 to 31.10.2018 vide Policy No. P/191132/01/2018/000727 (Madiclassic Insurance Policy). Said Policy was covered for principal insured Debnarayan Pal and his spouse Sumitra Pal that is the complainant with the limit of coverage of Rs.2,00,000/-. At the time of purchase of said policy insurer Sumitra Pal was in sound health. During the continuation of the said Policy insured Sumitra Pal felt illness and went to Shifaa Hospital on 07.09.2017 and she was admitted there and she was released on 09.09.2017. She claimed the cost of the treatment bill but OP No.1 did not pay the same in his favour. Hence, she lodged this complaint.
OP NO.1 and 2 appeared in this case and filed W/V. They denied the entire allegations which has mentioned in petition of complaint. He further stated that they had on inquiry found that claim is false and fabulous as such they refused the same.
Trial
During trial complainant filed affidavit in chief. OP NO.1 filed questionnaire and complainant gave answer. OP NO.1 & 2 did not file any affidavit in chief.
DOCUMENTS
Complainant produced the following documents Viz:-
- Original Policy which was valid for the period from 01.11.2017 tp 31.10.2018............(Four sheets)
- Xerox copy of Discharge Summary issued by Shifaa Hospital.......(Two sheets)
- Xerox copy of detailed IP bill..........(Three sheets)
- Xerox copy of repudiation of claim dated 01.04.2018........(One sheet)
(3)
- Xerox copy of complaint which was lodged by the complainant before Consumer Assistant Bureau , Nadia.........(One sheet)
Brief Notes of Argument
Complainant files BNA. OP No.1 filed BNA.
Decision with Reasons
We have carefully gone through the petition of complaint, W/V, affidavit in chief of the complainant, documents filed by the complainant and BNA of both the parties. We have carefully considered the same.
On perusal of original Policy, we find that complainant and her husband purchased the said policy for the coverage of Rs.2,00,000/- and said policy found was valid from 01.11.2017 to 31.10.2018.
During the continuation of the said policy complainant felt ill and she was treated of Shifaa Hospital , Bangalore and he incurred cost of Rs.8780/-.
Complainant alleged in the petition of complaint that complainant incurred Rs.50,000/- for her treatment but complainant could not produce any document in support of the fact that she incurred Rs.50,000/- for her treatment before Shifaa Hospital. She only filed bill for her indoor treatment amounting to Rs.8780/-. Ld. Adv. for the OP No.1 & 2 argued before this Commission that the said bill is false one. Perused the W/V of the OP No.1 & 2 also perused the BNA of OP No.1 & 2. Perused the letter of OP NO.1 dated 11.04.2018 regarding repudiation of claim.
On perusal of the said document, we find that they stated as follows:-
“Our medical team has perused your representation and the medical records referred above and has noted the contents. The team which re-examined the claim records has observed that as per letter dated 01/03/2018 from the treating doctor, the insured patient has anaemia due to bleeding per rectum. But as per submitted prescriptions, on examination no bleeding per rectum and no haemorrhoids. There is discrepancy seen in treating doctor letter and submitted prescriptions. Our medical team is the opinion that patient treated mainly for nutritional anaemia, which is not payable as per policy terms and conditions.”
(4)
On careful scrutiny of the treatment papers of Shifaa Hospital, we find that she was treated for 07.09.2017 to 09.09.2017 and incurred cost of Rs.8780/-.
The reason which has been assigned by OP NO.1 at the time of repudiation of claim bears no merit.
Accordingly, we find that OP No.1 & 2 did not consider the claim of the complainant in proper perspective. They whimsically refused the claim of the complainant.
Having regard to the aforesaid discussion we are of the firmed view that complainant has able to established her grievance by sufficient documents before this Commission.
In the result present case succeeds.
Hence,
It is
Ordered
that the present case be and same is allowed on contest against the OP NO.1 & 2 with cost of Rs.3,000/- (Rupees Three thousand) to be paid by OP NO.1 & 2 in favour of the complainant.
OP No.1 & 2 jointly or severally are directed to pay Rs.8780/-(Rupees eight thousand seven hundred eighty) in favour of the complainant within one month from this date failing which aforesaid amount shall carry interest @ 9% per annum from this day to till the date of actual payment.
OP No.1 & 2 are further directed to comply this order within one month failing which complainant shall have liberty to put this order into execution.
(5)
OP NO.1 & 2 are further directed to pay Rs.5,000/-(Rupees five thousand) as compensation in favour of the complainant positively within one month from this day.
Let a copy of this order be supplied to both the parties as free of costs.
Dictated & corrected by me
............................................
PRESIDENT
(Shri DAMAN PROSAD BISWAS,) ..................... ..........................................
PRESIDENT
(Shri DAMAN PROSAD BISWAS,)
We concur,
........................................ .........................................
MEMBER MEMBER
(NIROD BARAN ROY CHOWDHURY) (MALLIKA SAMADDAR)
