In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I / Case No. 37 / 2010.
1) Dr. Lalit Kumar Sinha,
1, Jadulal Mullick Road, Kolkata-700006. ---------- Complainant
---Versus---
1) M/s. Royal Sundaram Alliance Insurance Co. Ltd.,
“Sundaram Towers”, 45 & 46, Whites Road, Vhennai-600 014.
2) Medicare TPA Services (I) Pvt. Ltd.,
6, Bishop Lefroy Road, Kolkata-700020. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Smt. Jhumki Saha, Member.
Dr. A. B. Chakraborty, Member
Order No. 2 0 Dated 31/01/2012.
The petition of complaint u/s 12 of the C.P. Act, 1986 has been filed by complainant Dr. Lalit Kr. Sinha against the o.ps. M/s. Royal Sundaram Alliance Insurance Co. Ltd. and another. The case of the complainant in short is that he took a mediclaim policy from o.p. no.1 having master policy no.HLSB1L0013from 4.4.09 to 3.4.10 midnight and thereafter o 6.8.09 complainant was admitted in Apollo Gleneagles Hospital from 6.8.09 to 8.8.09. At the time of discharge and that the relevant point of time complainant under valid insurance coverage. Complainant subsequently lodged a claim with all papers for Rs.35,286.54 as against the said policy and o.p. no.2 on 8.8.09 repudiated the claim on the ground of that cashless claim was not admissible. Complainant thereafter negotiated with o.ps. stating interalia that complainant is continuing treatment per day by incurring Rs.500/- on account of medicine cost and such other treatment and complainant lastly submitted claim demanding Rs.2,50,000/- vide notice of demand dt.19.11.09 by regd. post with a/d through ld. advocate. But o.ps. did not pay heed to them. Hence the instant case has been filed by the complainant with a prayer mentioned in the prayer portion of the petition of complaint.
O.p. no.1 had entered its appearance by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case and o.p. no.2 did not contest this case and matter was heard ex parte as against o.p. no.2.
Decision with reasons:
We have gone through the pleadings of the parties, evidence and documents in particular. It is an admitted position that complainant had mediclaim policy with o.ps. and plea taken by o.p. in the matter of repudiation is not sustainable in law as we come to find from the materials on record available. We do not find any cogent reason for repudiation of claim of the complainant for Rs.33,787.44. But complainant has not filed any piece of paper showing expenditure of total amount of Rs.2,50,000/- in respect of his claim and as such, the aforesaid claim of Rs.2,50,000/- could not be substantiated by complainant by filing valid documents or something like that acceptable to this Forum. Therefore, we hold that complainant is entitled to get refund of Rs.33,787.44 from o.p. no.1 and repudiation of the said sum by the o.ps. is a clear deficiency being a service provider to its consumer / complainant and complainant is entitled to relief as prayed for.
Hence, ordered,
That the petition of complaint is allowed on contest with cost against o.p. no.1 and ex parte against o.p. no.2 without cost. O.p. no.1 directed to pay a sum of Rs.33,787,44 (Rupees thirty three thousand seven hundred eighty seven and paise forty four) only together with interest @ 9% p.a. from the date of claim till the date of realization . O.p. no.1 is further directed to pay compensation of Rs.15,000/- (Rupees fifteen thousand) only for harassment and mental agony and litigation cost of Rs.7000/- (Rupees seven thousand) only to the complainant within 45 days from the date of communication of this order, i.d. an interest @ 9% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties.
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MEMBER MEMBER PRESIDENT
