BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

CACHAR :: SILCHAR

Con. Case No. 5 of 2016

                        Sri Dipak Kumar Dass,

                        Vill- Talugram Part-1, P.O- Sonaimukh.

                        P.S.- Sonai & District- Cachar, ………………………………  Complainant.     

                                                                        -V/S-

            1.         Heritage Health TPA Pvt. Ltd. Represented by its Manager. 

                        Nicco House, 5^th Floor, Hare Street.

                        Kolkata, West Bengal, 700001……………………………..… Opp. Party No.1

            2.         The Branch Manager, United India Insurance Co.Ltd.

                        Silchar Division Shillongpatty, (Shyamaprasad Road),

                        Silchar Town, P.O. & P.S. Silchar……………………………  Opp. Party No.2

Present: -                                Sri Bishnu Debnath,                                                 President,

District Consumer Forum,

                                                Cachar, Silchar.                                            

Mrs. Chandana Purkayastha,                      Member,

                                                            District Consumer Forum,

                                                            Cachar, Silchar.                                            

                                                            Shri Kamal Kumar Sarda,                           Member,

                                                            District Consumer Forum,

                                                            Cachar, Silchar.      

                   Appeared :-     Mr.  Ansarul Hoque, Advocate for the Complainant.

                                             Sri   Jagathjyoti Paul, Advocate for the O.Ps.

                         Date of Evidence                                          29-08-2016, 03-10-2016

                         Date of written argument                            21-12-2017, 20-02-2018

                         Date of oral argument                                 14-03-2018, 15-03-2018

                         Date of judgment                                         09-05-2018     

JUDGMENT AND ORDER

                  Sri Bishnu Debnath,

1. The Complainant Dipak Kumar Dass brought the instant complaint against United Insurance Co. Ltd. Silchar Division and against Heritage Health TPA Pvt. Ltd. under the provision of Consumer Protection Act, 1986 for award of compensation for not settling his Mediclaim with his satisfaction.

    

2. The following fact is brought before this District Forum for award of compensation. He purchased Mediclaim Health Insurance Policy No. 130500/48/12/97/00000921 and 130500/48/13/97/00000913. The Period of Insurance was from 06/03/2013 to 05/03/2014. As he felt ill as per advice of Doctor of S.M.Dev Civil Hospital Sonography of his abdomen was done on 12/06/2013. Report revealed 22mm stone detected on right side Kidney. Accordingly, Dr. Aniruddha Biswas started treatment through Lithotripsy from 24/07/2013 to 02/07/2014. During treatment he spent Rs.27,339.93/- and accordingly submitted claim of reimbursement before the Branch Manager (Divisional Manager) of United Insurance Co. Ltd. on 04.01.2014. But the O.P. settled the Claim at Rs.19,159/-against claim of Rs.27,339.93. Hence, he by his letter dated 23/03/2015 demanding the balance amount of 6,373/- but O.P. did not responded.

3. The O.P. Insurance Co. with W/S stated inter alia that the claim was settled by Heritage Health TPA (Third Party Administrator) Pvt. Ltd. as per Mediclaim Rules and Policy condition and total claim amount settled at Rs.19,159/-. The balance amount of Rs.6373/- were not admitted for the reason stated in Annexure ‘A’. The O.P.No.1, i.e Heritage Health TPA Pvt. Ltd. did not submit any W/S.

4. During hearing the Complainant submitted deposition with documents. The Insurance Co. also submitted deposition of Sri. Dilip Kumar Dey, the Assistant Manager and exhibited the Annexure ‘A’ and another documents. After closing evidence both side above submitted written argument.

5. I have heard both sides’ counsels, perused written argument and evidence on record.

6. It is admitted fact that the O.P. settled the claim of the Complainant at Rs.19,159/- and the claimant demand the balance claim amount of Rs,6373/- which was repudiated by the O.P. for the reasons stated in the Ext.A.

7. I have gone through the content of Ext.A. As per that the document Rs.300/- was not admitted as consultation fees of Doctor because printed money receipt was not produced by the Complainant. The O.P. also did not admitt the amount of Rs.1250 as charge of CT scan because original report is not produced. More over O.T. charge of Rs.2000/- was not admitted because no proper printed money receipt produced by the complainant.

8. I have gone through the complaint and deposition of the Complainant to find out as when C.T. scan was done and as per whose advice the same was done. Nothing whispered in the Complaint as well as in the evidence that C.T. scan was done. So, the O.P. has rightly denied the receipt of C.T for Rs.1250/-.

9. Moreover I do not find in the exhibited document any receipt of consultation fees of Doctor. That is why, it is also held that the O.P. rightly denied Rs.300/- as consultation fees of Doctor.

10. However, in this case from evidence on record it is crystal clear that lithotripsy was done under care of Dr. A. Biswas from 24/04/2013 to 02/07/2014 and accordingly the Complainant exhibited a bill of OT charge etc. vide Ext.6 (19). The O.P. raised objection on the ground that said OT charge of Rs.2000/- cannot be admitted because no proper printed money receipt submitted by the Complainant. In this aspect I have gone through the Ext. 6 (19). The said document bears the date, serial number and signature. So, I do not find any reason to disallow the said document by the O.P. This is a money receipt because all essential particular are available. Hence, in my opinion, the O.P. committed disservice by the rejecting the Ext. 6(19).

11. Anyhow, as per Ext.A the O.P. rejected some receipt of Medicine on the plea that some receipt bear date 30 days prior to the date of admission for treatment and some other documents bear dates acrossing 60 days from the date of discharge.

12. From the evidence on record it is crystal clear that actual lithotripsy was conducted from 24/07/2013 to 02/07/2014 vide Ext.9. Thus, as per Insurance Policy Rule vide 3.30 and 3.31, the Complainant is not entitled reimbursement of any expenditure for the said illness prior to the date on 24/06/2013 and after discharge exceeding date on 02/09/2014 which means he is entitled to reimbursement expenditure for treatment for the period from 24/06/2013 to 02/09/2014. The Ext. A revealed that a Bill No. 195 was raised on 08/02/2013 i.e 30 days prior to the date of conducting lithotripsy. So, the Claimant is not entitled to reimbursement the bill amount of Rs.610 only. But all other medicine bill mentioned in the Ext.A raised within the period as per the Insurance rules.

13. Therefore, the Complainant is entitled balance amount of Rs.6373 minus Rs.300/-, Rs.610/- and 1,250/-. Therefore the O.P. Insurance Company is asked to pay Rs.6,373 – Rs.2,160 = Rs.4,213/- with interest on that amount at rate of 6% per annum with effect from the date submission of the claim application. As the O.P. unjustifiably deducted Rs.6373/- instead of Rs.2,160/-. They are both jointly and severally liable to pay compensation of Rs.10,000/- and cost of the proceeding of Rs.2,000/-.

14. The above awarded total amount with up-to-date interest on Rs.4,213/- to be paid within 45 days from today. In default, interest at rate of 10% per annum to be added to the awarded amount from the date of defaulter.

15. Supply free certified copy of judgment to the parties with the above. This Case is disposed of on contest. Given under my hand and seal of this District Forum on the 9^th day of May, 2018.