West Bengal

Paschim Midnapore

CC/181/2016

Sri Arpan Krishna Pramanik - Complainant(s)

Versus

National Insurance Co. Ltd. - Opp.Party(s)

12 Jul 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

Sagarika Sarkar, Member. 

and 

Pulak Kumar Singha, Member.

 

Complaint Case No.181/2016

 

1. Sri  Arpan @ Arpan Krishna Pramanik, S/o Sri Annada Krishna Pramanik,
2. Sri Annada Krishna Pramanik , S/o Late Gopal Krishna Pramanik, religion- Hindu, by profession business, resident of Dwaribandh, P.O. & P.S. Medinipur, District- Paschim Medinipur…..………..……Complainant.

                                                                              Vs.

             National Insurance Co. Ltd., notice to be served through the Divisional Manager,

             Medinipur Branch at Station Road, P.O. & P.S. Medinipur, District Paschim  

             Medinipur....……….….Opp. Party.

                                                    

              For the Complainant: Mr.  Partha Kumar Basu, Advocate.

              For the O.P.               : Mr. Mrinal Kanti Chowdhury, Advocate.

 

Decided on: -12/07/2017

                               

ORDER

                          Bibekananda Pramanik, President – Complainants, named above, have filed this consumer complaint  u/s 12 of the C.P. Act  thereby alleging deficiency in service against the O.P- National Insurance Company Ltd.

Facts of the case, in brief, are that the complainants are the policy holders of a Mediclaim Insurance Group/Paribar policy under the O.P. vide policy no.153800/48/15/8500001878.  Complainant no.2 is the father of the minor complainant

Contd…………………..P/2

                                                                           

                                                                                        ( 2 )

 no.1, who had a lump in his left foot between the left thumb and the adjacent finger for which the complainant no.1  underwent  an operation at Spandan Nursing Home at Medinipur by a surgeon on 13/03/2016 as an indoor patient and he was discharged after one day of  his admission.  After such operation, biopsy was done but fortunately the result was negative.  For such operation of the complainant no.1, a sum of Rs.11,044.34/- was spent.  A claim was submitted to the O.P.-Insurance Company for reimbursement of the said medical expenses of Rs.11,044.34/- and after  receiving the said claim , the O.P. asked for indoor case papers of the nursing home which is absolutely the properly of the nursing home and they also denied to supply those papers to the complainant.  Complainant no.2 intimated the O.P. regarding such refusal of the nursing home to hand over the “indoor case papers” vide letter dated 13/06/2016 and requested the O.P. to contact with the nursing home, if required.  Even thereafter neither any reply was given to the complainant by the O.P. nor any payment towards such claim has been made by the O.P.  It is stated by the complainants that they are   legally entitled to get the mediclaim amount spent for the said treatment.  The complainants are also entitled to get compensation to the tune of Rs.10,000/- for harassment and cost of the proceeding.  Hence the complaint praying for directing the O.P. to pay Rs.21,044.34/- to the complainants towards mediclaim as well as for compensation and for cost.

The opposite party-Insurance Company has contested this case by filling a written objection.

Denying and disputing the case of the complainant,  it is the specific case of the O.P.-Insurance Company that the complainants did not produce any document to the company as well as to the TPA for which the TPA is unable to process the claim of the complainants.  It is further stated by the O.P.-Insurance Company that the claim of the complainants is not covered under the insurance policy as per terms and conditions of the policy.  The O.P. therefore claims that they have no deficiency in service on their part and the petition of complaint is therefore liable to be rejected.

To prove their case, the complainants have examined the complainant no.2 Annada Krishna Pramanik as PW-1 by tendering a written examination-in-chief, supported by affidavit and the documents, relied upon by the complainants, have been marked as exhibit 1 to 27 respectively.  On the other hand, O.P.-Insurance Company adduced no evidence.

Contd…………………..P/3

 

                                            

                                                                                      ( 3 )

 

                                                                 Points for decision

1. Is the case maintainable in it’s present form and prayer?
2. Are the complainants consumers of the O.P.-Insurance Company?
3. Is there any deficiency in service on the part of the O.P.-Insurance Company?
4. Are the complainants entitled to get the reliefs, as sought for?    

                   

Decision with reasons

For the sake of convenience and brevity, all the above points are taken up together for consideration.

                       Maintainability of this case has not been challenged at the time of hearing of the present case.  We also find that there is nothing on record to show that the present case is not maintainable. This point is therefore decided in the affirmative and in favour of the complainants. 

                       It is not denied and disputed that the complainants are the policy holder vide policy no. 153800/48/15/8500001878 of a Mediclaim Insurance Group/Paribar policy under the O.P.-Insurance Company.  It is the case of the complainants that since there was a lump under the left foot between the left thumb and adjacent finger of the complainant no.1, so he had to undergo an operation of the said lump at Spandan Nursing Home at Medinipur by a surgeon on 13/03/2016 as an indoor patient and he was discharged after a day of his operation.  It is also the case of the complainants that for such operation, a sum of Rs.11,044.34/- was spent.  In support of their said case, the complainants have filed medical papers regarding such operation which have been marked as exhibit-14, 19, 20, 21, 22 to 27 respectively.  O.P. has also not specifically denied regarding such surgery and treatment of the complainant no.1.  It is also undisputed that the complainants are the policy holders of a mediclaim policy named as Medical Insurance Group/Paribar policy under the O.P.  It is not denied and disputed that after such operation, the claim for reimbursements of mediclaim under the policy was submitted by the complainants to the O.P.-Insurance Company.  In their written objection as well as at the time of hearing of argument, it was submitted on behalf of the O.P.-Insurance Company that since the complainant did not produce any document to the company as well as to the TPA, the claim was not processed.  As against such objection, it was submitted on behalf of the complainants that they duly submitted all necessary medical papers regarding the operation and treatment of the

Contd…………………..P/4

 

                                                                                                ( 4 )

complainant no.1.  In paragraph 11of the petition of complaint it has been stated by the complainants that after submission of the claim form, the O.P. asked for indoor  case papers of the nursing home but the nursing home denied to supply all those papers to the complainant.  Ld. Lawyer for the O.P.-Insurance Company submitted at the time of hearing of argument that since the complainant did not provide their TPA the indoors papers, so the TPA could not process the claim.  From exhibit 2, we find that the concerned TPA asked the complainant to provide them duration of present ailment and indoor case papers.  In reply to such letter of the TPA, the complainant sent a letter dated 13/06/2014 (exhibit 1) and in the said letter the complainants no.2 has clearly mentioned that he has already submitted the prescription in original and it is not possible for him to collect the indoor case papers of the concerned nursing home and by that letter, he gave his consent and authorization to the TPA to make contact with that the nursing home authorities for collection all those papers.  Admittedly even after the said letter dated 13/06/2016, so sent by the complainant no.2, the concerned TPA of the O.P.-Insurance Company did not make any enquiry for which the claim of policy has not been settled.  When the complainant has submitted his claim along with all medical papers and money receipts of such treatment, then it was the duty of the concerned TPA of the O,P,-Insurance Company to enquire about the same from the concerned doctor and nursing home but instead of doing so, TPA concerned has asked the complainant to provide them with indoor case papers which is practically not possible for a patient party.  It is seen in many cases that these TPAs are causing delay in settlement of claim on such flimsy ground for which the policy holders are being suffered.  In the present case also, the complainants’ claim of medical reimbursement  under the policy in question has not yet been settled by the O.P.-Insurance Company on such flimsy ground which amounts to deficiency in service on the part of the O.P.-Insurance Company.  The petition of complaint therefore deserves to be allowed and we hold so.

All the points are accordingly disposed of in favour of the complainants.

In the result, the complaint case succeeds. 

 

                                       Hence, it is,

                                          Ordered,

                   that the complaint case no.181/2016  is  allowed on contest with cost against the O.P.-Insurance Company.  O.P.-Insurance Company is

Contd…………………..P/5

 

                                                                                         ( 5 )

directed to pay Rs.11,044.34/- with interest @9% p.a. from the date of filing of the present complaint.  O.P.-Insurance Company is further directed to pay Rs.5,000/- as compensation and Rs.3,000/- as litigation cost to the complainants.  All such above payments are to be made within a month from this date of order.

                               Let plain copy of this order be given to the parties free of cost.

Dictated and Corrected by me

       

               President                 Member                     Member                        President

                                                                                                                 District Forum

                                                                                                              Paschim Medinipur