West Bengal

Paschim Midnapore

CC/44/2016

Satish Chandra Bera - Complainant(s)

Versus

Manager, National Insurance Co. Ltd. - Opp.Party(s)

Mr. Subrata Das.

29 Aug 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

Mrs. Debi Sengupta, Member

and

Kapot Kumar Chattopadhyay

   

Complaint Case No.44/2016

                                                        

Satish Chandra Bera, S/o-Nibaran Chandra Bera,

Vill-Aragabardh, P.O.-Hour, P.S.-Panskura,  Dist-Purba Medinipur…..….………Complainant

Versus

The Manager, National Insurance Company Ltd., Midnapore Branch,

P.O.-Midnapore, P.S.-Kotwali, Dist-Paschim Medinipur …Opposite. Party.

 

 For the Complainant: Mr. Subrata Das, Advocate.

 For the O.P.              : Mr.Anathbandhu Ghosh, Advocate.     

 

Decided on: -29/08/2016

                               

ORDER

   Mrs. Debi Sengupta, Member - The case of the complainant in a nutshell is that the complainant purchased  a mediclaim policy in the year 2007 from  the agent of O.P.-Insurance Company and paid Rs.2,081/- as premium to the        O.P.-Insurance Co. This policy was valid for one year. Till purchasing of the policy the complainant used to renew the same in every year. In the year 01/06/2015 to 01/06/2016 the complainant renewed his mediclaim policy. It is to be mentioned that the complainant became the consumer under the O.P.-National Insurance Company and his policy No. for the year 01/06/2015 to 01/06/2016is No.153800/48/14/850000395. The complainant states that on 04/05/2015 the complainant became seriously ill due to chest pain and came to his physician for treatment and after investigation the said doctor, advised the complainant for

Contd……………….P/2

 

( 2 )     

hospitalization as early as possible. According to the advice of the Dr. the complainant was taken to the Ruby General at Kasba, E.M.Bye Pass, Kolkata-700167 by ambulance on 04/05/2015 at 10.27a.m. as indoor patient. Subsequently several tests was made and the complainant was discharged from the hospital on 6^th May, 2015. The complainant contends that for his treatment he spend Rs.37,784/- in total for fees of doctors and other charges of the hospital and different tests and the complainant states that after releasing from the hospital complainant intimated the matter  to the O.P.-National Insurance Company and claims the amount of expenditure incurred for his treatment along with the  copy of documents. But O.P.-National Insurance Company without giving any explanation paid Rs.16,079/- out of 37,784/-. Therefore the complainant made an application on 12/06/2015 clamming total amount to the O.P.-National Insurance Company. Having received the application the O.P. did not settled the claim and did not pay any heed to the request of the complainant.  Thereafter the complainant went several times to the office of the complainant and requested them to pay the entire amount to the complainant but the O.P.-National Insurance Company did not care the request to the complainant. The complainant states that he is entitled get the entire amount as per policy terms and conditions. The complainant further states that there is deficiency of service on the part of the O.P.-National Insurance Company and the relief claimed by the complainant is just and the complainant prayed before the Forum directing the O.P.-National Insurance Company to pay balance amount Rs.21,705/- for the treatment  of the complainant and for compensation for deficiency of service and the cost of the proceeding.

O.P.-National Insurance Company contested the case by filling written objection. In the written objection O.P.-National Insurance Company states that the petition of complainant is not maintainable in law and also in present form and prayer and the complaint is also barred by limitation estoppels acquiescence and waiver and the same has been designed only to harass the O.P.  O.P.-National Insurance Company also denied the allegation made against the O.P. in para-six of his written objection. O.P. in his written objection contained that the TPA   Rotehsheild Health Care Service Ltd. has settled the claim of the complainant according to the policy terms and conditions approved by IRDA. The total payment of Rs.42,262/-  was made to the insured against the bill of Rs.89,822/-  following the policy condition and barring inadmissible expenses and also for no furnishing of non supporting documents and inadmissible expenses. According to clause of the policy

Contd……………….P/3

 

( 3 )

condition deduction was made. From the above facts and circumstances O.P. states that there is no deficiency in service from the part of the O.P.-National Insurance Company and according to the policy terms and condition the settlement of the claim of the complainant is just and proper and the O.P.-National Insurance Company prays for dismissal of the suit with cost.

   

Points for decision

 

1. Whether the case is maintainable are not ?
2. Whether there is deficiency of service ?
3. Is the complainant entitled to the reliefs as prayed for ?

 

Decision with reason

Issues nos. 1 to 3.

All the issues are taken up to getting for discussion as those are interlinked to each other for the purpose of arriving at a correct decision in the dispute.

At the very outset it is to mention here that neither the complainant nor the O.P.-National Insurance Company adduced any sort of evidence either oral or documentary but they have relied upon some documents although those were not proved as per law. Be that as it may we find that the main prayer of the complainant is that to direct the O.P. to pay the balance amount of the complainant and also prays for compensation and the cost of the proceeding.

Regarding the allegation of the complainant that, for his treatment he spends expended Rs.37,784/- in total for fees of doctor charges of hospital and for different test. But the O.P.-National Insurance Company paid only Rs.16,079/- out of Rs.37,784 without any reasons. Ld. Lawyer for the complainant argued that as per terms of the policy the complainant is entitled to get entire amount as the complainant spends for his treatment but the O.P.-National Insurance Company did not pay the same. The Ld. Lawyer further argued that on 12/06/2015the complainant made an application to the O.P.-National Insurance Company for claiming the total amount of expenditure incurred for his treatment. Having received the application the O.P. did not settle the matter and did not pay any heed to the request of the complainant. So there is gross deficiency on the part of the O.P.

Ld. Lawyer also argued that the said case is maintainable the cause of action arose on 04/05/2015 and on 12/06/2015 within the jurisdiction of this Forum.

Contd……………….P/4

 

(4 )

Ld. Lawyer disputes that is there is deficiency of service on the part of the O.P. so the complainant is entitled to get the relief as prayed for.

Ld. Lawyer for the O.P. argued that the case is not maintainable and it is barred by limitation and the prayer of the complainant is improper illegal and unjust Ld. Lawyer states that the third party administrator settled the claim of the complainant and there are inadmissible expenses by the complainant. According to the policy condition the bill amount was more than authorization and the complainant failed to furnish supporting documents and inadmissible expenses. So it cannot be said that there is deficiency of service on the part of the O.P.-National Insurance Company and the payment of claim of Rs.16,079/- is    just and proper.

In the view of the facts and circumstances we find that the O.P.-National Insurance Company submits some document but it is not clear that why the payment of the Rs.37,787/-  cannot be allowed. In support of nonpayment of total claim amount the O.P.  has submitted Xerox copy of some documents without authentication. The O.P. has failed to produce necessary document as they have pleaded. So we find there is deficiency of service   on the port of the O.P. Therefore the prayers made by the complainant can be granted in his favour.

                                                                   Hence, it is

Ordered

                                                                 that the complaint case and the same is allowed on contest with cost against the O.P.

                                            O.P. is hereby directed to pay balance amount of Rs.21,705/- for the expenditure of the treatment of the complainant.

                                           O.P. is also directed to pay Rs.5,000/- as compensation  for deficiency of service and Rs.2,000/- for cost of the proceeding to the complainant within 60 days for the date of this order.

                                       Let plain copy of this order be given to the parties free of cost.                   

                  Dictated and Corrected by me

                               Sd/- D. Sengupta.            Sd/- K.K.Chattopadhyay.           Sd/-B. Pramanik. 

                                    Member                                  Member                               President

                                                                                                                           District Forum

                                                                                                                         Paschim Medinipur