Date of Filing: 22.03.2017. Date of Disposal: 02.03.2023.
Complainant :Sri Pallab Kumar Roy, S/O Late Sudhendu Mohan Roy,
Resident No. 7, Natunpally (East), Near Uttarayan Marriage Hall, P.O. & Dist. Burdwan, Pin-713101.
-VERSUS -
Opposite Party :1. Branch Manager, The Oriental Insurance Company Limited, having its office at Court Compound, Burdwan, P.O. & P.S. & Dist. Burdwan, Pin-713101.
2. Oriental Insurance Company Ltd, Rep. by its Director, having office at A-25/27, Asaf Ali Road, New Delhi-110002.
3. Medi Assist India TPA Pvt. Ltd. Rep. by its Director, having its office at Premier Court, 4th Floor, 4, Chandi Chowk Street,
Kolkata-700072.
Present : Mohammad Muizzuddeen -Hon’ble President.
: Mrs. Lipika Ghosh - Hon’ble Member.
: Mr. Atanu Kr. Dutta. - Hon’ble Member.
Appeared for the Complainant :Sri Suvro Chakraborty Ld. Advocate.
Appeared for the Opposite Party :Sri Saurav Kumar Mitra Ld. Advocate.
FINAL ORDER
On 22.03.2017 the complainant Pallab Kumar Roy, has filed this complaint u/S 12 of the Consumer Protection Act, 1986 against the OPs.
The case of the complainant, in brief, is that the complainant incepted a Medi-claim Insurance Policy being No. 313102/48/2016/607 for the year 2015-16 and it was valid from 12.06.2015 to 11.06.2016. After the renewal of the said policy which was valid from 12.06.2016 to 11.06.2017 and the total sum assured was Rs. 2,00,000/- and total premium was Rs. 3,399/- and it was covered the health risk of the complainant, his wife namely Bani Roy and his two sons Subhajyoti Roy and Debojyoti Roy. During the continuation of the said policy for the year 2016-17, the wife of the complainant became ill and as per advice of the treating doctor, she was admitted at Apollo Gleneagles Hospital, Kolkata on 07.06.2016 and her treatment continued up to 20.06.2016 and medical expenses was Rs. 1,04,454/- . As the complainant disclosed about the medi-claim policy before the Hospital Authority, they informed about such treatment to the OP No.3 and the OP No.3 made payment of Rs. 72,991/- to the Hospital Authority and remaining amount of Rs. 31,464/- was paid by the complainant himself. It is further stated that after discharging her wife from the Hospital, the complainant submitted the claim form along with photocopy of policy certificate, admission and discharge certificate, bills etc. before the OP No.3 through Courier and the complainant made several communications with the OP No.3 by requesting them for payment of remaining claim. Lastly the OP No.3 disbursed a sum of Rs. 2,893/- in the Bank Account of the complainant on 09.08.2016 but he did not intimate anything regarding the deduction of Rs. 28,570/- out of Rs. 31,464/- . Then the complainant submitted written representation before the OP No.1 on 08.09.2016 and 21.11.2016 but did not receive any reply or relief. They did not bother to intimate anything about the reasons of deduction amount of Rs. 28,570/- in spite of getting several requests. In this way, the OPs committed deficiency in service and unfair trade practice upon the complainant for which he suffered from huge mental pain, agony and harassment.
The cause of action a rose on 09.08.2016.
Upon this background, the complainant prayed for directing the OPs to pay a sum of Rs.28,570/- to the complainant along with a direction to pay interest @ 12% p.a upon
Rs. 28,570/- . The complainant also prayed for compensation of Rs.30, 000/- for mental pain, agony and harassment and Rs.20, 000/- as litigation cost.
As the OP No.3 did not file Written Version within the stipulated period for filing the same, the case did run ex parte against the OP No.3.
OP Nos. 1 & 2 have contested the case by filing Written Objection denying all the material allegations contending inter alia that the complainant has no cause of action to file the present complaint or that the complaint is not maintainable under the provisions of the Consumer Protection Ac t, 2019 and that the complaint is mis-conceived one and that the complainant is not a consumer under the OP as per provisions of the C. P. Ac t, 1986 and that the complaint is defect of parties. As such the complainant is not entitled to get any relief.
The specific case of the OP Nos. 1 & 2 is that they admitted the said policy covering the risk of treatment of the complainant and his wife and two sons subject to the terms and conditions. On requisition for cashless facility, so received from Apollo Gleneagles Hospitals , Kolkata for an estimated amount of Rs. 1,01,165/- , the requisition was considered and an initial amount of Rs.74,810/- was approved by the Third Party administer , Medi- Assit, ie. OP No.3. Subsequently, on product ion of all the documents for settlement of claim , the OP No.3 by considering the condition of the policy the claim was settled and remaining part of the claim i.e. Rs. 2893/- was paid to the complainant. That the contract of insurance is a contact of good f faith an trust and as Medi Assist –OP No.3 settled the claim amount and the same has been paid to the complainant and the complainant knowing fully well that he is not entitled to get any further amount, he has filed this case for harassing the OPs. There is no deficiency in service and unfair trade practice on the part of the OPs.
Upon this background, the OPs prayed for dismissals of the case.
Decision with Reasons.
In order to prove the case, the complainant has filed evidence-on-affidavit and he also filed Xerox copies of documents at the time of filing of the complaint. But the OP Nos. 1 & 2 did not file any questionnaire to the said evidence of the complainant as they were not willing to the file the same. As the OP Nos. 1 & 2 did not file evidence-on-affidavit in spite of having several adjournments for the same, it was closed.
The complainant has filed Written Notes of Argument but the OP No.1 & 2 did not file the same even after making specific order to file the same. Even, today they did not file Written Notes of Argument.
Perused the evidence-on-affidavit and the Xerox copies of the documents so filed by the complainant. We also perused the W.N.A. filed by the complainant.
If is found that the complainant has corroborated the facts depicted in the complaint and the OP Nos. 1 & 2 did not shake the said evidence by putting questionnaire.
On perusal of the record and the documents that the Insurance Medi-claim Policy was covered in respect of health risk of the complainant, his wife Bani Roy and his two sons. The medical receipt dt. 21.06.2016 shows that the admission date was on 07.06.2016 and discharge date was 21.06.2016 and total expenses was Rs.1,04,454.94 and the OP No.3 paid Rs. 72,991/- and the complainant deposited Rs. 31,464/- by cash. It is the evidence on record that subsequently on 09.08.2016 OP No.3 also disbursed a sum of Rs. 2,893/- in the bank account of the complainant out of Rs. 31,464/- which was due after payment of Rs.72, 991/- by OP No.3 but no paper and no reason is forthcoming on behalf of the OPs as to why they did not pay Rs. 28,570/- . Therefore, the document as submitted by the complainant clearly indicates that the total medical expenses was Rs. 1,04,454.94 and the OP Nos. 1 & 2 did not file any documents to show that the Appollo Gleneagles Hospital, Kolkata submitted the receipts showing medical expenses as Rs. 1,01,165/-. Apart from it mere filing the Written Version stating that there are no maintainability ground, no cause of action and not a consumer under the OPs , misconceived one, defect of parties etc. along with specific case as stated in the Written Version is not sufficient proof by as because the said facts must be proved by substantive piece of evidence . Here, in the instant case the OP No. 1&2 did not file any evidence, whether oral or documentary. Furthermore, the OP No.3 did not file any Written Version, to filing evidence by OP No.3 is far away and the case is heard ex parte against him.
In this way, the complainant suffered from mental pain, agony and harassment. He is also entitled to get litigation cost for filing the case under compulsion.
Under the above facts and circumstances, we are of opinion that the complainant has been able to prove the case against the OPs and the complainant is entitled to get relief.
Thus the case succeeds.
Hence, it is
ORDERED
That the Consumer Complaint NO. 43/2017 be and the same is allowed on contest against the OP Nos. 1 & 2 and ex parte against the OP No.3 but without any costs.
OP Nos. 1,2 & 3 are jointly and severally liable to pay the amount in this case.
OPs are directed to pay a sum of Rs. 28,570/-(Rupees Twenty Eight Thousand Five Hundred Seventy only) to the complainant and Rs. 20,000/-(Rupees Twenty Thousand only) as compensation along with litigation cost of Rs.10, 000/-(Rupees Ten Thousand only) to the complainant within 45 days from the date of the receipt of this order, failing which the said amount shall carry interest @ 12% p.a. till realization.
Let a copy of this order be given to the parties on free of cost.
Dictated & corrected by me.
President
D.C.D.R.C , Purba Bardhaman.
Member Member President
D.C.D.R.C , Purba Bardhaman. D.C.D.R.C, Purba Bardhaman. D.C.D.R.C , Purba Bardhaman.
