IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
MURSHIDABAD , AT BERHAMPORE.
CASE No. CC No. 91/2013.
Date of Filing: Date of Admission : Date of Disposal:
24.07.2013 12.08.2013 11.12.2017
Santosh Kumar Paul
Vill. Keshabnagar,
P.O. Cossimbazar,
Dist. Murshidabad, Pin 742102. ……… Complainant.
-vs-
1. The Branch Manager,
LICI, Berhampore,
Dist. Murshidabad, Pin 742101.
2. The Manager(H.I).
SR. Divisional Manager-LICI,
Kolkata Suburban Divisional Office,
DD-5, Sector-1,
Salt Lake City, Kolkata-700064. …..... Opposite Parties.
Sri S. Sinha, Advocate ...………. for Complainant
Sri Saugata Biswas, Advocate …………. for Opposite Parties
Present : Smt. Chandrima Chakraborty ……. Member.
Sri Manas Kumar Mukherjee ............ Member.
Cont. ……….…. 2
= 2 =
J U D G M E N T
Chandrima Chakraborty, Presiding Member.
Interference of this Forum has been sought for by the Complainant, contending gross negligence, deficiency and unfair trade practice in rendering service towards the Complainant by the Opposite Party.
In succinct, the fact stated in the complaint, is that, the Complainant was a Policy Holder of “Jeevan Arogya” , being Policy No. 429167207. The wife of the Complainant became ill and admitted in the Belona Nursing Home & diagnostic Centre (P) Ltd. on 12.11.2012 and her surgery had been done on 14.11.2012 and she was discharged on 20.11.2012. Thereafter the Complainant had submitted the claim amounting to Rs. 59,409/- only before the Opposite Party but the Opposite Party had rejected the said claim on 20.02.2013.
The Complainant had lodged a complaint before the Consumer Affairs Department but of no result what amounts to negligence and deficiency in rendering service by the Opposite Party towards the Complainant for which being victimized and harassed the Complainant has to file the instant case seeking adequate redressal against the Opposite Party.
Resisting the complaint, the Opposite Party No. 1 filed the Written Version denying the contention made by the Complainant in his complaint and stating inter alia that the case is not maintainable and the complainant has no cause of action to file the instant case.
Cont. ……….…. 3
= 3 =
The specific case of the Opposite Party No. 1 Insurance Co., in terse, is that there is no deficiency in service on the part of the Opposite Party Insurance Co. and they have correctly repudiated the claim of the Complainant. The Complainant obtained the LICI Policy commenced on 28.09.2011 and the date of last payment of premium on 28.09.2030. The Complainant submitted his claim on 08.01.2013 and the Insurance Co. rejected the said claim on 20.02.2013 under the Clause WOP with a remark that the specific waiting period in respect of the list is applicable which denotes that in respect of each Insure no benefit are available hereunder and no payment will made by corporation for any claim under this Policy no account of hospitalization or surgery directly or indirectly caused by based on arising out of or how so ever atributarily with any of the following during the specific waiting period and the duration of the said specific period is 2 years from the date of the cover commencement of the Policy in respect of each Insurer. But the surgery has been done to the wife of the Complainant on 12.11.2012 which is within that waiting period and the claim submitted by the Complainant within this specific period for which this Opposite Party has rightly rejected the said claim of the Complainant.
Thereafter the Complainant informed the matter to the KSDO on 12.03.2013 and the KSCO has also rejected the said claim on 19.03.2013 on the same ground which was informed to the Complainant by this Opposite Party.
Thus the Opposite Party No. 1 rightly rejected the claim of the Complainant and denies any deficiency and negligence towards the Complainant for which the complaint is liable to be dismissed.
Cont. ……….…. 4
= 4 =
Despite service of the notice, the Opposite Party No. 2 never appeared before the Forum in person and/or through their authorized representative/Ld. Advocate to contest the case by filing Written Version and so the instant case has been heard ex-parte against the Opposite Party No. 2.
Point for Determination
1. Whether the instant case is maintainable ?
2. Whether the complainant is a consumer ?
3. Whether there is negligence or deficiency in service
on the part of the O.Ps ?
4. Whether the complainant is entitled to get the relief as prayed for ?
Decision with Reasons
All the points are taken up together for consideration for convenience and brevity.
The main dispute between the Complainant and the Opposite Parties is that, whether the Opposite Parties are justified to repudiate the claim submitted by the Complainant or not and whether the Complainant is entitled to get the claim as prayed for from the Opposite Parties or not.
But at the date of argument it is found that the Ld. Advocate on behalf of the Opposite Party No. 1 has filed the hazirah but the Ld. Advocate on behalf of the Complainant has further filed the time petition praying time for hearing argument
Cont. ……….…. 5
= 5 =
but neither Ld. Advocate for Complainant was present to move the said time petition nor the Ld. Advocate for Opposite Party No. 1 was present before the Forum to do the hearing of the argument on repeated calls till 2.35 pm and so the Final Order shall be passed on merit.
On overall evaluation of the case record and critically perusing the material evidences and all documents filed by both the parties it is specifically evident that admittedly the Complainant had obtained a LICI Policy named “Jeevan Arogya” , being Policy No. 429167207 from the Opposite Parties commenced on 28.09.2011.
It is further revealed from the case record that admittedly the wife of the Complainant admitted in the Belona Nursing Home & diagnostic Centre (P) Ltd. on 12.11.2012 due to her sudden illness and detected Fibroid and her surgery had been done on 14.11.2012 in the said Nursing Home and she was duly discharged from the said Nursing Home on 20.11.2012.
The record reveals that admittedly the Complainant had submitted the claim amounting to Rs. 59,409/- only before the Opposite Party along with all relevant documents but the Opposite Party had rejected the said claim on 20.02.2013 and the fact remains that admittedly the said claim was also rejected by KSDO on subsequent application filed by Complainant.
It is clearly reveals from the Written Version filed by the contesting Opposite Party No. 1 that the Insurance Co. Opposite Party had rejected and repudiated the claim submitted by the Complainant under the Clause WOP and the Policy condition and
Cont. ……….…. 6
= 6 =
privilege under Table 4. But in fact neither the Complainant nor the contesting Opposite Party had ever submitted the total ‘Terms & Conditions’ of the said Policy in question before the Forum for which the Forum is incapable to follow and/or compare the ‘Terms & Conditions’ of the said Policy in question with the real fact and cannot go through those ‘Terms & Conditions’ of the said Policy in question, if any, that no Insurer can get the benefit of any surgery within 2 years from the date of commencement of the said Policy.
Now the fact remains that this Consumer Protection Act is a beneficial legislation and is consumer friendly law and is enacted for the benefit of the consumers as a whole. So in this particular case where no parties has submitted the ‘Terms & Conditions’ of the said Policy in question wherefrom the Forum can able to take the proper decision and moreover where both parties are very much reluctant to conduct the instant case, the Forum decide to go with the benefit of the Consumer/Complainant.
Thus the unanimous decision of the Forum is that the Opposite Party No. 1 is liable to pay the actual treatment cost in favour of the Complainant but without any compensation and litigation cost as because the Complainant himself is very much reluctant to do the hearing the argument of this case which is clearly evident from the ‘Order Sheet’ of the Case Record that the date for hearing argument was fixed from 09.09.2015.
Therefore in light of the above analysis, we are of the opinion that the Complainant is entitled to get the relief in part as prayed for and consequentially the points for determination are decided partly in affirmative.
Cont. ……….…. 7
= 7 =
In short, the Complainant deserves success in part.
In the result, we proceed to pass
O R D E R
That the case be and the same is allowed in part on contest against the Opposite Party no. 1 and also allowed in part ex-parte against the Opposite Party No. 2 but without any cost.
That the Opposite Party No. 1 is directed to pay the actual treatment cost of Rs. 59,409/- only to the Complainant within one month from the date of this ‘Order’.
In the event of non compliance of any portion of the order by the Opposite Party/s within a period of one month from the date of this order, the default Opposite Party/s shall have to pay a sum of Rs. 100/- per day, from the date of this order till full satisfaction of the decree, which amount shall be deposited by the said default Opposite Party/s 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.
MEMBER PRESIDING MEMBER
