West Bengal

Birbhum

CC/70/2017

Paritosh Roy, S/O Lt D.Roy - Complainant(s)

Versus

Branch Manager, The Oriental Ins Co Ltd, Suri Branch - Opp.Party(s)

Sanjit Kr Acharya

18 Aug 2023

ORDER

Shri Sudip Majumder. President in Charge.

            The complainant/petitioner files this case U/S 12 of Consumer Protection Act, 1986. The fact of the case in brief is that the petitioner Sri Paritosh Roy, permanent resident of Vill. Mukhuriya, P.O. Hatjanbazar, P.S. Suri, District-Birbhum, purchased a Mediclaim Policy from the OP/ Oriental Ins. Co. Ltd. being Policy No. 3131003/48/2016/340 for his family i.e. for himself, his wife-Chhanda Mazumder (Roy) and his son Ayanabha Roy. The policy commenced on 30/06/2014 and was valid till the midnight of 30/06/2016 and by this way the complainant/insured became a consumer/customer of the OP i.e. Insurance Company.

            It is the further case of the complainant that Chhanda Mazumder (Roy) the wife of the complainant having some ailments consulted with doctor Anjan Guha, Gynaecologist on 20/11/2015 at Apcar Garden, BNR More, Asansol, Burdwan, and the doctor after examining said Chhanda Mazumdar (Roy) advised her for U.S.G.

            That said Chhanda Mazumder (Roy) underwent U.S.G. on 22/11/2015 and in that report it was found that there is overial cyst.

            That the complainant there after took his wife for further consultation before doctor Sambhunath Bandyopadhaya and the doctor after examining policy holder Chhanda Mazumdar(Roy) advised for operation the cyst.

           

 

 

 

Chhanda Mazumdar(Roy) was admitted at Eve’s Clinic, 14/1 A Dumdum Road, Kolkata-700030 and the operation was done on 24/02/2016 and she was discharged on 28/02/2016. The complainant incurred expenses of Rs. 35,000/(Thirty five thousand only) for the same.

It is the next case of the complainant that after treatment the complainant/insured returned to her house and thereafter the complainant/insured lodged her legitimate claim before the Insurance Company with all relevant papers in original. The Insurance Company finally repudiated the claim of the complainant/insured by showing some baseless grounds.        

That the opposite party insurance company repudiated the claim by writing report made by Heritage Health TPA Pvt. Ltd. dated 16/06/2016 “ as per discharge certificate of EVE’s Clinic dated 24/02/2016 patient Chhanda Mazumdar (Roy) was suffering from right sided ovarian cyst and under gone overiontomy with bilateral salpingo oophoroectomy. The procedure undergone by the patient are surgeries of the genitor urinal system and expenses in that regard were not payable for the first two years of the policy. As such, the claim has been repudiated as per clause no 4.3 of the policy.”

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. To pass an order directing the Op to pay the insurance claim of Rs. 35,000/(Thirty five thousand only) to the complainant.
2. To pass an order directing the OP to pay interest @ 12% on Rs. 35,000/(Thirty five thousand only) since 24/02/2016 till realization of the claim.
3. To pass an order directing the Op to Rs. 10,000/(Ten thousand only) as litigation cost.
4. Other relief or reliefs.

The OP/ Oriental Ins. Co. Ltd., Suri Branch has contested the case by filing written version denying all material allegation of the complainant, contending, inter alia, that the case is not maintainable and the complaint has no cause of action to bring this case.

OP/Oriental Ins. Co. Ltd. repudiated the claim and mentioned in their W/N/A as “The procedure undergone by the patient are surgeries of the genitor Urinal system and as per provisions of 4.3 of Happy Family FLOATER policy the claim is not payable for the first two years of the policy and considering the PID i.e. 01/07/2014 the claim has been repudiated and as such the claim submitted by the insured has been found to be inadmissible.”

Ultimately the OP prayed for dismissal of the case.

 

 

 

 

Both the parties submitted written notes on argument (W/N/A). Some documents have also been filed by the complainant’s side and compared with original documents. Thereafter, respective Ld. Advocates for both sides made oral arguments in support of their case.

            Heard Ld. advocates for both sides.

            Considered.

            Perused all the documents.

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 Ops?
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 being Policy No. 3131003/48/2016/340  on payment of proper fees and this policy is valid till the midnight of 30/06/2016. Thus the complainant is a consumer under the OP/Oriental Insurance Company Ltd. and the OP/Oriental Insurance Company Ltd. is the service provider. Hence, the complainant is a consumer as per               Sec. 2(1)d(ii) of the Consumer Protection Act, 1986.

Point No. 2:

            Pecuniary jurisdiction of this Forum/Commission as per Sec. 11(1) of the Consumer Protection Act, 1986 is Rs. 20,00,000/. OP/Oriental Insurance  Co. Ltd.,  Suri Branch is situated in Birbhum District i.e. within the territorial jurisdiction of this Forum/Commission as per Sec. 11(2) of the Consumer Protection Act, 1986. So, this Forum/Commission has territorial and pecuniary jurisdiction.

In this case, the cause of action arose from 24/02/2016 and the case has been filed on 29/08/2017 and as such it can be said that the complainant has filed this case within the statutory period of the C.P. Act, 1986 and as such the instant complaint is not barred by limitation U/S 24A of the C.P. Act, 1986.

Point No. 3:

It appears from the documentary evidence as available in the case record that the complainant was admitted in EVE’s CLINIC Nursing Home and Policy Clinic, 14F/1A Dum Dum Kolkata- 700 030 on 24/02/2016, the operation was done by Dr. Sambhunath Bandyopadhaya and thereafter said patient i.e. wife of the complainant was discharged on 28/02/2016. Complainant incurred expenses of Rs. 35,000/ (Thirty five thousand only) for such operation of his wife. Thereafter complainant lodged his legitimate claim of

Rs. 35,000/ (Thirty five thousand only) before the OP/Oriental Insurance Company Ltd. with all relevant papers in original.

After treatment the complainant returned her home and lodged her legitimate claim of Rs. 35,000/ (Thirty five thousand only) before the OP/Oriental Insurance Company Limited with all relevant papers in original.

Point No. 4:

            From the documentary evidence as available in the case record it is crystal clear that the wife of the complainant i.e. the patient was suffering from right sided ovarian cyst and the same was operated on 24/02/2016. As per  exclusionary clause 4.3 (ii) during the period of insurance cover ..“The expenses on treatment of following ailment/disease/surgeries for specified periods are not payable if contracted and/or manifest during the currency of the policy- ii) Ploycystic ovarian disease-1 year.” That the policy was commenced on 30/06/2014 and the surgeries was undergone on 24/02/2016, i.e. after one and half year and as such, the complainant is entitled to get the insurance claim as per clause 4.3 (ii).

The claim of the complainant repudiated by the OP/Oriental Insurance Company on the basis of the report made by the HERITAGE HEALTH TPA PVT. LTD. We think this is a vexatious one.

From the above discussion this Commission is of the view that the complainant was admitted in the said Nursing Home for four days and that time the insurance policy was valid. Further it is necessary to mention that this type of illness is not excluded from the terms and condition of the policy Exclusionary clause 4.3 (ii). It is crystal clear that the complainant was admitted in the said Nursing Home  and undergone overiotomy with bilateral salpingo oophoroectomy and the complainant paid for the same Rs. 35,000/-(Thirty five thousand only).  Hence, the complainant is entitled to get the claim.

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

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

• 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. calculating 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. 70/2017 be and same is allowed in part on contest with costs. The OP/Oriental Insurance Company Ltd. is directed to pay               Rs. 35,000/ (Thirty five thousand only) as insurance claim to the complainant along with interest @ 9% per annum calculated on and from 29/08/2017 (i.e. from the date of filing of this case) till realization. The OP/Oriental Insurance Company Ltd. is also directed to pay Rs. 10,000/ (Ten thousand only) to the complainant/petitioner as cost of litigation.

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