Dr. Subir Kumar Chaudhuri ,Member

Order No.   18    Dated  25-02-2013.

            The case of the complainant in short is that sometimes in the year 2007, an agent of o.p. no.1 visited the complainant at his residence and requested him to purchase a hospitalization benefit insurance policy in the name of the mother of the complainant, Smt. Gouri Rani Ghosh and to convince the complainant gave the complainant a brochure of the said policy at his residence for his perusal.

            Complainant duly went through the said brochure. He was suitably impressed by the fact that in the said hospitalization benefit policy, not only the expenditure with respect to the hospitalization is included, but also the pre and post hospitalization expenditures are also included, as is evident in the clauses 3.2 and 3.3. of the said brochure.

            Complainant was suitably impressed by the aforesaid fact, apart from the fact that o.p. no.2 is a govt. concern and that it has earned a huge goodwill. Besides his mother is a frail lady and prone to illness and the subsequent treatment would necessitate the presence of such an insurance policy.

            Complainant, a few days later, expressed to the said agent his desire to purchase the said insurance policy. The agent duly came to the residence of the complainant on the appointed date along with the relevant forms and completed all the requisites regarding purchase of the said insurance policy in favour of the complainant. The complainant, therefore, purchased the said insurance policy under the name of his mother Smt. Gouri Rani Ghosh , the insurance policy no. being 100600/48/08/8500007717, DO/BO-100600, agent code no.19056.

            After the expiry of the duration of the said insurance policy unclaimed, the same had been further renewed on 2008 and then again on 28.2.09, which was valid till 27.2.10.

            On 15.1.10 the mother of the complainant slipped and fell in the bathroom and sustained severe fracture on her left femur neck. She was duly consulted by the Orthopaedic Dr. Ashoke Kumar Das on 16.1.10 and he suggested immediate hospitalization at CMRI. The complainant had to pay the doctor’s fees for consultation against receipt.

            On 16.1.10 the mother of the complainant was operated and the operation was successfully completed. After the said operation was over, the complainant had to pay for the surgical fees and the other assistants including the anesthetists’ fees apart from the booking of the operation theatre. He also had to purchase several medicines which formed part of treatment during the pre-operative and post-operative period. He was given receipts against all these payments.

            The said patient had been discharged on 21.1.10. On that day, the complainant had paid for the bed charge and the visiting fees for the doctor and also other medicines, which formed part of the post-operative treatment. He was given valid receipts against the said payment. The complainant put forth a claim of the total sum of Rs.34,394/-.

            The complainant was surprised to receive a letter dt.12.6.10 from o.p. no.2, together with a cheque being no.30780 dt.12.6.10 drawn on HDFC Bank, Sarat Bosse Road Branch, Kolkata, for Rs.9424/-, instead of the claimed amount of Rs.34,394/-. In the said letter, it is stated by o.p. no.2 that the amount of Rs.9424/- from the full and final settlement of the claim made by complainant.

            O.p. no.2  had deliberately misquoted the dated of the doctor’s receipt as 31.12.09 when in reality it is clearly shown that the date as put down by the doctor himself is 31.1.10. Basing on this distorted fact, o.ps. have refused to sanction the claim for the doctor’s fees amounting to Rs.22,000/-.

            Complainant sent a demand notice dt.1.7.10 to o.ps. through his ld. advocate Sri Achyutananda Ghosh, wherein it was requested to o.ps. to pay the amount of Rs.22,000/- to the complainant against the money receipts dt.16.1.10 and 31.1.10 issued by Dr. Ashok Kumar Das as per the terms and conditions laid down in the policy, but in spite of receipt of the same, till date, no response was made by them, hence the case.

            Complainant states that o.ps. have committed gross negligence by deliberately ignoring the terms and conditions laid down in the policy and holding off the payment of Rs.22,000/- from the complainant without having any valid ground or reason to do so. Hence the case was filed by complainant with the prayer contained in the petition of complaint.

            O.p. no.1  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. O.p. no.2 did not contest the case by filing w/v and matter was heard ex parte against o.p. no.2. Ld. lawyer of o.p. no.1 in the course of argument submitted 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 insurance policy being no.100600/48/08/8500007717, DO/Bo-106600, agent code no.19056 and it was renewed and valid upto 27.2.10 and on 15.1.10 mother of complainant sustained severe fracture injuries and she was hospitalized and her operation took place on 16.1.10 and was discharged on 21.1.10 and complainant had paid for the treatment of his mother. Thereafter, complainant made a claim of Rs.34,394/- and o.p. no.2 by cheque no.30780 paid Rs.9424/- instead of Rs.34,394/- and thereafter complainant made several correspondences along with doctor’s certificate, but without any fruitful result.

            In view of the findings above and on perusal of the entire materials on record we find that the action on the part of o.ps. disallowing Rs.22,000/- from the total claim of Rs.34,394/- amounts to deficiency in service being service provider to its consumer / complainant and complainant is entitled to relief particularly when complainant is not a defaulter and it is settled principle of law that insurance company cannot disallow the justified claim of the claimant for breach of any clause of insurance policy as has been derived from the spirit of the decision of Hon’ble Supreme Court of India published in CTJ May 2010 Vol-18 No.5 Page 66.

            Hence, ordered,

            That the case is allowed on contest with cost against o.p. no.1 and ex parte without cost against o.p. no.2. O.p. no.1 is directed to pay Rs.22,000/- (Rupees twenty two thousand) only being the balance amount of the total claim of Rs.34,304/- of the complainant and is further directed to pay compensation of Rs.10,000/- (Rupees ten 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.