Fact of the case of the Petitioner in short is that this Complainant purchased mediclaim policy of Rs.5,000,00/- from Oriental Insurance Co. Ltd. O.P. no.2 on being apprised by O.P. no.3 / Bank where Savings Bank Account of Complainant bearing No.1295000100112921 is being mentioned and number of said mediclaim policy is 313102 / 48 2016 / 2087. Said insurance policy was valid for the period 19-11-2015 to midnight of 18-11-2016.
This Complainant has paid premium @ Rs.6960/- p.a. as per terms & conditions of the said mediclaim policy.
In the mid-night of 02-03-2016 this Complainant became seriously ill as such, he was brought to nursing home / O.P. no.4 for his treatment on 03-03-2016 and he was treated there and subsequently he was discharged on 06-03-2016 from the said nursing home.
Rs.24,184/- were expanded for the treatment of the Complainant. So, Complainant submitted his claim along with bill for his treatment to the O.P. no.2 on 22-03-2016 ; but O.P. no.2 has not paid any amount of his treatment. So, this Complainant has filed this complaint and has made prayer to reimburse of Rs.24,184 as cost of his hospitalization and treatment and Rs.3104/- was also expended for cost of medicine. He also has made prayer to pass an order to the tune of Rs.5000/- for his mental pain and agony and Rs.10,000/- as cost of litigation and other reliefs.
Notice of this case was issued upon the all O.Ps.; said notices were served upon all O.Ps. ; but O.P. no.1, 2 & 3 have not appeared in this case to contest and O.P. no.4 has made appearance and filed W.V. stating inter alia in support of the case of the Complainant.
In this case Kamakshya Prasad Bauri Complainant submitted his affidavit evidence. Several bills have been filed in support of his claim.
Decision with reason.
We have carefully heard the submissions made by the Ld. Advocate for the Complainant.
Perused the petition of complaint and the documents. It appears from the materials on record and the Xerox copy of policy that Policy No.313102 / 48 / 2016 / 2087 the case medical policy was purchased by this Complainant covering himself and his wife and son and his name was incorporated in this policy as Insured. It also reveals that this policy was valid for the period 19-11-2015 to mid-night of 18-11-2016 and total sum assured in this policy was Rs.5,000,00/- and annual premium was fixed at Rs.6,960/-. As per terms & condition of the policy that this policy shall be for hospitalization expenses for medical and surgical treatment at nursing home / hospital in India as inpatient defined in the policy. As per complaint that this Complainant admitted into nursing home on 03-03-2016 i.e. within the period of validity of mediclaim policy.
It also reveals from letter that this Complainant submitted his claim in prescribed form for reimbursement of Rs.24,184/- along with documents mentioning date of admission and date of discharge and Discharge Certificate issued by O.P. no.4 also proves that this complainant was admitted on 03-03-2016 and he was discharged from the said nursing home on 06-03-2016. It also reveals from the bill issued by O.P. no.4 that total treatment charge of the Complainant was Rs.24,184/-.
3-03-2016 in O.P. no. 4 nursing home for his treatment within period of validity of case policy. He was discharged from there on 06-03-2016 and Rs.24,184 was expended for his treatment as inpatient in the nursing home / O.P. no.4.
This fact has remained unchallenged. So, we do not like to disbelieve the unchallenged statement of P.W. – 1 about his admission in the O.P. no.4 nursing home for his treatment and he expended Rs.24,184/- for his treatment as inpatient.
It has been observed by Hon’ble National Commission in 2015(1) CPR 402 (NC) inter alia that purpose of Medical Insurance is to reimburse insured for treatment of any disease or ailment during period of insurance policy.
So, Complainant being insured is entitled to reimburse of Rs.24,184/- which he expended for his treatment as inpatient.
We find that the Complainant is not entitled to reimburse his cost of Rs.3,104/- as the same was not expended as inpatient as per terms & condition of case policy. Moreover, said cost of Rs.3,104/- has not been submitted in claim application by Complainant before O.P. no.2 / Insurance Co.
So, Complainant is not entitled to reimburse of Rs.3,104/- expended after his discharge for O.P. no.4, Nursing Home.
Considering the materials on record we like to award Rs.2,000/- (Two thousand) for mental pain and agony of the Complainant and also Rs.1,000/- (One thousand) as cost of litigation.
In view of the above facts & circumstances we hold that the Complainant is entitled to reimburse of Rs.24,184/- (Twenty Four thousand one hundred and Eighty Four) from O.P. no.2 Insurance Co.
Complainant is also liable to be dismissed against O.P. no.1, 3 & 4 as they had no role in the matter of making reimbursement of case medical expenses of Complainant.
In the result the case succeeds in part.
Hence, it is
Ordered
That the C. C. no.49 / 2016 be and same is hereby allowed exparte against Oriental Insurance Co. Ltd./O.P. no.2 and dismissed exparte against the rest O.Ps. no.1, 3, 4.
O.P. no.2 Insurance Co. Ltd. is hereby directed to pay Rs.24,184/- to the Complainant expended by him as inpatient to O.P. no.4 Nursing Home for his treatment.
O.P. no.2 is also further directed to pay Rs.2,000/- (Two thousand) to Complainant as Compensation for mental pain and agony of Complainant and he is also further directed to pay Rs.1,000/- (One thousand) to Complainant as cost of Litigation.
O.P. no.2 Oriental Insurance Co. Ltd. Burdwan Branch is hereby further directed to pay the amount awarded above to Complainant by thirty (30) days from the date of receipt of copy of this Judgment; failing which Complainant is at liberty to implement this Order with due course of Law.
Let a plain copy of this Judgment be supplied to the parties free of cost.
