In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No. 293 / 2011.
1) Sri Anjan Kumar Dutta,
128/2/B, B.L. Saha Road, Kolkata-7000053. ---------- Complainant
---Versus---
1) National Insurance Co. Ltd., Ballygunge Branch,
3A, Gariahat Road, Kolkata-700016.
2) The Claim Executive, Heritage Health TPA Pvt. Ltd.,
Nieco House, 5th Floor, 2, Hare Street, Kolkata-700001. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. A. B. Chakraborty, Member
Order No. 8 Dated 2 2 / 0 3 / 2 0 1 2 .
The petition of complaint u/s 12 of the C.P. Act, 1986 has been filed by the complainant Anjan Kumar Dutta against the o.ps. National Insurance Co. Ltd. and another. The case of the complainant in short is that complainant has been maintaining a mediclaim policy with cashless facility bearing no.101901/48/10/8500000/442/101901. In the month of January 2001 compliant had some urinary problem and was advised by treating doctor for USG of whole abdomen and after USG it was diagnosed that he was suffering from enlarge prostate and cholelithiasis and accordingly laparoscopic surgery cholecystectomy was done at Apollo Hospital on 22.2.11. He was discharged on 23.2.11. On lodging the claim with o.ps, o.ps. paid Rs.36,000/- leaving a balance of Rs.15,431/-. Thereafter discharged on 23.2.11 from Apollo Hospital some urinary problem cropped up and he had to take admission to Ramkrishna Mission Seva Pratisthan where cauterization was done at a cost of Rs.6272/- and again on 11.3.11 he had to go for change of catheter from the said hospital on 11.3.11 at a cost of Rs.450/-. Thereafter for his enlarge prostate he took admission in Woodland Nursing Home on 20.3.11 under Dr. Vinayak Sen and operation was done on 21.3.11 and he was discharged on 24.3.11 after payment of Rs.66,283/- in total. Thereafter complainant lodged total claim of Rs.1,25,893/- with the o.ps. but on 23.7.11 o.p. no.2 rejected the claim under clause 5.3 of the standard mediclaim policy. In the meantime complainant received on 14.7.11a cheque of rs.19,642/- for the operation held on Apollo Hospital and the complainant accepted the sum without prejudice to his rights and claim as above. Hence the instant case lodged by complainant with the prayer contained in the prayer portion of petition of complaint.
O.ps. did not contest the instant case by filing w/v and as such, the instant case was heard ex parte.
Decision with reasons:
We have gone through the pleadings of complainant and evidence and documents in particular and we find that the evidence of complainant has remained unchallenged and unrebutted . We find on perusal of the entire materials on record that o.ps. had sufficient deficiency on their part being service provider towards their consumer / complainant and we are of the view that complainant has made out his case against o.ps. and complainant is entitled to relief as prayed for.
Hence, ordered,
That the petition of complaint is allowed ex parte against o.ps. with cost. O.ps. are jointly / severally directed to pay a sum of Rs.70,251/- (Rupees seventy thousand two hundred fifty one) only together with interest @ 10% p.a. from the date of repudiation till the date of realization and are further directed to pay compensation of Rs.15,000/- (Rupees fifteen thousand) only to complainant for his harassment and mental agony and litigations cost of Rs.5000/- (Rupees five thousand ) only within 45 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of complainant till full realization.
Supply certified copy of this order to the parties.
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MEMBER PRESIDENT
