West Bengal

Paschim Midnapore

CC/55/2015

Smt. Rita Sarkar - Complainant(s)

Versus

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

15 Oct 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

And

 Mrs. Debi Sengupta, Member.

   

Complaint Case No.55/2015

                                                       

Smt. Rita Sarkar………………..….……Complainant.

Versus

Divisional Manager, United India Insurance Co. Ltd. & ano…..Opp. Parties.

 

              For the Complainant : Mr. Bidyut Kr. Pratihar, Advocate.

              For the O.P.                : -

 

Decided on: - 15/10/2015

                               

ORDER

                         Mrs. Debi Sengupta, Member - The case of the complainant in a brief, is that the complainant’s husband purchased a mediclaim policy of OP No.1 from its local branch office at Kharagpur covering himself as well as his spouse Smt. Rita Sarkar and his son. The policy No. of the mediclaim is 2013/48410000654/1 covering the period 03/03/2014 to 28/02/2015 for assuring a sum of Rs.2,00,000/-.

          Here the complainant was suffering from vomiting tendency and nausea with loss of appetite.  For proper treatment she went to Dr. Hirak Dasgupta M.B.B.S., M.D. (Medicine on 30/04/2014). He treated the complainant and after various tests the Dr. could not detect the actual ailments and referred the complainant to a specialist Doctor P.C. Das. She was examined by doctor P.C.Das on 29/09/2014 but he also could not detect the decease.

Thereafter the complainant as per the advice of agent of Op. No.2 admitted at Sanjiban Hospital for getting cashless treatment on 02/10/2014 Sanjiban Hospital referred the matter to Medicare TPA service(1) Pvt. Ltd. being Op. no.3 authorized agent of

Contd…………..P/2

                                                                      

( 2 )

OP. No.1 for cashless treatment  of the complainant. Op. No.3. Unfortunately by a letter dated 08/10/2014 denied of providing cashless facility to the complainant. But the complainant had to continue her treatment at Sanjiban Hospital. She was discharged from the said Hospital on 13/10/2014 on payment of Rs.69,121.00 towards medical bills.  Again  the complainant got her admission in Apollo Gleneagles Hospital, Kolkata on the same date on 13/10/2014. She was treated there for few days and discharged on 22/10/2014 with a advice of Haemodealysis thrice weekly basis and a bill of Rs.1,56,620/- had to be paid by the complainant to the Hospital authority.

The complainant had no health problem before her primary treatment. After through investigation the Sanjiban Hospital for the first time detected the problem of the complainant.

The complainant states in the complaint that there was no suppression of any material facts or the suppression about her preexisting decease.

The complainant states that she had a mediclaim policy covering the amount of cashless facilities and the Ops., have got no right to deny the same and refused to provide cashless facilities by the Ops. amount to deficiency in service having no other way the complainant has been forced to file this complainant before this Forum with a prayer to reimburse a sum of Rs.2,00,000/- and  also prayed for damage for non providing cashless facility and other relief/reliefs.

Thus the complainant is the consumer under the Op. Therefore the complainant is entitled to get compensation from the OP.

The Ld. Advocate for the complainant filed relevant documents on the point of service of notice. So there exists a strong reason to believe that the OPs are willfully avoiding their appearance in this case. In view of the present circumstances in the materials on record there are no option but to hear the case ex parte.

In this connection some documents namely photocopy in patient bills, discharge summery and certificate interim bills inpatient bill, interim bill prescription of Doctor Hirak Dasgupta, rejection letter of Rita Sarkar insurance policy has been filed by the complaint.

We have carefully considered the case supported by the above documentary evidence. So, it is a fit case to hold but the complainant has proved the allegation deficiency in service against the Op.

Contd…………..P/3

 

   ( 3 )   

                   

Decision with reasons

                             That such refusal/denial of cash less facility of the complainant is deficiency in service from the side of OP. The complainant being a consumer under the provisions of C.P.

            Act, under the given facts and circumstances and observation above this is a fit case held that the allegation of deficiency of service against the Ops.    

                                                  Hence, it is,

                                                                       Ordered,

                                                                               that the complaint case be and the same is allowed exparte.

   Op be directed to reimburse a sum of Rs.2,00,000/-(Two lac) to the complainant and the Ops. be also directed to pay a sum of Rs.30,000/-(Thirty thousand) as damage for not providing cashless facility to the complainant within sixty days from the date of this orders. In default the complainant is at hereby to proceed with the matter in accordance with the provisions of law in this behalf.

             Dictated & Corrected by me

             

                           Member                                                                                     President

                                                                                                                          District Forum

                                                                                                                      Paschim Medinipur