IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MURSHIDABAD AT BERHAMPORE.
CASE No.CC/93/2014.
Date of Filing: 10.07.2014. Date of Final Order: 01.03.2017.
Complainant: Swapan Chowdhury, S/O Late fate Chand Chowdhury,
Vill. Dakshin Sundarshanganj, P.O.& P.S. Lalgola, Dist. Murshidabad.
-Vs-
Opposite Party: 1. Divisional Manager, National Insurance Co. Ltd, Berhampore Branch,
26/23/1, S.S. Sen Road, P.O.& P.S. Berhampore, Dist. Murshidabad, Pin-742101.
2. Divisional Manager, Genins India TPA Ltd,
Office at 19, R.N. Mukherjee Road, 2nd floor, Kolkata- 700001.
3. The Manager, MD India Health Care Services (TPA) Pvt. Ltd.
169, Sarat Bose Road, 3rd floor, Kolkata-26.
Present: Sri Anupam Bhattacharyya …………………. President.
Smt. Pranati Ali ……….……………….……………. Member
FINAL ORDER
Sri Anupam Bhattacharyya, Presiding Member.
The instant complaint has been filed by the complainant u/s 12 of C. P. Act, 1986 praying for payment of Rs.1,22,629/- for medical expenses towards claim of medi-claim Insurance Policy and for compensation of Rs.10,000/- and cost of Rs.2000/-.
The complainant’s case, in brief, is that the complainant had medi claim policy No. 154000/48/12/850000109 for the period from 22.8.12 to 21.8.13 from OP No.1 through OP No.2&3 and the same was commenced from 22.6.2005. The complainant was admitted at Belle Vue Clinic; Kolkata on 20.12.12 with abdomen pain where bilateral Inguinal Harnia operation was held by Dr. Bishnu Kr. Vartia on 21.12.12 and discharged on 24.12.12 and the s aid disease was first detected by Dr. Subhas Dugar on 5.11.12. The complainant spent Rs.1, 22,629/- for such treatment. He applied claim amount for reimbursement to OP No.1 by letter dt. 28.1.13 and also to OP No.2. Thereafter, the complainant filed another application dt. 21.3.14 claiming Rs.1, 22,629/- to OP which was received on 24.3.14 by OP Insurance Company. The complainant requested the OPs for payment several times but neither paid nor repudiated and such inaction is deficiency on the part of the OP-Insurance Company. Then, the complainant has filed the instant complaint. Hence, the instant complaint case.
The written version filed by the OPNo.1 National Insurance Co. Ltd , in brief, is that the complainant did not follow the mandatory provisions of the policy. The complainant ought to have file documents before the OP No.3, MD India Health Care Services but did not file the same there. As the complainant has violated the terms and conditions of the Policy, he is not entitled to get any relief and prays for rejection of the claim petition. Hence, the instant written version.
Considering the pleadings of both sides the following points have been raised for the disposal of this case.
Point for Consideration.
- Whether the complaint is maintainable in its present form and law?
- Whether the case is bad for mis-joinder of parties?
- Whether the case is barred by limitation?
- Whether the complainant is entitled to get relief as prayed for ?
- To what other relief/reliefs the complainant is entitled to get?
Decision with Reasons.
Point Nos. 1 to 5.
All the points are taken up together for the sake of convenience.
The instant complaint is for payment of Rs.1,22,629/- for medical expenses towards claim of medi-claim Insurance Policy and for compensation of Rs.10,000/- and cost of Rs.2000.
On the other hand the OP’s case is that complainant did not follow the mandatory provisions of the policy. The complainant ought to have file documents before the OP No.3, MD India Health Care Services but did not file the same there. As the complainant has violated the terms and conditions of the Policy, he is not entitled to get any relief.
In this case the complainant himself has filed evidence on affidavit and tendered for cross-examination on dock and he was cross-examined by the Ld. Lawyer for OP-Insurance Company in full and has filed the relevant documents including the bill and voucher for his treatment in Belle Vue Clinic, Kolkata.
On the other hand the OP has filed the concerned Medi-claim Policy document and a calculation sheet as to extent of entitlement of claim of the complainant according to coverage.
In this regard the Ld. Lawyer for the OP-Insurance Co has advanced argument that the coverage of the impugned Medi-claim Policy is for Rs.30,000/- where the complainant has claimed Rs.1,22,629/-.
He has advanced argument referring the terms of policy against the claim towards particular head of expenses that the complaint is entitled to get 1% of coverage towards room charge which is Rs.300/- per day where entitled room charge will be Rs.1200/-.
Similarly, the complainant is entitled to get Rs.7500/- towards Medical Practitioner’s fees as per Clause 2.2 is 25% of the sum insured ie. Rs.30, 000/- x25% = Rs.7500/-.
Regarding other expenses as per clause 2.3 for any one illness is 50% of sum insured which is Rs.15, 000/-.
Regarding the objection of the OP No.1 Insurance Co. Ltd as raised in written version as to non-compliance of the terms of the policy in the matter of filing documents through Op no.3 the complainant P.W-1 has deposed in his cross-examination that his policy is with OpNo.1-National Insurance Co. Ltd and for that he did not intimate Op no.2&3 for his treatment.
He has also deposed in cross that he filed all the relevant documents to OP No.2 but did not submit the same to OP No.3.
Considering the materials on record and considering the arguments advanced by both sides as discussed above we are in the agreement with the argument advanced by the Ld. Lawyer for the OP-Insurance Company as to entitlement of the claim of the complainant for expenses towards medical treatment in total Rs.23,700/- already discussed in detail with break-up and as such we find that the complainant is entitled to get only Rs.23,700/- along with interest @7% p.a. from the date of filing the instant complaint before this Forum on 10.7.14 till realization.
On the basis of above discussions we find that all the points are disposed of in part in favour of the complainant and as such we find that the complainant is entitled to get Rs.23, 700/- along with interest @7% p.a. from the date of filing claim application before OP No.1 till realization.
According to settled principle interest being allowed the complainant is not entitled to get any further amount towards compensation.
The complainant having no claim against the OP Nos. 2&3, the case be dismissed against the OP Nos. 2&3.
Hence,
Ordered
that the Consumer Complaint No. 93/2014 be and the same is hereby allowed on contest in part.
The complainant is entitled to get Rs.23, 700/- along with interest @7% p.a. from the date of filing the instant complaint before this Forum on 10.7.14 till realization.
The OP No.1-Divisional Manager, National Insurance Co. Ltd. is directed to pay Rs.23, 700/- to the complainant along with interest @7% p.a. from the date of filing this complaint before the Forum on 10.7.14 till realization within two months from the date of this order failing which the OP No.1 is directed to pay Rs.50/- as fine for day’s delay and the amount so accumulated shall 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.
