Dr. Subir Kumar Chaudhuri ,Member

Order No.   30    Dated  27-02-2013.

            The case of the complainant in short is that complainant is a man of 56 years. Medicare TPA Service (I) Pv t. Ltd. i.e. o.p. no.1 insured the complainant and his family consisting of himself, his wife Dipta Bose and his daughter Dipannita Bose, then a minor, for its ‘group’ Medi-claim Cash Less Insurance Policy (‘the said policy’) and as agreed the complainant is regularly paying the premium by installment, which now is of rs.1894/- per month, through the complainant’s Standard Chartered Bank Credit Card and the amounts spent through this credit card of the complainant are being debited to the account of the complainant automatically whenever it becomes due. Thus it became obligatory on the part of o.ps. to provide insurance safeguard to obtain / hire medical service to the complainant as well as to his wife and daughter at any material time of subsistence of the group insurance policy.

            Complainant had chest congestion from the morning of 20.9.09. As it started getting worse, Dr. Ranjit Roy, was called upon by the complainant’s wife who suggested immediate hospitalization and accordingly the complaiant friends and family members had him admitted to Microlaps Nursing Home.

            Proforma o.p. had duly got in touch  with the o.p. informing the admission of the complainant and an inspector from the office of o.p. had come on inspection at proforma o.p. for verification and had also met the complainant when the complainant was asked to produce the said card which the complainant had duly done. This inspector of o.p. had assured the complainant that his office would send the necessary documentation / payment to proforma o.p. so that the complainant could be released on 23.9.09.

            But to the utter surprise of the complainant, on late afternoon on 23.9.09 proforma o.p. regrettably informed the complainant that instead of sending the necessary documents to proforma o.p. taking on  the responsibility of directly paying the bills for the complain ant of th e proforma o.p., the o.p. had instead sent a fax to proforma o.p. to the effect that for taking decision in respect of making payment of the bills of the complainant, o.p. no.1 required the receipt for due balance payment of the premium of Rs.15,152/-.

            Since o.p. did not pay, having no alternative the complainant had to arrange for funds and had himself released from proforma o.p. on 24.9.09 after directly paying all the dues of proforma o.p.

            The complainant was discharged at least a day earlier on 23.9.09, itself but because o.p. failed, neglected and/or refused to pay the dues to proforma o.p. and delayed in sending their letter regarding non-payment, the complainant was forced to be confined for an extra day at the proforma o.p. and was discharged on 24.9.09 during which period the complainant could not do his professional work for which the complainant has suffer professional loss.  

            Because of the failure, neglect and/or refusal, of the o.p. nos.1 to 3 to make the payments of the aforesaid payments of the proforma o.p. the complainant has suffered losses, injuries and damages. Hence the case was filed by complainant with the prayer contained in the petition of complaint.  

            O.p. nos.1 to 3 had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case. Proforma o.p. no.4 did not contest the case by filing w/v and matter was heard ex parte against proforma o.p. no.4. Ld. lawyer of o.ps. in the course of argument stated that the case has got no merit and the same is liable to be dismissed.

Decision with reasons:

            We have gone through the pleadings of the parties, evidence and documents in particular and we find that complainant had mediclaim cashless insurance policy with o.p. no.1 and complainant having chest pain was hospitalized in o.p. no.4 in the nursing home on 20.9.09 and at the time of admission the card of the complainant was given by o.p. and the same was shown to o.p. no.4 and therefore, o.p. no.4 did not take any deposit from complainant and complainant was asked to produce the card and inspector of o.ps.  had assured that their office would send payment to o.p. no.4 so that complainant can be released on 23.9.09, but on 23.9.09 o.p. no.4 informed complainant instead of sending necessary documentation to o.p. no.4 for taking responsibility for making payment of bills by complainant finding no other alternative complainant had to arrange the fund and paid the amount to o.p. no.4 on 24.9.09 and complainant had to incur profuse loss awaiting necessary direction from o.ps. for making payment of charges to o.p. no.4 during puja vacation and this action on the part of o.p. nos.1 to 3 amounts to deficiency in serviced being service provider to its consumer / complainant and complainant is entitled to relief.

            Hence, ordered,

            That the case is allowed on contest with cost against o.p. nos.1 to 3 and ex parte without cost against proforma o.p. no.4. O.p. nos.1 to 3 are jointly and/or severally directed to pay a sum of Rs.98,256/- (Rupees ninety eight thousand two hundred fifty six) only to the complainant for the amount incurred by him for his treatment in the nursing home of o.p. no.4 and are further directed to pay compensation of Rs.30,000/- (Rupees thirty thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 9% shall accrue over the entire sum due to the credit of the complainant till full realization.

            Complainant is at liberty to file execution case before this Forum in case of non execution of the aforesaid order in its entirety within the stipulated period under the provision of the COPRA, 1986.

            Supply certified copy of this order to the parties free of cost.