Date of Filing: 10.02.2022 Date of Disposal: 29.05.2024
Complainant : Sri Rupal Dutta, S/o-Lt. Rabindramohan Dutta, residing at M32, Sagor Bhanga Colony, P.O.-Sagar Bhanga, P.S.-Coke Oven, Dist.-Paschim Bardhaman, W.B.-713211.
-VERSUS -
Opposite Party : 1.Managing Director of Bajaj Allianz General Insurance Co. Ltd. Having its office at Bajaj Allianz House, Air Port Road, P.O.& P.S.- Yerwada, Dist. Pune, Maharashtra, Pin-411006.
2. Branch Manager, Bajaj Allianz Gen. Insurance Co. Ltd. Durgapur Branch, having its office at Cross Pace Building, Plot No.821(P), behind Junction Mall, City Center, P.O.-City Center, P.S- Durgapur, Dist. Paschim Bardhaman, 713216.
3. Branch Manager of Canara Bank, SME Branch, Durgapur, P.O-Sagar Bhanga, P.S-Coke Oven, Dist. Paschim Bardhaman, 713211.
Present : Mrs. Lipika Ghosh - Hon’ble President-in-Charge.
: Mr. Atanu Kr. Dutta. - Hon’ble Member.
Appeared for the Complainant: Amit Kr. Shaw Ld. Advocate
Appeared for the Opposite Party1&2: Soumalya Ganguli Ld. Advocate
Appeared for the Opposite Party 3:
F I N A L O R D E R
Today is fixed for hearing of arguments and order.
Complainant is present through the Ld. Advocate.
Ld Advocate for the OP NO. 3 files an adjournment petition which is considered and rejected as the case is running exparte against the OP No 3.
The case is taken-up for further hearing and order.
Heard argument from the side of the complainant in full.
On 10.02.2022, the complainant Sri Rupal Dutta has filed an application u/S. 35 of the C. P. Act, 2019 against the Opposite Parties.
The case of the complainant, in brief, is that the complainant took a mediclaim policy from the O.Ps on 27.09.2018 being Policy No.OG-20-9999-9960-00000086 and the same had been renewed time to time and was valid upto26.09.2021 midnight. The sum assured in respect of the policy was Rs.500000/- (five Lakh) only. The complainant himself, his wife and only daughter were covered under the said insurance policy. The total premium was paid Rs.15,417/-. The policy was taken through the O.P. NO.3, Canara Bank, SME Branch, Durgapur. The daughter of the complainant namely Madhura Dutta was got injured by twisting knee on 22.12.2019. She was admitted into peerless Hospitex Hospital and Research Center Ltd. on 06.07.2021 under the treatment of Dr. Swarnendu Samanta. As per discharge certificate on 07.07.2021 her left knee was explored via standard Orthroscopic Portals treatment under spinal anaesthesia after appropriate assessment and due consent and after proper antiseptic dressing and draping. She was discharged on 10.07.2021. Total medical expenses incurred towards her treatment was Rs.2,06,814 only. The complainant further requested to provide cashless facility, the O.P.-Insurance company refused to provide the same and intimated accordingly on 09.07.2021. The complainant compelled to bear all medical expenses from his own pocket. That the complainant lodged claim on 14.07.2021, which was registered as claim No.OC-22-1002-6021-00005218 and thereby claimed for reimbursement of the expenses occurred towards the treatment. The O.Ps time to time sent e-mail to the complainant and thereby sought for necessary documents/information. The complainant time to time provided the said documents to the O.Ps. The complainant lodged complaint before the Assistant Director, Consumer Affairs & FBP, Durgapur Regional Office, Durgapur, Paschim Bardhaman but his effort stood fruitless due to non-cooperation of the O.Ps. The complainant has complied with all the legal formalities and submitted the duly filled up Reimbursement Claim Form along with all the relevant documents. The complainant was entitled to get cashless facility ad as the same was refused by the O.P. –Insurance Company, he is further entitled to get the reimbursement of the medical expenses/insurance claim from the O.Ps. But the O.Ps deprived the legitimate claim of the complainant without any justified ground, which is nothing but deficiency in-service. The cause of action has arisen on and from 12.07.2021 when the complainant lodged the claim and the cause of action is continuing as the claim has not yet settled.
Upon this background, the complainant prays for a direction upon the O.Ps to pay the claim amount of Rs.2,06,814/- only towards reimbursement of the medical expenses, along with interest thereon, for delay in settlement of claim from the date of lodging the claim, till the date of payment and Rs.50,000/- as compensation towards mental pain, agony, & sufferings and also cost of the present suit Rs Rs.20,000/-. Though the case was running ex parte against all the O.Ps (OP No 1 and 2 files W/V which is not accepted) but at the stage of arguments, the O.P. Nos.1&2 filed W.N.A. and O.P. No.3 filed only W/V, which is not accepted as the case is running ex parte.
In the WNA, O.P. Nos.1 & 2 has denied all the material allegations raised against them.
The specific case of the O.P.Nos.1&2 is that complainant submitted false charges against O.P. No.2 in connection with claim and deficiency in service. It is regretted by the O.Ps for its inability to consider the claim due to non-cooperation and non-submission of proper documents. Hence, the cause of action does not arise at all on and from 12.07.2021. In the above charges, it seems that the complainant has ill motive to earn money in unlawful manner. Therefore all allegations contrary to and /or inconsistent therewith are denied. Hence this complainant’s claim be dismissed summarily with exemplary cost.
Decision with Reasons
In order to prove the case, the complainant has filed evidence-on-affidavit, W.N.A. On the other hand, at the stage of arguments, the O.P. Nos.1 & 2 has filed W.N.A.
Perused the complaint, evidence-on-affidavit & the W.N.A. of both the complainant as well as O.P.Nos.1 & 2. We also perused the Xerox copy of documents submitted by the complainant. The complainant corroborated the facts of the case depicted in the complaint by evidence-on-affidavit that a Mediclaim Policy was obtained from the O.Ps on 27.09.2018 being Policy No.OG-20-9999-9960-00000086 and the same had been renewed from time to time and was valid upto26.09.2021 midnight. The sum assured in respect of the policy was Rs.5, 00,000/- (five Lakh) only. The complainant himself, his wife and only daughter were covered under the said insurance policy. The total premium was paid Rs.15, 417/-. The policy was taken through the O.P. No.3-Canara Bank, SME Branch, Durgapur.The daughter of the complainant namely Madhura Dutta was got injured by twisting knee on 22.12.2019. She was admitted into Peerless Hospitex Hospital and Research Center Ltd. on 06.07.2021 under the Dr. Swarnendu Samanta. Immediately the hospital authority informed the O.P. about the matter for obtaining cashless facility but the same was denied by a letter dated 09.07.2021 issued by the O.P.
From the discharge certificate issued by the Hospital Authority, it appears that the patient was discharged on 10.07.2021.
From the final bill statement dated 10.07.2021 issued by the Peerless Hospitex Hospital and Research Center, it appears that complainant incurred a sum of Rs.1,17,989/- for the treatment of her daughter. Though the complainant submitted claim form but no reimbursement was made.
From the letter dated 02.11.2021 of Assistant Director of Consumer Affairs & FBP, Paschim Bardhhaman RO, it appears that a tripartite meeting schedule to be held on 12.11.2021 at 12 noon but non response on the part of the O.P. meeting could not be held.
Therefore, the O.Ps are bound to pay the said claim of the complainant. The O.Ps have failed to prove their pleas as taken by them rather the complainant has proved that he has a claim of total expenses of Rs.1,17,989/- for treatment of his daughter who was admitted in the Peerless Hospitex Hospital and Research Center Ltd. on 06.07.2021 and discharged on 10.07.2021.
Under the above facts and circumstances of the case, we are of opinion that O.Ps committed deficiency in service and the complainant is entitled to get his relief. The O.Ps are also liable to pay compensation to the complainant as they committed harassment and mental agony to the complainant without disbursing his claim according to law and the complainant is also entitled to get a litigation cost.
As a result the case succeeds.
Hence, it is
Ordered
that the case be and the same is allowed on contest against the O.P. Nos.1 & 2 but without any cost and dismissed against O.P. No.3.
O.P. Nos.1 & 2 are jointly and severally liable to reimburse the claim of the complainant i.e., Rs.1, 17,989/-only.
O.P. Nos.1 & 2 are directed to pay a sum of Rs.1, 17,989/-(One Lakh Seventeen Thousand Nine Hundred Eighty Nine) only by an account payee cheque to the complainant jointly and severally.
O.Ps are also directed to pay a compensation of Rs. 15,000/- and litigation cost of Rs 5,000/- to the complainant jointly or severally within 45 days from the date of receipt of the final order failing of which the amount shall carry interest @ 6 per cent per annum till the date of realisation.
Let a copy of this order be given to the parties on free of cost.
Member President-in-Charge
D.C.D.R.C., Purba Bardhaman D.C.D.R.C., Purba Bardhaman
