Order No. -28 Dt.-26/06/2015
Smt. Bina Choudhuri, Member
This is an application u/s 12 of the C.P.Act, 1986 filed by Sri. Bipin Behari Gupta, complainant against the Divisional Manager, National Insurance Co. Ltd. and Md. India Health Care Services (TPA) Pvt. Ltd.
Complainant’s case in brief is that the complainant is a mediclaim policy holder being policy no. 153900/48/11/8500001724, sum assured Rs.2,00,000/- for the period 20/09/2011 to midnight 19/09/2012 of National Insurance Company Ltd., Thana More, Jalpaiguri. The complainant admitted the Max Super Speciality Hospital on 20/03/2012 with secondary Osteoarthritis of his left hip and released from hospital on 29/03/2012 and for his treatment he has to bear a sum of Rs.3,84,013/- only . It is alleged that the aforesaid Insurance Company settled a part amount of Rs.55,250 only but about rest amount is silent. The complainant already submitted all relevant documents and repeatedly knocked the door of the Insurance Company and lastly he send a legal notice through his Ld. Advocate to the Divisional Manager, National Insurance Company Ltd, Thana More, Jalpaiguri on 24/05/2013 but no response has yet been made.Hence this case.
The claim of the complainant is Rs.1,00,000/- for his treatment and Rs.10,000/- is for mental harassment
The O.P.no 1 Insurance Company has contested this case by filing Written version denying and disputing the claims and contentions of the complainant with prayer for dismissal of the case. But O.P.no.2 Md. India Health Care Services(TPA) Pvt. Ltd. did not turn up before the Ld. Forum inspite of receiving the notice to contest the case.
POINTS FOR CONSIDERATION.
1.Is the complainant a consumer as per C.P.Act?
2.Is the case maintainable as alleged ?
- Is/Was there any deficiency of service on the part of O.Ps. as alleged?
- Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
All four points are taken up together for consideration and decision for the sake of convenience.
We have gone through the Complaint petition, xerox copies of documents filed by the complainant, written versions, filed by O.P. No.1 and written arguments filed by both parties and also heard the oral arguments advanced by the Ld. Lawyers of both parties.
It is admitted that the complainant is a mediclaim policy holder of O.P.1. So, the complainant is a consumer as per provision of the C.P.Act.
Now after due consideration of arguments advanced by the Ld. Lawyers of both parties and on perusal of materials on record filed by the complainant we find that the O.P. has already paid a sum of Rs.55,250/- only to the complainant but in respect of his dues claim insured amount the O.P. is totally silent inspite of his repeated request. Lastly the complainant sent a legal notice to O.P.1 on 24/05/2013 requesting to settle the claim within 15 days of receipt of the notice. Receiving the legal notice, O.P.1 wrote a letter only on 27/05/2013 to O.P.2 requesting him to send the file of the complainant to O.P.1, immediately. But thereafter no action has been taken by the O.P.1 for settlement of the claim. In the written argument filed by O.P.1 has stated that the claimant accepted the amount with full and final settlement to enjoy the said amount but in his written version he didn’t agitate this point, even O.P.1 couldn’t submit discharge voucher or single paper/documents before the Ld. Forum from which it could be presumed that the part payment was made with full and final settlement and complainant has accepted the payment as full and final settlement of the claim. Inspite of repeated knocking by the complainant the O.Ps. remain silent regarding full and final settlement of the claim of the complainant till filing of Written argument. Therefore we find and hold that as there was no response from the insurance company about the insurance claim till long period it amounts to deficiency in service on the part of the O.P. Insurance Company.
In view of the matter we find and hold that the complainant is entitled to get Rs.1,00,000/- from the O.P. for their deficiency of service for non-payment of insured amount and we think that there is no necessity to pay compensation to the complainant.
All four points are disposed of .
In the result the case/application succeeds.
Hence, it is
O R D E R E D
that the case is allowed on contest in part without cost against O.P.1 and ex-parte against O.P.2. The complainant do get an award of Rs.1,00,000/- only. The O.P.1 National Insurance Co. Ltd. is hereby directed to pay to the complainant the aforesaid awarded amount within one month from this date failing which the O.P.1 shall have to pay interest @Rs.8% p.a. on awarded amount of Rs.1,00,000/- till realisation and the complainant shall be at liberty to realize the same by putting this order into execution in accordance with law.
Let copy of this final order be supplied to the parties free of cost forthwith in terms of Rule.5(10) of West Bengal Consumer Protection Rules 1987.
