West Bengal

Paschim Midnapore

CC/117/2015

Balai Das - Complainant(s)

Versus

Divisional Manager, National Insurance Co.Ltd. - Opp.Party(s)

Subal Chakraborty

29 Jul 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President

and

Mrs. Debi Sengupta, Member

   

Complaint Case No. 117/2015

Balai Das, S/o, Late Jugal Kishore Das,

Vill.- Manikpur, P.O. & P.S. Medinipur,

Dist.- Paschim Medinipur, Pin-721101……..….……Complainant.

Versus

 

1. Divisional Manager, National Insurance Company Ltd., Medinipur Division Office,  At- Station Road, P.O. & P.S. Medinipur, Dist- Paschim Medinipur
2. Rothshield Health care (TPA) Services Ltd., Corporate Office 402 Raheja Chambers, Nariman Point Mumbai-400021, India..………...........…..Opp. Parties.

 

              For the Complainant: Mr.  Subal Chakraborty, Advocate.

              For the O.P.               : Mr. Anath Bandhu Ghosh, Advocate.

 

Decided on: -29/07/2016

                               

ORDER

                          Bibekananda Pramanik, President – Facts of the case, in brief, is that the complainant is a policy holder under the opposite party- National Insurance Company Ltd. i.e. the opposite party no.1 for Parivar Medi-Claim policy being no.153800/48/14/850000168 and the date of proposal and declaration of that policy was 20/12/2010.  Thereafter the complainant continued the said policy during the policy period from 03/01/2015 to 2/01/2016 and the  sum insured is Rs.5,00,000/-.  Opposite party no.2 is the TPA of that policy.  Sangita Das, daughter of the complainant, aged about 25 years is also included in the said Parivar Medi-claim Policy. She was admitted in Christian Medical College Clinical Immunology and Rheumatology with symptoms by lateral knee

Contd………………P/2

 

                                                                                             ( 2 )

 and wrist pain with swelling for the period from 6/2/2015 to 9/2/2015.  The complainant thereafter submitted two claims to the opposite party firstly, on 23/1/2015 for Rs.1,39,650/- and secondly, on 6/02/2015 for Rs.1,36,210/-.  Out of those two claims, the opposite party settled the first claim by paying an amount of Rs.1,38,845/- but in case of second claim, the opposite party has only settled a sum of Rs.11,155/- against the claim  of Rs.1,36,210/-.  It is stated that though the insured amount of the above policy is Rs.5,00,000/- but the opposite parties have paid only Rs.1,38,845/- + Rs.11,155/- i.e. total Rs.1,50,000/-. The opposite party illegally repudiated the rest claim which is beyond the norms and condition of the policy.  Opposite party most illegally violated the policy condition and did not pay an amount of Rs.1,25,055/- to the complainant.  By a notice dated 31/7/2015, through his Advocate Subal Chakraborty, complainant demanded the claim amount but opposite party paid no heed to such notice.  Hence the complaint, praying for directing the opposite party to make payment of the claim benefit of policy amount into Rs.1,25,055/- and compensation of Rs.50,000/- with interest. 

                     Opposite party no.2 received notice of this case but he did not appear to contest this case.   Hence the case was order to be heard ex parte against opposite party no.2.

                The opposite party no.1 has contested this case by filling a written objection.                                  

                Denying and disputing the case of the complainant, it is the specific case of the opposite party no.1 that the complainant submitted claim form along with related papers to them and from the said claim form along with related papers opposite party no.1 came to know that the complainant’s wife Sangita Das was admitted in Christian Medical College for undergoing treatment of Enthesitis with related Arthritis Osteopenia.  After receiving such claim form, process of the claim was started and after processing the claim on basis of the documents, opposite party-Insurance Company sent an amount of Rs.1,38,845/- only to the complainant against bill amount of Rs.1,39,650/- only as per assessment of opposite party no.2.  Thereafter the insured paid Rs.11,155/- only to the complainant against bill no.D930392  dated 25/01/2015, B032634881 dated 19/01/2015 and D930392 dated 25/01/2015 total amounting to Rs.11,155/- but the opposite party-Insurance Company paid Rs.11,155/- to the complainant.  It is stated that the amount of Rs. 1,09,760/- was deducted for the reason that sum insured was exhausted.  Hence, excess amount was deducted and also deducted the bill no.B032658463 dated 19/01/2015 of Rs.15,000/- due to  non-submission of bill details.  It is stated that there is no deficiency in service on the part of the opposite party and the settlement of claim was done following

Contd………………P/3

                                                                                            ( 3 )

the policy condition and other factors as stated above and it cannot be said to be unjust and improper.  Opposite party no.1 therefore claims dismissal of the complaint with cost.

  

Point for decision

                       Is the complainant entitled to get the reliefs, as sought for ?    

                   

Decision with reasons

     In this case, neither the complainant nor the opposite party has adduced any sort of evidence, either oral or documentary,  but they have relied upon some documents, so filed by them.

     Admittedly,  the complainant obtained the Parivar Medi-Claim policy for himself and his family members from the opposite party-Insurance Company vide policy no.153800/48/14/8500001681 and initially the said policy was enrolled with sum assured of  Rs.3,00,000/- and subsequently the said amount was enhanced to Rs.5,00,000/- w.e.f. 3/1/2014.  It is also admitted that after submission of claim form regarding the said mediclaim policy, the opposite party-Insurance Company paid Rs.1,50,000/- to the complainant towards 50% of sum assured of Rs.3,00,000/-.  According to the complainant since the sum assured was subsequently enhanced to Rs.5,00,000/-, so they are entitled to get 50% of Rs.5,00,000/- i.e. Rs.2,50,000/- but instead of paying the said amount, the opposite party has paid only 1,50,000/- and they illegally repudiated the rest claim amount of Rs.1,25,055/-.  As against this, it is the case of the opposite party that admittedly the claimant is having Arthritis and as per policy clause 4.1 was pre existing and the claimant is entitled to get benefit of the enhanced sum assured i.e. Rs.5,00,000/-  after completion of 4 years from  enhancement.   It is not denied and disputed  that the sum assured Rs.3,00,000/- was enhanced to Rs.5,00,000/-w.e.f. 3/1/2014. So according to the said clause 4.1 of the policy condition the claimant is entitled to get 50% of that enhanced amount of Rs.5,00,000/- after completion of 4 years from the date of enhancement.  Therefore the opposite party has rightly allowed 50% of initial sum assured of Rs.3,00,000/- and they did no illegality in not allowing 50% over the enhanced amount of Rs.5,00,000/- since 4 years have not yet been completed after the date of enhancement of the policy amount.  Therefore, we find no illegality in repudiating the further claim of Rs.1,25,055/- and in repudiating the said amount of claim, the opposite party–Insurance Company committed  no deficiency in service.  We therefore find no merit in the petition of complaint and the same is therefore liable to be rejected.

Contd………………P/4

 

( 4 )

 

                                                  Hence, it is,           

                                                                      Ordered,

                                   that the complaint case no.117/2015  is hereby dismissed on contest but in the circumstances without cost.

                               Let plain copy of this order be given to the parties free of cost.

 

            Dictated and Corrected by me

                      Sd/-B. Pramanik.                            Sd/- D. Sengupta.                 Sd/-B. Pramanik. 

                           President                                           Member                              President

                                                                                                                            District Forum

                                                                                                                         Paschim Medinipur