The instant case was instituted on the basis of a written complaint filed by one Susanta Modak, S/O. Subhash Modak P.O & P.S. Kaliaiganj, District Uttar Dinajpur u/s.12 of Consumer Protection Act, 1986 which was registered as Consumer Case No. 33/17 in this Forum.
The fact of the case as revealed from the petition of complaint as well as the evidence is that the complainant is an agent of LICI and he purchased a Group Mediclaim Insurance Scheme policy for Club Member Agents from the New India Assurance Company through LICI in the year 2012 – 2013 being policy No.120300/34/12/05/00000001 and it was renewed for the year 2013 – 2014 and the renewed policy No.12030034130500000001. In the year 2013 the complainant was suffering from various illnesses and he was treated by local doctor. The local doctor referred him for better treatment. Then he went to Nila Hospital, Chennai. After Primary checkup he was admitted there where the doctor after check up given him report as type II Diabetes mellitus, Lichen Planus Tongue, Balamophosthitis and anxiety disorder and he was taken to O.T. The complainant admitted in the hospital from 20.08.13 to 01.09.13. The total medical expenses was Rs.28,253/-. After discharge the complainant returned back on 13.09.13 and submitted his claim for medical reimbursement at LICI office, Kaliaganj Branch, Uttar Dinajpur along with all original medical papers. But the LICI did not respond even after expiry of six months. Thereafter the complainant further informed the O.P.No1 and other O.Ps several times through letter, telephone and email. Lastly on 21.12.14 the complainant sent all medical documents to the O.Ps but ultimately the O.Ps did not give any positive result for which the complainant was compelled to file the case before this Forum claiming compensation of Rs.28,253/- with interest for medical reimbursement, Rs.1,00,000/- for harassment and metal pain and agony, compensation Rs.1,00,000/- and Rs.50,000/- as litigation cost.
The petition has been contested by filing separate written version on behalf of O.P.No.1 and 2/LIC in which the LIC has denied the entire materials allegation as leveled against the LIC contending inter alia that the instant case is not maintainable in its present form.
The definite defence case is that the mediclaim policy is service by New India Assurance Co., Bombai and reimbursement of claim will be provided by the New India Assurance Co. Ltd. through their T.P.A Medi Assist. India, T.P.A. Pvt. Ltd. As such the LIC has no legal right or power to interfere with the acts and activities of the T.P.A. The further defence case is that the O.P/LIC is not responsible for settlement of the mediclaim. As it is agreed at the corporate level that the mediclaim policy will be serviced by the New India Assurance Co. Pvt. Ltd. through their T.P.A Medi Assist. India T.P.A. Pvt. Ltd. The further defence case is that there was no deficiency in service on the part of LIC and the LIC did not make any unfair trade practice, as such the instant case is liable to be dismissed.
The defence case as made out by the O.P.Nos.4 &5 i.e New India Assurance Co. Ltd. is that the complainant was suffering from various ailments and he was treated locally and ultimately he was treated at Nila Hospital, Chennai where the doctor opines that the complainant was suffering from type II diabetes Melaitus.
The definite defence case is that the instant case is barred by law of limitation and the case is not filed within the period of limitation. The further defence case is that the patient was not referred by any doctor for higher treatment and the nature of treatment can be done only as outdoor patient, as the complainant was suffering from Type II diabetes. Considering such facts and circumstances the instant case is liable to be dismissed with cost.
DECISION WITH REASONS:-
At the time of argument the Ld. Lawyer of the complainant argued that the complainant was treated at Nila Hospital as he was suffering from different ailments in the year 2013. Ultimately the complainant was referred by local doctor for higher treatment. The Ld. Lawyer of the complainant further submitted that the complainant was admitted to Nila Hospital for primary checkup at Chennai where the doctor opined on the basis of report that the complainant was suffering from type II diabetes melaitus, Lichen planus Tongue, Balamophosthitis and anxiety disorder. For which the complainant was admitted to Nila Hospital from 20/08/2013 to 01/09/2013 and his medical expenditure was Rs.28253/-. The O.Ps did not pay the amount as such the instant case has been filed.
On the other hand the Ld. Lawyer of the O.P Nos- 4 & 5 argued that the complainant is not entitled to get any amount as the policy does not permit to grant such relief as prayed for. As such the claim of the complainant is to be dismissed. Now it is to be considered whether the complainant was referred by any local doctor for higher treatment. In Para 2 of the petition it has been mentioned that the complainant was treated by local doctor and ultimately the complainant was referred by the local doctor. But not a single prescription has been filed by the complainant to show that the complainant was referred by any local doctor. Though in the cross examination of P.W1 has stated that the complainant was treated by local doctors namely S.K.Ghosh, Dr. Sekhar Bandhapadhay, Dr. Himadri Sekhar Mazumdar at kaliyaganj, Dr. Arup Ghosh at Siliguri, Dr. Saikat Saha at Siliguri and Dr. Barman. But not a single prescription has been filed by the complainant to prove that he was advised by any doctor for higher treatment. The Ld. Lawyer of the O.P / Insurance Company submitted that as per policy “if during the continuance of the policy any insured person shall contract any disease or suffer in from any illness ( herein after call disease) or sustained any bodily injury through accident ( herein after called injury) and if such disease or injury shall require any such person, upon the advice of a duly qualified physician / Medical specialist / Medical practitioner ( herein after called Medical Practitioner) or of a duly qualified surgeon ( herein after called Surgeon) to incur hospitalization / domiciliary Hospitalization expenses for medical / surgical treatment any Nursing Home / Hospital in India are herein defined ( herein after called Hospital) as an impatient, the company will pay to the insured person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably and necessarily thereof by or on behalf of such insured person, but not exceeding the sum assured for the person in any on period of such insurance as mentioned in the schedule hereto”. So, according to the terms and conditions of the policy he must be referred by a doctor but no where it is found that the complainant was referred by any doctor. Moreover, on perusal of the report of Nila Hospital it was found that the complainant was suffering from type II Diabetes. That indicates before the policy the complainant was suffering from diabetes and the policy was done in suppression of the fact that the complainant was suffering from diabetes. Such concealment of the fact is a good ground of repudiation of the claim. So considering such facts and circumstances the claim as prayed for by the complainant is not entertainable. The Ld. Lawyer of the O.P further argued that the case is barred by law of limitation and the instance case has been filed after lapse of 2(two) years. But the argument as raised by the Ld. Lawyer of the O.P is not tenable as because the Insurance Company on 09/10/2015 gave a reply of the letter dated 26/09/2015 and the instant case was filed on 17/05/2017. So the instant case has been filed within 2 (two) years. Considering such facts and circumstances the instant case is liable to be dismissed.
C. F paid is correct,
Hence, it is
ORDERED:-
That the complainant case being No. CC-33/17 be and the same is dismissed but without any cost.
Let a copy of this order be given to the parties free of cost on proper application.
