Present : Sri A.K. Das, President
Sri L.K. Banerjee, Member
Order no. 7 dt. 15/11/2007
The present case being no.296/2006 was filed by Sri Soumendra Nath Mallick, S/o, Sri Krishna Prosanna Mallick, 11A Raja Brojendra Street, Kol-7 against the o.ps. viz (1) National Insurance Co. Ltd., Division-III, 1, Shakespeare Sarani, P.S. Park Street, 6th Floor, Kolkata-71, (2) The Senior Divisional Manager, National Insurance Co. Ltd., Division-III, 1, Shakespeare Sarani, P.S. Park street, 6th Floor, Kolkata-71 and (3) The Golden Trust Financial Services, 16, R.N. Mukherji Road, Kolkata-1before the forum praying for various reliefs as specified at page 9-10 of the main petition.
The case was filed u/s 12 of C.P. Act 1986.
The facts are in brief as follows.
That the complainant along with his wife is a policy holder with the o.p nos.1 and 2 through the o.p. no.3 as member of Golden Trust Financial Services (GTFS). It is a Group Medical Policy being no.100300/46/01/8500/07/03/85/30050. The policy was for the period from 23.11.03 to 22.11.04 (midnight). Policy amount was Rs.20,000/- (each). The complainant’s wife also a policy holder was suffering from malaria on and from 6.1.04 as per advice of the physician took admission in L.B. Nursing Home at 204, A.P.C. Road, Kol-4 and she was there for a period from 20.1.04 to 26.1.04. It appears from the record that she was under treatment from 6.1.04 to 4.2.04 under Dr. Ajit Kr. Gupta. For treatment she incurred an expenditure of Rs.8341.76.
On 23.2.04 the petitioner informed the GTFS about hospitalization of his wife who in turn requested him to submit claim form along with relevant documents. On 7.4.04 the claim form was submitted by the petitioner for onwards transmission of the same to the o.p. no.1 for settlement of claim. On 1.6.04 GTPS informed the petitioner to supply documents which were missing in the claim form for settlement of claim. The request was complied with on 13.7.04 and it was received by GTFS on 14.7.04.
After a prolong period the petitioner was informed on 9.2.05 that his claim was repudiated and the o.ps. have closed his claim as “no claim” on the ground of violation of condition no.5.3 and 5.4 of the policy. Thereafter he complainant made several correspondences with the o.ps. to review, modify and evaluate the decision but in vain. Finding no remedy in this regard the petitioner approached this forum for justice.
The o.p. nos.1 and 2 have not appeared and filed any w/v. O.p. no.3 appeared and contested the case by filing w/v.
O.p. No.3 contended in the w/v that “they are only obliged to collect premium from the proposers and remit the same to the o.p. no.1 and apart from this, there had been no other liability to be borne by the proforma o.p. no.3 in that regard. Moreover, the petitioner has no specific relief against the proforma o.p. no.3.
It appears from the record that the o.p. nos.1 and 2 have not applied their mind while dealing with the petitioner’s claim. The petitioner relied upon the annex marked A-1 to A-6 in support of his case.
It appears that the petitioner submitted claim form on 13.7.04 and the o.p. nos.1 and 2 having well oiled administrative machinery took more than 7 months time to inform its decision on 9.2.05. Fact that the petitioner could not submit its claim form and fail to inform the o.ps. about his hospitalization in time as per clause nos.5.3 and 5.4 of the policy. This is in violation of the condition of the clause contained in the policy. But the petitioner made it clear about the cause of his delay in submitting the claim form.
It is fact that certain practical condition prevented the petitioner from filing claim form in time. Non-information and non-submission of claim form in time could not be the sole ground for repudiation of claim of the petitioner. The insurance company is not a profiling concern so it should look and consider the applicant’s claim with a humane touch. Here the o.p’s action smacks of dereliction of duty and amounts to non action and negligence and deficiency in service. The o.ps. have not contested the case and have no leg to stand upon the case. The o.p. no.3 has no liability in settling the claim of the petitioner.
Having considered all such aspects so long discussed in detail, the forum have come to conclusion that the petitioner has been able to prove his case to the hilt so as to get adequate relief within the ambit of the C.P. Act,1986.
The case succeeds on contest.
Hence,
Ordered,
The o.p. nos.1 and 2 are directed to pay the claim amount of the petitioner of Rs.8341.76 (Rupees eight thousand three hundred forty one and seventy six paise) only incurred by the petitioner at the time of treatment and also pay a sum of Rs.2000/- (Rupees two thousand) and Rs.1000/- (Rupees one thousand) respectively only as compensation and litigation cost for causing needless mental agony, harassment to the petitioner through its negligence, inaction and deficiency.
The o.ps. are also directed to pay to the petitioner 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.p. nos.1 and 2 to the petitioner within 60 days from this date of the order.
The o.p. no.3 the proforma party has no liability for payment of the claim amount of the petitioner.
The office will make available a copy of this order to the concerned parties free of cost as per rules.
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Member President
