The case of the complainant, in brief, is that the complainant is a service man who is a Policy Holder of CIGNA TTK HEALTH INSURANCE COMPANY LTD., vide Policy No. PROHLRRO 10065280, Code - 1603522-01 Consumer ID - 1000200527, under plan Pro-health protect, Policy No. Prohlr 010065280, date of inception 31/03/2016 Policy expiry date - 30/03/2017 and has been an installment premium paying Policy Holder and Beneficiary. The complainant’s minor son (Complainant No. 2) suffered from Swelling, Muscular Stiff and Large Rash over his body on from 30/07/2016. Thereafter, the complainant and his minor child went to the Birpara State General Hospital where they were primary treated by doctor who advised for Echocardiographs, BHH anti CCP and also advised for hospitalization SOS. Being Policy Holder and Beneficiary and as per advise of the doctor he hospitalized patient Arbaj Ansari in VISON CARE HOSPITAL in collaboration with AMRRI HOSPITAL, Kolkata for better treatment and medical facilities.
The further case of the complainant is that the son of the complainant was admitted to VISON CARE HOSPITAL where his son was treated by the doctor since 31/07/2016 to 10/08/2016. His son was suffered from fever with rash and suffered Polyarthalgia for last one month and also chest pain for last seven days. Whereby he had medical condition of Acute Rhematic Fever with Cardioids and undergone various medical treatment and the complainants have submitted all relevant papers to the O.Ps. The complainant asked for cash less benefits under the policy validity insured to the O.Ps for his legal claim. O.P side replied through rejection letter vide Authorization No. BLR-0816-AT0000078 where it was remarked NOT PAYABLE, noting therein that need for hospitalization is not justified, goes in favour of observation and Oral/IIM medication and evaluation, hence cash less denied resulting unnecessary borrowing with high interests upon complainant to pay the bills and withdrawal of further treatment from concern hospital. Thereafter, the complainant had bound to undergo treatment with government institution due to denial of cash less facilities. The O.Ps advised the complainant to send a claim for consideration of reimbursement and accordingly complainant submitted legal claims under the Policy which was due received by the O.Ps on 24/07/2016. The complainant also made several correspondences to the O.Ps. The O.P informed the complainant that Mr. Barun Sarkar of Med link Intentional has been appointed by CIGNA TTK for the purpose of verification, collection information, documents and reports pertaining to Health claims of insured his son for Med claim No. BLR – 0870940. The complainant also served a legal notice upon the O.Ps. The O.Ps also made several reply but they did not pay the aforesaid Med claim to the complainant.
Due to the aforesaid act and non-payment Medi claim the complainant was suffered both mental and financial which were not at all expected and the O.Ps can not deny their negligence and deficiency in service on their part. As such the instant case has been filed by the complainant with a prayer to direct the O.Ps to pay Rs. 64,414.74/- with18% interest per annum and also to direct the O.Ps to pay Rs. 50,000/- for his mental agony and sufferings and the complainant also prayed for direction to the O.Ps to pay Rs. 1, 00,000/- for denial of cashless card service under the Insurance Policy and also prayed for direction upon the O.Ps to pay 10,000/- towards litigation costs.
All the O.Ps have appeared before this Forum and contested the case by filing written version.
The case of the O.Ps are that the case is barred by Non-joinder of necessary parties. The O.Ps have admitted in the W/V that complainant has only paid his first year premium of Rs. 17,140.65/- for the period of 31st March, 2016 to 30th March, 2017. Thereafter, the complainant did not renew his policy by paying renewal premiums and as such the policy was terminated as on date. The O.Ps have denied the other allegations as leveled by the complainant against them and took plea that there was no deficiency in service on the part of the O.Ps. the O.Ps have prayed for dismissal of the case.
The complainant as well as the O.Ps have filed evidence-on-affidavit and also filed written arguments in support of their respective cases.
We have also heard arguments from the both sides and also perused the materials on record meticulously.
Considering the above pleadings the following issues are necessarily come out to consideration to reach just decision of the case. Complainant has also filed some original documents with firisty. O.P side also filed document as per their firisty.
POINTS FOR CONSIDERATION
- Is the complainant a consumer u/s.2 (1)(d)(ii) of Consumer Protection Act, 1986 ?
- Has this Forum jurisdiction to entertain the instant case?
- Have the O.Ps any deficiency in service as alleged by the complainant?
- Is the complainant entitled to get any relief/reliefs as he prayed for?
DECISION WITH REASONS
Considering the nature and character of the case all the points are interlinked to each other as such all the points are taken up together for consideration for the sake of brevity and convenience.
It is evident on record that complainant is a Policy Holder of O.P vide his Policy No. PROHLRR0 10065281 and he has paid installment premium of the Policy Holder and Beneficiary. The O.Ps being an Insurance Company has received installment premiums from the complainant. It is also evident-on-record that several correspondence were made between the complainant and the O.Ps and during pendency of this case the complainant sent a request to the O.Ps to give his claim money through settlement but in lieu of giving the claim amount of Rs. 2,24,414.74/- the O.Ps have only paid Rs. 61,215/- .
Considering the above facts we find and hold the complainant is a bona fide consumer in terms of u/s.2 (1)(d)(ii) of Consumer Protection Act, 1986 under the O.Ps.
Whereas the complainant is a resident of Sharada Pally, P.O. & P.S. – Birpara, Dist. – Alipurduar, Pin – 735204 and O.P is a registered Insurance Company who used to deal with insurance business all over the India. As such we also find and hold that this Forum has territorial jurisdiction to try this case and whereas the claim amount is less than the pecuniary jurisdiction of this Forum as such this Forum has ample power to try this case.
On perusal of the materials available on the case record it is appeared that both side admitted that Insured Policy period is from 31/03/2016 to 30/03/2017. It is also admitted fact that the complainant has made only one premium amounting to Rs. 17,140.65/-. The complainant claimed the expensed amount of Rs. 64,414.74/- incurred medical treatment of his son the complainant no. 2 Md. Arbaj Ansari. It is revealed that despite claim of the complainant the O.P side has rejected the claim of the complainant vide their rejection letter dated 09/08/2016 (Annexure – ‘D’). During pendency of this case the O.P side admitted the claim of the complainant and sincerely apologized for delay in response to the claim of the complainant vide their letter dated Mon, Nov -7, 2016 at 3:40 PM. The O.P side stated in their petition for dismissal of the complaint that in view of the re-assessment, this opposite party has found an amount of Rs. 61,215/- is admissible towards the claim and the said amount has been paid to the complainant on 24th March, 2017 vide NEFT (transaction no. NFT – 170324683GN00079XXXXXXX) to the complainant’s Central Bank Account bearing no. 4000571030099531. In the written objection against the dismissal petition of the O.P side the complainant admitted that out of his claim amount of Rs. 2,24,414.74/- the O.P side has paid only Rs. 61,215/-. Therefore, it is crystally clear that during pendency of this case the O.P side made payment amounting to Rs. 61,215/- to the complainant despite his claim to the O.P side prior to filing this case. Under these circumstances we are of the view that the O.P side ought to pay or settle the claim amount of the complainant amicably prior to filing this case. The rejection on part of the O.P side has compelled the complainant to take the legal recourse against the O.Ps for which we have no hesitation to hold that there is deficiency in service on part of the O.P side.
Considering the positive results of the discussed points point no. 4 also bears positive result and that should be reflected in the ordering portion.
Thus all the points are disposed of accordingly.
Fees paid are correct.
Hence, for ends of justice; it is;-
ORDERED
that the instant case be and the same is allowed on contest with costs.
The complainant Md. Ashraf Ansari do get a decree of amounting to Rs. 64,415/- as his legitimate claim and he further do get a decree of Rs. 30,000/- for his mental agony and sufferings + Rs. 6,000/- as litigation costs against the O.Ps. All the O.Ps are hereby directed to pay the total decreetal amount of Rs. 1,00,415/- Minus(-) paid amount Rs. 61,215/- = Rs. 39,200/- (Thirty Nine Thousand and Two Hundred) only to the complainant jointly or separately in equal share within 30 days from this day failing which the complainant will be at liberty to put this decree into execution according to law.
In case of realization of the decreetal dues through execution the complainant be entitled to 8% interest per annum on the decreetal dues from the date of filing of this case from 17/02/2017 till liquidation of the entire decreetal dues.
