In the District Consumer Disputes Redressal Forum, Murshidabad
Berhampore, Murshidabad.
Case No. CC/53 /2016
Date of filing: 06/04/2016. Date of Final Order: 14/3/2017
Mr. Alak Kumar Majumder.
P.O.-Jiaganj Shibtalaghat.
Dist- Murshidabad, PIN-742123. ……………………………... Complainant
- Vs-
1). Chief Claim Officer, Heritage Health T.P.A. Pvt. Ltd. ,
5th Floor,2 No., Hare Street, Kol.-700001.
2). The Manager,
United India Insurance Limited ( Micro Branch).
Khady Samity Bhawan, Near Bed./ Collage, P.O.- Jiaganj.
Dist.- Murshidabad. PIN.-742123..…………….…………………. Opposite Party
Before: Hon’ble President, Anupam Bhattacharyya.
Hon’ble Member, Samaresh Kumar Mitra.
Hon’ble Member, Pranati Ali.
FINAL ORDER
Sri Samaresh Kumar Mitra, Member.
The case of the complainant is that he is an old person, aged about 71 to 72 years. When he went to Chennai on July, 2015 there he felt chest pain and rushed to doctor for treatment. Doctor admitted him on 20.07.2015 at Apollo Hospital Chennai and conducted a few medical tests and discharged him on 21.07.2015 at 7:30 p.m. alongwith relevant papers from the insurance desk and checked the prescribed medicines with an advice that bypass surgery have to conduct after 7 to 8 months. There is a business tie up between Heritage TPA & Apollo Hospital for a long time so both of them knows very well regarding the relevant documents necessary for insurance claim. Heritage TPA repeatedly harassed me that he is lacking documents. After the submission of claim Form, the insurance company did not settle claim of the complainant. At that time he had no idea regarding consumer Forum. The complainant took credit of Rs.50,000.00 from the market as he had an idea of getting the claim amount quickly. He prayed for redressal of getting his claim amount, as he could not get bypass surgery due to lack of money.
This complainant filed a complaint before Office of Assistant Director Consumer Affairs & Fair Business Practices, Murshidabad Regional Office for getting his claim money and the said office dropped the case with a remark that the OP remained absent so the mediation failed and also advised to take the recourse of consumer Forum for redressal.
Despite receiving notice OP No.1&2 did not appear and no written version filed so the proceeding run ex-parte against them.
The complainant filed evidence on affidavit in which he assailed that he went to the office of OP No.1 and purchased a health policy vide No. 031484/48/14/97/0000241. That in the year 2015 he went to Chennai Apollo Hospital with his relative and suddenly he got chest pain and was admitted in the said hospital on 20.7.2015 and doctor advised to him test and he did the same in that hospital. That on 21.07.2015 he was discharged and provided all documents relevant for claim from health insurance from the OP No.1 and informed those after7 to8 months Bypass Surgery is necessary. After returning from Chennai he went to OP no.1 for the claim amount. That during the course of all tests his family lend a sum of Rs.50,000.00 from the market at high interest and till date it amounts to Rs.81,000.00. He went to the office of the OP No.1&2 to get the claim amount but they pay no heed which amounts to deficiency of service on the part of OP for which the complainant filed the instant complaint before this Forum for redressal amounting Rs.81,000.00 for test and the expense of medicine and a sum of Rs.81,000.00 due to interest which is payable by him for lending money from the market.
Argument as advanced by the agent of the complainant heard ex-parte.
From the discussion herein above, we find the following Issues/Points for consideration.
ISSUES/POINTS FOR CONSIDERATION
1).Whether the Complainant Mr. Alak Kumar Majumder is a ‘Consumer’ of the opposite party?
2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?
3).Whether the O.Ps carried on unfair trade practice/rendered any deficiency in service towards the Complainant?
4). whether the complainants proved their case against the opposite party, as alleged and whether the opposite party is liable for compensation to them?
DECISION WITH REASONS
In the light of discussions here in above we find that the issues/points should be decided based on the above perspectives.
- Whether the Complainant Mr. Alak Kumar Majumder is a ‘Consumer’ of the opposite party?
From the materials on record it is transparent that the Complainant is a “Consumer” as provided by the spirit of section 2(1) (d)(ii) of the Consumer Protection Act,1986. The complainant herein is the consumer of the Opposite Party as he received an Individual Health Insurance Policy-2010 from the OP No.2 and OP No.1 is the responsible person for settling any claim so he is entitled to get service from the OPs.
(2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?
Both the complainants and opposite parties are residents/carrying on business within the district of Murshidabad. The complaint valued Rs.1,62,000/- in which Rs.81,000.00 for test and the expense of medicine and a sum of Rs.81,000.00 due to interest which is payable by him for lending money from the market and other expenses ad valorem which is within Rs.20,00,000/- limit of this Forum. So, this Forum has territorial/pecuniary jurisdiction to entertain and try the case.
(3).Whether the opposite party carried on Unfair Trade Practice/rendered any deficiency in service towards the Complainant?
It appears from the case record and the documents as produced by the complainant that the complainant took an Individual Health Insurance Policy-2010 from the OP No.2 for the period from 27.3.2015 to 26.03.2015 being policy No. 031484/48/14/97/0000241 prior to taking the said policy the complainant suffered chest pain when he was at Chennai and admitted to Apollo Hospital under a senior Cardiologist namely Dr. Y.V. Reddy at Chennai who advised him to take admission and following the advice of treating doctor he took admission on 20.07.2015 and conducted E.C.G., Eco Droplet, Angiogram and other tests and he was discharged on 21.7.2015. For conducting such investigation and receiving treatment at that hospital he compelled to expense a sum of Rs.41,139.00. After that he filed his claim Form before the Heritage Health T.P.A Pvt. Ltd in the month of August, 2015 following formalities. When he did not get the claim then he wrote a letter to the OP No.1 dated 30/9/2015 received on 05/10/2015 knowing his grievances another letter was written to The Claim Executive, Nicco House, 5th Floor, 2 No., Hare Street, Kol.-700001 for his kind perusal and to take necessary action so that he can get the claim. But the OP neither settles nor repudiates the claim of the complainant as a result he compelled to take the recourse of this Forum for redressal.
After perusing the case record and documents in the record the complainant received treatment from the Apollo Hospital Chennai on 20.7.2015 &21.07.2015 and discharged from the said Hospital subject to bypass surgery after 7 to 8 months and after returning from the hospital he filed claim Form before the OP and also wrote letters in that regard but the OP did not pay heed at the utterances of this complainant. Thereafter getting no alternative he filed the instant complaint before this Forum for redressal.
In response to the letter send to the OP No.1 dated 30.9.2015 the OP No.1 neither repudiated nor settled the claim of the complainant. Similarly, The Claim Executive, Nicco House, 5th Floor, 2, hare street, Kol.700001 received the petition of this complainant dated 11.8.2015 alongwith the documents related to the claim of the complainant but remained silent. The complainant before filing the complaint before this Forum sought redressal before the Assistant Director, CA&FBP, Murshidabad R.O. The mediation meetings arranged by the said Office on 14.3.2016 & 30.3.2016 failed due to absence of the OP No.1&2. After getting notice from this Forum OP did not turn up and filed no written version as a result the proceeding run ex-parte against them.
Reason not known to us why the OP remained silent at the utterances of this complainant and willfully avoided the mediation meetings of the Assistant Director, CA&FBP, Murshidabad, R.O. and the proceedings of this Forum. So the complaint petition filed by the complainant remains unchallenged as they did not file any written version or written argument by putting their appearances.
After perusing the treatment sheet, the interim bill and the money receipts as produced by the complainant we are in a opinion that the complainant expensed a sum of Rs.41,139.00 during the period 20.7.2015 to 21.07.2015 at Chennai Apollo Hospital as an inpatient and the treating doctor Dr. Y. Vijaychandra Reddy of impugned hospital certified that the complainant was admitted at Apollo Main Hospital on 20.7.2015 with symptoms of effort Angina and he underwent coronary angiogram on 20.7.2015 and discharged on 21.07.2015. So we can infer that the complainant received treatment from that hospital but the entitlement of claim in relation to inclusion and exclusion clause of the policy is a matter of argument by the parties.
From the above discussion we may safely conclude that the complainant is entitled to get a sum a sum of Rs.41,139.00 alongwith interest since the filing of the complaint case.
4. Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to him?
The discussion made herein before, we have no hesitation to come in a conclusion that the Complainant proved his case, so the Opposite Party could not avoid his responsibility of paying the claim of the complainant in part including interest thereon as ascertained by this Forum.
ORDER
Hence, it is ordered that the complaint case being No.53/2016 be and the same is allowed ex-parte in part against the Opposite Party No.2.
The Opposite party No.2 is directed to pay a sum of Rs.41,139/- to this complainant including interest @8% since the date of filing this complaint case till the payment within 45 days from the date of final order.
No other reliefs are awarded to the complainant for harassment and mental agony.
At the event of failure to comply with the order the Opposite Party shall pay fine @Rs.50/- for each day’s delay, if caused, on expiry of the aforesaid 45 days by depositing the accrued amount, if any, in the Consumer Legal Aid Account.
Let a plain copy of this Order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/ sent by ordinary Post for information & necessary action.
Dictated and corrected by me.
Member, Member, President,
