This complaint under C.P. Act.,1986 was initially filed against O.P. No. 1  MAX BUPA Health Insurance who did not contest the case. Then the O.P. No. 2 was added by amendment of the complaint.

The case of the complainant as per the amended complaint is as follows:-

“That the Complainant has a Health Insurance Policy in his name bearing the Policy No.00216400201700 which is valid from 31/10/2017 12:00 A.M. up to 30/10/2018 11:59

P.M. with the MAX BUPA HEALTH INSURANCE under Bajaj Finance Limited with an insured amount of Rs. 5 Lakhs.

It is pertinent to mention that the Complainant obtained a personal loan from Bajaj Finance Ltd. on 31/10/2017, at that time the agent of this company compelled the Complainant to insure his name in a health scheme under their company.

That on 16/11/2017 the complainant met with an accident on the road at a little distance away from his residence. A vehicle hit the Complainant from behind and as a result the Complainant suffered from multiple injuries on his body along with a tibial condyle fracture in his left leg in the said accident.

That the Complainant was immediately taken to the Maynaguri Gramin Hospital for First Aid from where he was referred to the Jalpaiguri Super Speciality Hospital on the same day of the accident.

That the Complainant was further referred to North Bengal Medical College & Hospital on the same day of the accident for better treatment.

That thereafter on 18/11/2017 the complainant was taken to Patna on road by an Ambulance for treatment as emergency railway reservation tickets could not be made available on 17/11/2017 by the family members of the Complainant.

That after various examination and findings the doctors in Patna Hospital named as “Gaurav Orthopedic Clinic” at E-53, Road No.12 (Extension) (East of Bhadurpur, Fly over) Rajender Nagar, Patna-800016, opined that the Complainant will have to undergo an operation for his tibial condyle fracture in his left leg in the said accident.

That on 20/11/2017 the Complainant was admitted in the said hospital. After completing all formalities on 25/11/2017 the operation was conducted and on 07/12/2017 the complainant was discharged from the Hospital.

That on 18/11/2017 the brother of the Complainant namely, Biplab Sarkar lodged a written complaint before the Maynaguri Police Station. After receiving the complaint Maynaguri P.S. started a case being No.387/17 dated 18/11/2017 under Section 279/338 I.P.C.

That after the operation of the Complainant, the complainant over telephone came into contact with the opposite party for the procedure for claiming the Insurance amount. As per instruction and advice of the Opposite Party the complainant sent by registered post all the original bills amounting to Rs. 1,20,799/-, all the Prescriptions and the Doctor’s Certificates along with the filled-up Form for the claim to the office of MAX BUPA HEALTH INSURANCE where he had a Health Insurance Policy in his name bearing the Policy No. 00216400201700. The said claim was registered as claim No. 303258 dated 09.03.2018.

That after this the Insurance Company communicated to the Complainant asking for the FIR copy, First Treatment Record of Government Hospital.

That thereafter the Complainant sent a letter along with the aforesaid documents by registered post to the Insurance Company.

That after that the complainant several times over telephone contacted the Opposite Party to know about the status of the Claim submitted by him.

That finally the Insurance Company sent a letter informing him that the claim had been denied and repudiated and stated that the authenticity and accomplishment of the documents for the claim procedure has not been established , hence the claim cannot be paid and therefore stands repudiated under clause 5M(3.b).

That after the operation, the complainant was rechecked on 12.02.2018 ,thereafter on 28.05.2018. The complainant was further asked to visit the doctor after 3 months of time from the last check up but due to his financial crisis he could not visit the doctor.

That after the submission of the bills the Complainant spent an amount of Rs. 50,000/- for the check-ups, transportation and the ongoing medicines for his recovery. “

Hence the complainant prayed for amount of Rs. 1,20,799/- for operation and and Rs. 50,000/- for check up purpose. The complainant also prayed for compensation ,cost and also interest.

The O.P. No. 1 did not contest the case.

The O.P. No. 2 contested the case by filing Written Version. The O.P. No. 2 stated that the complaint is not maintainable against the O.P. No.2 as framed or at all as O.P. No.2 is not necessary party to the above captioned complaint. It is further submitted that the O.P. No.2 is a financing company and provides loan to all the needy persons and thus the acceptance / rejection of the insurance solely depends upon the insurance partner / the Insurance Company and hence the O.P. No.2 should not be held accountable for rejection of insurance claim of the Complainant.

The O.P. No. 2 further stated that the complainant had availed 2 loans from the O.P. No.2 which are closed as on date and no objection Certificate has also been issued and the O.P. No. 2 also submitted that the complainant had availed a personal loan from O.P. No. 2 which was not repaid and to avoid repayment of the personal loan the complainant unnecessarily added the O.P. No. 2 in this case. The O.P. No. 2 also stated that the case should be dismissed against O.P. No. 2 as there is no cause of action.

Hence, the O.P. No. 2 prayed for dismissal of the case.

The Ld. Advocate for the complainant submitted that the O.P. No. 2 was in collusion with the O.P. No. 1 to repudiate his valid claim and actually the agent of O.P. No.2 forced the complainant to get the insurance from O.P. No. 1 and has prayed for a decree against both the O.P.s.

The O.P. No. 1 did not contest the case and none appeared for O.P. No 1. MAX BUPA Health Insurance.

The Ld. Advocate for O.P. No. 2 submitted that the O.P. No. 2 was unnecessarily made party as there was no insurance agreement with O.P. 2 and the complainant and this was done just to avoid payment of dues of O.P. No. 2 by the complainant who took personal loan from

O.P. No. 2. He also submitted that O.P. No. 2 has no connection with O.P. No.1 with whom the complainant had his Insurance Agreement. He also submitted that he has no objection if decree is awarded against O.P. No. 1.

We have considered the pleadings of the parties, the evidence and documents filed and the submission of both sides carefully. Ii is found that the Insurance Agreement of the complainant was with the O.P. No. 1 MAX BUPA Health Insurance.  The claim was also  made before the O.P. No. 1 and the repudiation of the claim was done by the O.P. No. 1.

At no stage the O.P. No. 2 was involved regarding the claim starting from the agreement to the repudiation of claim by O.P. No. 1. The complainant failed to establish any connection or role of O.P. No. 2 in this claim case as lodged by the complainant.

Therefore, we agree with the submission with the Ld. Advocate of O.P. No. 2 that the

O.P. No. 2 was made party in this case unnecessarily.

Hence, the claim of complainant against O.P. No. 2 has no basis and it fails as there is no Cause of Action as against O.P. No. 2.

But it appears from the materials on record that the O.P. No. 1 is liable in this case since O.P. No. 1 had the insurance agreement with the complainant and claim was placed before the O.P. No. 1. who repudiated that claim also.

The allegations of the complainant were not controverted by O.P. No. 1. In absence of any evidence to the contrary by O.P. No. 1. we find that there is no reason to disbelieve the complainant’s case as against O.P. No. 1 and the claim of the complainant against O.P. No. 1 is established by uncontroverted evidence of the complainant.

Accordingly the case succeeds against O.P. No. 1 ex-parte.

Hence it is,

ORDERED

that the case is allowed ex-parte as against the O.P. No. 1 MAX BUPA Health Insurance and dismissed on contest against the O.P. No. 2 Bajaj Finance Limited.

The O.P. No. 1 is liable to pay Rs. 1,20,799/- ( Rupees One Lakh Twenty Thousand Seven Hundred and Ninety Nine Only) for operation purpose and Rs. 50,000/-( Rupees Fifty Thousand Only) for check up purpose to the complainant within three months from this date along with interest @ 6% p.a. from the date of filing this case till the date of payment of the aforesaid decretal amount.