IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MURSHIDABAD AT BERHAMPORE.
CASE No.CC 40/2016.
Date of Filing: 16.03.2016. Date of Final Order: 16.03.2017.
Complainant: Barendra Kr. Roy, S/O Late Abja Prakash Roy, 61, R. N. Tagore Road,
P.S. P.O. Berhampore, Dist. Murshidabad.
-Vs-
Opposite Party: 1. Divisional Manager, The New India Assurance Co. Ltd, Berhampore Division.
37A, R. N. Tagore Road, Berhampore, Dist. Murshidabad. Pin 742101.
2. Branch Manager, Heritage Health TPA Service Ltd. Nicco House,5th Floor,
2, Hare Street, Kolkata-1.
Present: Sri Anupam Bhattacharyya …………………. President.
Sri Samaresh Kumar Mitra ……………………..Member.
Smt. Pranati Ali ……….……………….……………. Member
FINAL ORDER
Smt. Pranati Ali, Presiding Member.
Instant complaint has been filed by the complainant u/s 12 of C. P. Act, 1986 , for the direction to the OP to pay the claim amount of Rs.61,542/- and Rs.30,000/- as compensation to the complainant.
The complainant’s case, in brief, is that the complainant obtained a Medi-claim Policy with the OP for the safety and security of health of the complainant and his family members being vide No. 51290034140100000040. According to the complaint, the policy was introduced on 25.02.2010 and since it was renewed by paying premium regularly. On 17.08.2015 the daughter-in-law of the complainant/Smt Ananya Roy was suffered from serious bodily pain during pregnancy period and met her doctor/Dr Sanjib Mukherjee for treatment. After examination the doctor considered the case of emergency and advised to take admission in the Hospital for surgical operation as the doctor opined that the life of the mother and baby in womb was in danger. Next day on 18.08.2015 the Doctor performed the operation. The complainant spent Rs.61,542/- in total for the said operation and treatment of Smt Ananya Roy. After discharged from the Hospital, Smt Ananya Roy lodged a claim to the OP and the OP received the claim on 28.08.2015.But the OP was silent regarding the claim. On 13.01.2016 the complainant met and requested personally to the OP then on 20.01.2016 the OP without assigning any sufficient reason or causing any investigation turned down the claim of the complainant. Without considering the merit of the claim, the same was refused by the OP is an act of deficiency in service on the part of the OP. So, the complainant case to this Forum for proper redress.
On the other hand the OP No.1 appeared in this case by filing written version, where he denied all the material allegations made by the complainant. According to OP No.1 the complainant purchased policy in the name of daughter not daughter-in-law. The OP No.1 also denied that doctor’s advice as emergency case is false and even the expenditure amount of Rs.61,542/- by the complainant also a false statement. The OP No.1 further stated that as per exclusion Clause 4:4:13 of the policy Term Condition, the claim is not covered, which was obtained an Expert Medical Opinion from Dr. Vineet Kr. Mittal , MBBS, FIAGP. FILL, Dip, Health Insurance (III) Red. No. 49634 dt. 05.06.2016. So, the complaint is liable to be rejected.
The OP No.2 in spite of receiving notice did not turn up. So, the case proceeds ex parte against the OP No.2.
The only point for consideration is whether there is any deficiency in service on the part of the OP or not and whether the complainant is entitled to get any relief or not.
Decision with Reasons.
Both the parties submitted some documents in support of their case.
Perused the documents on the record, we observed that the only major dispute was that the OP repudiated the claim on the basis of clause 4:4:13 of the Policy, but the complainant argued on the basis of exceptional point of the same clause, i.e. certification by Gynecologist that it is life threatening. The said emergency abdominal operation was done by the doctor for internal bleeding of the pregnant lady with PN, APH, GDM to save the life which was evident by the submitted prescription of the concerned doctor, supportive expenditure bills related to the operation along with some computer generated documents explaining the reasons behind the emergency of the operation for saving life of the patient. So, the repudiation of the claim by the OP is not justified. It is a deficiency in service on the part of the OPs.
Record shows that the OP repudiated and returned all the original medical papers through letter dt. 20.01.16 which was submitted by the complainant. But the OP submitted written version along with a repudiation report signed by Dr. Vineet Kr. Mittal, Health Insurance Consultant of the OP dt. 05.06.2016 whereas this case if filed on 16.03.2016. All these are the example avoiding the payment to the complaint, which is negligence/deficiency in service by the OPs.
Regarding claim amount the OP has no whisper in the record. So, we can assume that OP has approved the amount and the complainant is entitled to that amount as per policy.
On the basis of above discussions and considering the documentary evidence we are of the view that the complainant is entitled to get claim amount of Rs.61,542/- along with Rs.5,000/- as compensation for harassment by the OPs.
Hence,
Ordered
that the Consumer Complaint No. 40/2016 be and the same is hereby allowed on contest without any order as to cost.
The OPs are jointly and/or severally directed to pay the claim amount of Rs.61,542/- along with Rs.5,000/- as compensation for harassment to the complaint within 60 days from the date of receipt of this order, f ailing which the OPs have to pay cost of Rs.50/- per day’s delay and the same is to be deposited in the Consumer Legal Aid Account.
Let a plain copy of this order be made available and be supplied free of cost, to each of the parties on contest in person, Ld. Advocate/Agent on record, by hand under proper acknowledgment / be sent forthwith under ordinary post to the concerned parties as per rules, for information and necessary action.
