Date of filing : 18.07.2018
Judgment : Dt.18.12.2019
Mrs. Balaka Chatterjee, Hon’ble Member
This petition of complaint is filed under section 12 of C.P.Act, 1986 by Dr. Santanu Das alleging deficiency in service on the part of the opposite parties (referred as OP hereinafter) namely (1) MD India Health Insurance TPA (P) Ltd. and (2) National Insurance Co. Ltd.
Case of the Complainant, in brief, is that the Complainant who described himself as ‘Medical Person’ has himself insured under the Group Insurance Policy issued from the end of the OP No.2 vide policy being No.15100501710005634 for the period of 31.8.2017 to 30.8.2018 and as per said policy the Complainant has been under coverage of Rs.2,00,000/- excepting cumulative bonus of Rs.80,000/- and has paid Rs.21,966/- towards premium. The Complainant has stated that he paid premium of the policy regularly from the time of inception of the said policy on 31.8.2005 and as such no claim was made on behalf of the Complainant but on 3.6.2018 suddenly the Complainant fell sick with acute chest pain and vertigo and shifted to Apollo glengles Hospital and Dr. P. C. Mondal, Sr. Consultant Interventional Cardiologist attached to the said Hospital advised the Complainant for urgent admission on 4.6.2018. The Complainant has further stated he got admitted on 4.6.2018 and was released on 6.8.2018 and as per advice of the treating doctor underwent several investigation and immediately took step to intimate insurance company through the Hospital for sanctioning cashsless facility but on receiving intimation from the Hospital the OP No.1 denied to offer cashless facility and the Complainant had to pay Rs.38,167/- for treatment, which caused harassment and mental agony and, therefore, the Complainant by filing the instant consumer complaint prayed for direction upon the OP to reimburse Rs.38,167/-, to pay Rs.30,000/- towards compensation and Rs.30,000/- as cost of litigation.
The Complainant annexed prescription dt.4.6.2018, repudiation of cashless facility, bill generated by the Hospital and receipt, discharge summary.
Notices were served but the OP No.1 did not turn up so the case proceeded ex-parte against OP No.1 vide order dt.2.11.2018.
The OP No.2 contested the case by filing written version denying and disputing all the allegations made out in the petition of complaint stating inter alia that cashless treatment facility was denied under the exclusion clause No.4.19 of the policy and denial of cashless treatment facility does not necessarily mean repudiation of claim for treatment but the Complainant did not file any claim to the Insurance Company in that regard and, therefore, there is no deficiency on the part of the OP No.2 and the case is not maintainable.
The OP No.2 has further stated that as per doctor’s prescription, it appears that some investigation has been suggested by the Doctor but no active line of treatment has been advised and no claim without having any treatment is required to be allowed and accordingly prays for passing necessary order.
The Complainant adduced evidence. The OP No.2 prayed for treating the written version as affidavit in chief. Prayer was allowed. Both parties file their respective questionnaire and reply.
In course of argument both parties filed written notes of argument and advanced their version respectively.
Points for determination
- Whether there is deficiency in service on the part of the OPs
- Whether the Complainant is entitled to the relief as prayed for
Decision with reasons
Point Nos.1 & 2 : Both the points are taken up together for comprehensive discussion and decision.
Admittedly, the Complainant was covered under medical insurance policy with cashless facility issued by the OP No.2.
The Complainant has alleged that the OPs deviated from the agreed terms of the said policy as they did not provide the Complainant cashless facilities and subsequently denied to disburse the required amount. The moot point in this case is whether the OPs deviated from the agreed terms of the said policy.
The Complainant has reiterated that the Insurers failed to act in accordance with the terms of the said Insurance Policy but the Complainant has not annexed the copy of the said policy wherefrom it would have been evident that what are the policy and whether any deviation therefrom by the OPs have taken place at all. Onus lies upon the claimant. However, in the instant case, the Complainant failed to discharge onus since I n absence of the agreed terms, it is not possible for us to determine whether any deviation therefrom has taken place at all.
Under such state of affairs, we are inclined to hold that the Complainant has failed to prove his case.
Point Nos.1 & 2 are decided accordingly.
In the result the consumer complaint does not succeed.
Hence
ordered
That the instant Consumer Complaint being No.CC/432/2018 is dismissed on contest without cost.
