Consumer Disputes Redressal Forum, Unit -I, Kolkata,

8B, Nelie Sengupta Sarani, Kolkata-700087.

CDF/Unit-I/Case No. 50 / 2008

1)           Sri Subir Roy,

4/1, Roy Bahadur A.C. Roy Road,

Kolkata-700034.                                                       ---------- Complainant

1)           Medicare TPA Services Pvt. Ltd.,

6, Bishop Lefroy Road, 10, Paul Mansion,

2)           The Oriental Insurance Co. Ltd.,

Present :        Sri S. K. Majumdar, President.

                        Sri T.K. Bhattacharya, Member

The instant case arises out of the petition of complaint filed by Sri Subir Roy of 4/1, Roy Bahadur A.C. Roy Road, P.S. Behala, Kolkata-34 filed on 13.2.08 against (1) Medicare TPA Services Pvt. Ltd., 6, Bishop Lefroy Road, Flat no.10, Paul Mansion, Kolkata-20 and (2) Oriental Insurance Co. Ltd. having registered office at Oriental House, A-25/27, Asaf Ali Road, New Delhi-110002 with a prayer to settle the amount claimed for such mediclaim policy together with the cost of compensation of Rs.1 lakh and litigation cost of Rs.10,000/- and to pass such orders as the Forum deems fit and proper.

            Specific case is that the o.p. no.1 approached the petitioner/complainant with an offer to accept a mediclaim policy and upon knowing the details of the said policy and facilities available therein, the complainant accepted the said proposal and duly paid the premium for the said mediclaim policy.

            In the early part of February, 2007, the complainant had to suffer for his abdominal pains and as per direction of Dr. Mrinmoy Nandy after proper diagnostic test, it had been found that the complainant was suffering from calculous cholecystitis and as per advice of Dr. Mrinmoy Nandy he was admitted to Woodlands Medical Care Ltd. There the complainant was operated by Dr. Mrinmoy Nandy on 1.6.07. The complainant was discharged on 4.6.07 (annex-receipt no.1009 dt.4.6.07 of Dr. Mrinmoy Nandi). From the discharge summary provided by the Woodland Medical Centre Ltd., it would be evident that the cholecystectomy operation of the complainant was done on 1.6.07 after all investigation of the complainant.

            Thereafter, in order to recover the amount which had been paid to the doctor and nursing home for such medical treatment, the complainant duly lodged the claim with o.p. no.1 in connection with his policy with o.p. no.2 through o.p. no.1 claiming reimbursement of Rs.37,762/- only as would be evident from the letter dt.1.10.07 of the complainant to o.p. no.1 (letter of the advocate on behalf of the complainant addressed to o.p. no.1).

            On receipt of a query from o.p. no.1, the complainant on 10.7.07 sent the supporting papers including the Claim Form, the Xerox copy of the policy, Discharge Summary, Fitness Certificate, receipt of fees by the surgeon, receipt of payment made at hospital, original bill of pathological test, ECG and X-ray reports and prescriptions (annex- enclosure of the letter dt.10.7.07 of the advocate addressed to o.p. no.1).

            In spite of such repeated request and demand of the complainant on submission of relevant papers, the o.p. no.1 neglected to respond to the proposed settlement of such claim made by the complainant.

            Hence, the case is filed by the complainant u/s 12 C.P. Act, 1986 for deficiency of service and unfair trade practices.

Decision with reasons:-

            Perused the petition of complaint, w/v of o.p. no.1, evidence on affidavit by the complainant, BNA by the complainant and documents on record. The BNA submitted by o.p. no.2 could not be considered due to non submission of w/v and evidence on affidavit. From the documents on record, it is evident that the o.p. no.1 has been sitting tight all along on the claim of the complainant without giving any opinion on the claim of the complainant. Their such behavior is nothing but another way of repudiation of the claim of the complainant. 

            In fact, from the supplementary evidence on affidavit by the complainant, it is evident that the complainant directly paid to Dr. Mrinmoy Nandy Rs.25,300/- vide bill no.1009 dt.14.6.07 and bill no.3026 dt.27.6.07 issued by Dr. Nandy in connection with the operation of the complainant at Woodlands Medical Centre Ltd. (annex- enclosures of petition of complaint).

            The complainant further incurred a sum of Rs.4200/- towards diagnostic test, x-ray, etc. (original cash memos/invoices filed with claim form).

            The complainant also paid Rs.8562/- to Woodlands Medical Centre Ltd. which is evident from the “Corporate Receipt” (annex- petition of complaint).

            Thus, the total amount paid by the complainant o Woodland Medical Centre is Rs.38,062/- (Rs.25,300 + Rs.4200 + Rs.8562).

            Besides this expenditure by the complainant to Woodlands Medical Centre Ltd. has claimed Rs.35,206/- excluding doctor’s fees and diagnostic test charge (annex- In-Patient Discharge Bill dt.4.6l.07).

            The total expenses towards the treatment of the complaiant amounts to Rs.73,268/- (Rs.25,300 + Rs.4200 + Rs.8562 + Rs.35,206).

            The complainant though incurred Rs.37,062/-, he was paid only Rs.17,000/- only by o.p. no.2. Hence, the complainant is yet to receive the balance amount of Rs.21,062/- (Rs.38,062 – Rs.17,000) only.

            Since, the o.p. no.2, the insurance company did not submit w/v or evidence on affidavit, they have forfeited their right by themselves to defend the case. In fact, it indicates that they have nothing in their hands to controvert the allegations of the complainant.

            It is interesting to note that neither o.p. no.1 nor o.p. no.2 cited any reasons for unexpressed repudiation of the claim of the complainant. In fact, their silence in responding to the claim of the complainant is nothing but repudiation of the claim.

            But the non submission of w/v and evidence on affidavit by o.p. no.2 indicates that they had nothing in their hands to controvert the allegations made by the complainant. O.p. no.1 in their w/v and BNA did not ever stated that the complainant was not entitled to get the outstanding amount of money from the o.p. no.2.

            Thus, in view of the position cited above, we are of the opinion that the complainant succeeds the case.

            Hence, ordered,

            that the o.p. no.1 is directed (1) to pay Rs.21,062/- (Rupees twenty one thousand sixty two) only which the complainant is entitled to have within 30 days from the date of communication of this order and in default, the amount will carry an interest @ 10% p.a. till the recovery of the amount in full, (ii) to pay Rs.20,000/- (Rupees twenty thousand) only as compensation for causing mental suffering and harassment to the complainant and (iii) to pay litigation cost of Rs.5000/- within 30 days from the date of communication of this order and in default, the said amount will carry an interest @ 10% p.a. till its full recovery.

            Fees paid are correct.

            The case is thus disposed of from this Forum.

            Supply certified copy of this order to the parties on payment of prescribed fees.

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