Case No. CC/13/2020
COMPLAINANT :1. Ranjana Rudra (Aged about 54 years),
Wife of Sukesh Chandra Rudra,
2. Sukesh Chandra Rudra (Aged about 61 Yrs)
Son of Lane Satish Chandra Rudra,
Both residents of Shyamaprosad Palli,
P.O.&P.S. Ranaghat, Dist. Nadia.
V-E-R-S-U-S
OPPOSITE PARTIES / 1. National Insurance Company Ltd.,
Represented by its Branch Manager,
Having its Branch Office at:
7, Rabindra Sarani, P.O.&P.S. Ranaghat,
Dist. Nadia, Pin-741201.
2. Manager and Authorized Signatory
Rathsheild Insurance TPA Ltd.
Having its Office at 402, Raheja Chambers,
Nariman Point, Mumbai-400021,
Email:info@rothshield.co.in
Ld. Advocate(s)
For Complainant: Souvik Bhattacharya
For OP/OPs :Raj Kumar Mondal
Date of filing of the case :10.02.2020
Date of Disposal of the case :15.05.2024
Final Order / Judgment dtd.15.05.2024
The concise fact of the case of the complainant is that the complainants Ranjana Rudra and Sukesh Chandra Rudra opened Mediclaim Policy on 21.07.2016 being policy no.154302/48/16/8500000793 which is known as “Parivar Mediclaim” issued by National Insurance Company Limited for the period 21.07.2016 to 28.07.2017 with a premium of Rs.13,822/-. In the name of the complainants for a sum assured Rs.5,00,000/-. The complainants renewed the said policy for the period 21.07.2017 to 20.07.2018 with payment of Rs.13,822/-. Thereafter, the complainants to again renewed the said policy from 21.07.2018 to 20.07.2019 after paying premium of Rs.13,822/- and the OP No.1 issued the policy no.154302501810000620. The complainants again renewed the said policy on 23.07.2019 upto 22.07.2020 for a premium of Rs.13,822/- being policy no.154320250191574. The complainant Sukesh Chandra Rudra was suffering from left shoulder pain radiating towards left upper limb since 03.05.2019 and visiting to Dr. Somnath Ghatak who-advised the complainant for some medicines. Since there was no relief, so complainant no.2 was medically treated with Dr. Debapi Roy on 28.05.2019 who advised him some medicines. Subsequently, the complainants were medically treated by Dr. Santanu Banerjee on 13.06.2019 but there was no relief. So, the complainant no.2 was further medically treated at Apollo Hospital , Chennai on 28.06.2019 wherein he was advised for surgery . He underwent C-5, C-6 &C-7 lamincetomy and excision of intradural part of the lesion on 29.06.2019. After that patient was shifted to Neuro I.C.U and he was discharged from the hospital on 04.07.2019. The complainant no.2 paid Rs.3,68,241.55 towards medical bill on 08.07.2019 for his medical treatment. The complainants informed the matter to the OP No.1 along with relevant documents and the OP No.1 asked the complainants to send the additional documents to process the said claim on 07.08.2019. So, the OPs are bound to reimburse the medical expenses of the complainants. The complainants sent the additional documents on 20.09.2019 which the OP No.1 duly received the complainants sent all the documents except the copy of policy proposal which is under the custody of OP No.1 but the OP NO.1 did not reply. The OP No.1 also did not indemnify the said amount of medical expenses , so the present case is filed. The cause of action for the present case arose on 26.11.2019 and on subsequent dates till the filing of this case. The aforesaid activities of the OP No.1 amounts to unfair trade practice for which the complainants suffered mentally and physically as well as economically . So, the complainants prayed for an award for a sum of Rs.3,68,241.55 towards medical expenses incurred by the complainants, Rs.1,00,000/- towards harassment for deficiency in service and Rs.30,000/- for litigation cost.
The OP No.1 contested the case by filing W/V wherein they denied each and every allegation of the complainants. The OP NO.1 challenged the case as not maintainable on the ground that the case is bad for defect of parties, barred by limitation as not maintainable. The positive defence case of OP No.1 is after receiving the claim of the complainants the OP No.1 asked the complainants several times to submit all the related documents for processing the claim but the complainants did not submit all the documents regarding his treatment as per the policy conditions and as such the claim is pending for settlement . The claim of the complainant is excessive , baseless and imaginary and without any mathematical calculation . The said claim is against the conditions of the policy. The OP No.1 has not conducted any medical negligence and deficiency in service or unfair trade practice. The OP NO.1 claimed that the case is liable to be rejected with cost.
The OP No.2 preferred not to contest the case , so as per order no.20 dated 12.12.2022 the case was decided to be heard ex-parte against OP No.2 Rathsheild Insurance T.P.A Limited.
The point of disputes raised by the complainants and the defence case made out by the OP No.1 persuaded this Commission to adjudicate the following points for proper disposal of the case.
Points for Determination
Point No.1.
Whether the case is maintainable in its present form and prayer.
Point No.2.
Whether the complainant is entitled to get the relief as prayed for.
Point No.3.
To what other relief if any the complainant is entitled to get.
Decision with Reasons
Point No.1.
The OP No.1 challenged the case as not maintainable on the ground that it is bad for defect of parties and barred by limitation but in course of argument Ld. Advocate for the OP No.1 could not advance any argument as to why the case is not maintainable for under which provision it is barred.
However, having perused the pleadings of the parties and the evidence in the case record the Commission finds that cause of action for the present case arose on 26.11.2019 and the present case is filed on 10.02.2020. So, it is well within the limitation period. The OP No.1 could not satisfy as to who others are the proper and necessary parties in this case. So, the present case is not bad for defect of parties.
Accordingly, point no.1 is answered in affirmative and decided in favour of the complainants.
Point No.2&3.
Both the points are closely interlinked with each other and as such these are taken up together for brevity and convenience of discussion.
It is the admitted fact that the complainants registered insurance policy with the OP No.1 and paid premium for time to time. The OP No.1 did not deny the said fact.
The OP No.1 seems to have claimed that after receiving the claim of the complainant they asked the complainant to submit all the related documents for processing the claim.
The complainants in order to substantiate the case adduced oral evidence in the form of evidence on affidavit and documentary evidence.
The complainant proved Annexure-A which is the original policy.
Annexure-A1 is the original policy for the effect of complainant Ranjana Rudra.
Annexure-A2 being premium certificate for a sum of Rs.16,310/-. The complainant further proved Annexure-A3 which shows that the complainant paid Rs.16,310/- towards premium.
Annexure-A4 is the Tax invoice of premium paid for Rs.13,822/-.
Annexure-A5 is the collection receipt for Rs.16,310/- issued by the OP No.1.
Annexure-A6 is the another insurance premium receipt.
Annexure-A7 is the premium certificate.
Annexure-A8 is the another Tax Invoice for insurance premium in the name of the complainant.
Annexure-A9 is the collection receipt in the name of the complainant Ranjana Rudra.
Annexure-B is the medical prescription of complainant no.2 issued by Dr. Somnath Ghatak dated 03.05.2019.
Annexure-C is the another medical prescription issued by Dr. Somnath Ghatak in favour of the complainant Sukesh Chandra Rudra dated 30.08.2019.
Annexure-D is the medical prescription of Orthopaedic Dr. Debapi Roy dated 28.05.2019.
Annexure-E is the medical prescription issued by Dr. Santanu Banerjee dated 13.06.2019 the name of the complainant no.2.
Annexure-F is the Discharge Summery of OP NO.2 issued by Apollo Hospital.
Annexure-G is the Medical Bill of supply in the name of the patient Mr. Sukesh Chandra Rudra for a total sum of Rs.3,68,242/-.
The complainant also proved Annexure-H being a letter of requirement of Additional documents dated 07.08.2019 issued by OP No.2 to the complainant. The complainant in reply to the said letter submitted another letter dated 20.09.2019 being annexure-I in which the complainant duly explained that he had the said documents.
The complainant further proved annexure-J being a letter dated 26.04.2019 to the OP No.1 stating inter-alia that he had already submitted the documents.
The main defence of the OP No.1 is that the complainant did not submit the medical documents, so they did not discharge the medical bill. It is the case of OP No.1 that due to non-submission of the documents the claim is pending for settlement.
The pleadings of the OP No.1 clearly shows that the OP No.1 did not reject the claim of the complainant or also never repudiate the claim of the complainant. The only defence case is that due to delay in submission of the documents the claim is pending for settlement.
The OP No.1 could not file or prove any document to establish that they asked for the documents from the complainant at any point of time.
The OP No.1 was asked some questions in cross-examination wherein they replied that the OP No.1 issued medical policy in favour of the complainant. The OP No.1 also admitted in answer to question no.3 that the complainant informed the matter to OP No.1.
The OP No.1 stated in answer no.4 and answer no.6 that OP NO.2 asked the complainant to send additional documents for processing the claim but the complainant denied it. In fact OP No.2 did not prefer to contest the case and as such the plea of the OP No.1 that the OP NO.2 asked several times to the complainant to submit the required documents for processing the claim stands not proved.
The complainant answered to the questionnaires of OP No.1 stating inter-alia that he had sent all the documents as per letter dated 07.08.2019 served upon them by OP No.2 to the OP No.1 on 20.09.2019 which was duly received by OP No.1 because the OP No.1 verbally assured that as the policy was issued by OP No.1 so all the correspondences should have been made through OP No.1 and after receiving the said documents on 20.09.2019 the OP No.1 never returned the same to file before OP No.2 and the said letter dated 20.09.2019 has already been filed before this Commission.
Thus it is crystal clear and evident that the complainant has already submitted the documents to the OPs. It is also important to consider that an answer given in cross-examination has a special effect. Since the complainant categorically stated in cross-examination that he had filed the documents to the OPs and taking into consideration further that the complainant proved the said document as annexure-H and I the Commission draws the positive interference that the complainant submitted the documents to the OPs as per requirement.
Regard being also had to the further answer to the questionnaires being answer No.3,4 and 5 where in the letter dated 20.09.2019 supports the entire case of the complainant. There is nothing within the four-corners of the case record that the OP NO.2 did not receive the said documents.
Ld. Defence Counsel for OP No.1 argued that OP No.2 did not produce the documents despite issuance of summons by this Commission during hearing of this case. So, he had no scope to scrutiny the document.
Ld. Advocate for the complainant counter argued that the TPA is the third party administrator who should act in liaison with the OP No.1. So, the complainant should not suffer for the mis-understanding between the OP No.1 and OP No.2.
The argument is duly acceptable in as much as the complainant seems to have already filed the documents and the OP No.2 never challenged the said claim. So, the complainant should not be victimised for the mis-communication or mis-understanding between the opposite parties. That apart the OP No.1 could not prove any documents to show that he had called for the said documents from the OP No.2 before filing of this case.
The aforesaid misdeeds and inaction on the part of the OPs tantatmounts to deficiency in service which caused harassment and deficiency in service.
In the backdrop of the aforesaid assessment of evidence and the observation made in the foregoing paragraphs the Commission comes to the finding that the complainant successfully proved the case against the OPs upto the hilt.
Accordingly, point no.2&3 are answered in affirmative in favour of the complainant.
Consequently, the complaint case succeeds with cost.
Hence,
It is
Ordered
that the complaint case no.CC/13/2020 be and the same is allowed on contest against OP No.1 and ex-parte against OP No.2 with cost of Rs.10,000/- (Rupees ten thousand). The complainant do get an award for a sum of Rs.3,68,241.55 (Rupees three lakh sixty eight thousand two hundred forty one and fifty five paisa) against the OPs towards medical expenses incurred by the complainants, Rs.1,00,000/- (Rupees one lakh) towards harassment due to deficiency in service and Rs.10,000/- (Rupees ten thousand) towards litigation cost. The opposite parties are jointly and severally liable to pay the award money. Both the OPs are directed jointly and severally to pay Rs.4,78,241.55 (Rupees four lakh seventy eight thousand two hundred forty one and fifty five paisa) to the complainants within 30 days from the date of passing the final order failing which the entire award money shall carry an interest @8% p.a from the date of passing the final order till the date of its realisation.
All Interim Applications (I.A) stand disposed of accordingly.
D.A to note in the trial register.
The case is accordingly disposed of.
Let a copy of this final order be supplied to both the parties at free of costs.
Dictated & corrected by me
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PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,) ................ ..........................................
PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,)
I concur,
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MEMBER
(NIROD BARAN ROY CHOWDHURY)
