Sri Arup Das,
76/1, Kabi Sukanta Sarani, P.O.Beleghata,
P.S. Nanti House, Kolkata-85 ……. Complainant
vs.
National Insurance Co. Ltd. Division-III,
1, Shakespeare Sarani, 6th floor, Kolkata-71 and others… Opposite parties
Present : Sri A.K. Das, President
Sri L.K. Banerjee, Member
Order no. 11 dt. 09.10.2007
The present case being no.77/2006 was filed by Sri Arup Das, S/o. Mantu Lal Das, 76/1, Kabi Sukanta Sarani, P.O. Beleghata, P.S. Nandi House, Kol-85 the petitioner to the petition of complaint against the o.ps. viz (1) National Insurance Co, Ltd., Division-III, 1, Shakespeare Sarani, 6th floor, P.S. Park ‘Street, Kol-71, (2) The Sr. Divisional Manager, National Insurance Co. Ltd., Division-III, 1, Shakespeare Sarani, 6th floor, Kol-71 and (3) Golden Multi Services Club, 16, R.N. Mukherjee Road, 1st floor, Kol-1 before the forum praying for various reliefs as specified at pages 11-12 of the main petition.
The case was filed u/s 12 of the C.P. act, 1986. The facts of the case are in brief as follows.
That the complainant was a Group Medical Policy holder with the o.p. nos.1 and 2 through the proforma o.p. no.3. The policy being no.100300/46/01 /8500/07/03/85/30031 was issued by the o.p. no.1 under serial no.01845186/ 103040289919 dt.23.7.03 in the name of the Golden Multi Services Club of G.T.F.S. the proforma o.p. no.3 being the insured by giving / assuring charge to the petitioner as the insured person. The insurance policy was valid for the period from 23.7.03 to 22.7.04 (midnight). The total sum assured for the policy was Rs.15,000/-, annex-A. That the petitioner in the month of Sept. 2003 fell uneasy in the abdomen pain consulted physicians who in turn advised him to take admission in the Divine Nurisng Home Pvt. Ltd., 11A, Abinash Chandra Banerjee Lane, Kol-10 for various tests and operation. Accordingly, the petitioner took admission on 9.12.03 and discharged on 14.112.03 after treatment. For treatment in the nursing home petitioner incurred an expenditure to the tune of Rs.13,436.50.
That the petitioner informed about his treatment in the nursing home to the o.p. no.3 on 29.12.03 and on 20.4.04 submitted his claim form along with relevant papers to the o.p. no.3 and it was duty registered as claim no.600/0304/9/Kol/9844 for transmission the same to the o.p. no.1 for reimbursement of the amount of Rs.13,436.50 as incurred by him during his treatment. Annex-C & D reveal the correspondences made between the o.p. no.3 and the petitioner for more papers on treatment. Being satisfied the o.p. no.3 transmitted to claim form to the o.p. no.1 on 7.7.04. On 5.2.05 the o.p. no.2 intimated the petitioner that his claim has been closed as “no claim” citing the conditions of the terms of he policy Clause no.5.3 and 5.4, annex-E.
Therefore, the petitioner made several correspondences to the o.p. nos.1 and 2 for settlement of his claim. Being dissatisfied with no positive response from the o.p. nos.1 and 2 the petitioner approached the forum for justice. Hence, this case is for adjudication .
The o.p. no.3 has contested the case by way of filing affidavit on evidence denying therein very emphatically all the material allegations to the petition of complaint. No. w/o has been filed by the o.p. nos.1 and 2 though they appeared through the ld. Counsel and contested the case.
The o.p. nos. 1 and 2 relied upon their denial letter dt.5.2.05, annex-E, wherein it stated and treated the claim of the petitioner as ‘no claim’. The o.p. no.3 stated in averment that “ the o.p. nos.1 and 2 are the sole and absolute authority to take decision in that regard according to their own wisdom and the proforma o.p. no.3 has no authority to settle the claim. Moreover, as regards to settlement of he claim, the o.p. nos.1 and 2 did never consult with proforma o.p. no.3 and they are not even obliged to do so”.
To defend he contention of the petition of complaint the complainant relied upon the annex-A-F wherefrom it appears that the petitioner was an insurance policy holder for the period from 23.7.05 to 22.7.04. The policy amount was Rs.15,000/-, the petitioner operated upon in the nursing home, incurred expenditure to the tune of Rs.13,436.50 for treatment, claim form along with all relevant documents submitted through the proforma o.p. no.3, claim was repudiated.
Now the question arises whether the petitioner is entitled to get any relief under the C.P. Act, 1986.
The o.ps. repudiated the claim of the petitioner on the ground of policy clause nos.5.3 and 5.4, which means non-intimation of hospitalization within 7 days of hospitalization and non-submission of claim form within 30 days from the date of discharge.
It appears that the petitioner intimated the proforma o.p. no.3 about his treatment in the nursing home on 29.12.03. Therefore for procedural purpose a lot of time was wasted for submission of claim form. It also appears that copy of the terms and conditions of the policy was not supplied to the petitioner. The claim form through o.p. no.3 was submitted on 7.7.04 and repudiation letter came on 5.2.05.
It is an established principle upheld by the Hon’ble National Commission that non submission of claim form in time or non intimation of hospitalization within a stipulated period cannot be the sole ground for repudiation of the claim of the complainant.
The o.ps. while dealing with the claim of the petitioner could have dealt the matter with a human touch.
The forum perused all the documents available with the record, considered the arguments, submission made by the parties and have come to conclusion that the complainant has been able to prove his case to the hilt so as to get adequate relief in this case within the ambit of C.P. Act, 1986. Fact is that the claim of the petitioner is genuine and simply technicality of procedure of submission of claim form in time could not be the ground for ‘no claim’ of the petitioner. Moreover, the amount was not a big one as incurred by the petitioner during his treatment in a hospital.
The o.ps. took more than six months to intimate the petitioner that he fate of his claim. This is a gross deficiency in service and non action on the part often o.ps. for rendering timely service to petitioner. This non action caused mental agony harassment to the petitioner.
Having considered all such aspects the forum is of the opinion that the case succeeds on contest.
Hence,
Ordered,
The o.p. nos.1 and 2 are directed to reimburse the claim amount of the petitioner to the tune of Rs.13,436.50 (Rupees thirteen thousand four hundred thirty six and fifty paise) only as incurred by him during his treatment in the nursing home and also pay a sum of Rs.2000/- (Rupees two thousand) only and Rs.1000/- (Rupees one thousand) only respectively as compensation and litigation cost for causing needless mental agony and harassment o the petitioner through its negligence, inaction and deficiency. The o.ps. are also directed to pay to the complainant simple interest @ 8% p.a. beginning from this day on the aforesaid sums till the full payment of the sums as ordered is made, if the o.ps. do not pay such sums within that time as now given.
The payment should be made by the o.ps. to the petitioner within 45 days from this date of the order .
This office will make available a copy of this order to the concerned parties free of cost as per rules.
