In the Court of the Consumer Disputes Redressal Forum, Unit -I, Kolkata, 8B, Nelie Sengupta Sarani, Kolkata-700087. CDF/Unit-I/Case No. 104 / 2011. 1) Smt. Renu Sengupta, 49/5, H/140, Karlmarx Sarani, Kolkata-23. ---------- Complainant ---Versus--- 1) National Insurance Co. Ltd. 3, Middleton Street, P.O.9229 P.S. Park Street, Kolkata-71. 2) M/s. Heritage Health TPA Pvt. Ltd. Nicco House, 5th Floor, 2, Hare Street, P.S. Hare Street, Kolkata-1. ---------- Opposite Parties Present : Sri Sankar Nath Das, President. Dr. Subir Kumar Chaudhuri ,Member Smt. Sharmi Basu ,Member Order No. 19 Dated 14-02-2013. The case of the complainant in short is that complainant had been suffering from excessive bleeding and pain in the lower abdomen since 3 weeks but had severe pain with excessive bleeding in the lower abdomen on 30.12.10 and went to Dr. Tirtha Mukherjee, Consultant Gynecologist on 30.12.10 for treatment and had been advised for urgent admission for further investigation. Complainant as per advice with the help of her husband Mr. Jayprakash Singh got herself admitted in one Arogya Maternity & Nursing Home for further treatment on 31.12.10 and Rs.5000/- was paid in advance. After that several tests had been carried out by the nursing home authority wh ere bulky uterus, bulky ovaries with small cysts resulting to sub-acute appendicitis had been diagnosed and operation (laparoscopy) suggested. The various tests had been carried out by one Medvue Medical Services. The said nursing home advised for immediate operation as a relief to the diagnosed problem and the complainant had to submit a requisition form to carry out the same. The operation of appendicitis and removal of left cyst was conducted on 3.1.11 and the same was conducted successfully. After Dr. Debcharan Ghosh and Dr. Tirtha Mukherjee conducted the operation the complainant had been shifted to normal bed and all the post operational treatments were carried out. Dr. Tirtha Mukherjee visited the complainant to check the progress. The complainant was discharged at last on 6.1.11. The complainant had to pay Rs.1500/.- to one ESS BIOTEQ CENTRE against rental charges for Laparoscopic Surgery System on behalf of Arogya Maternity & Nursing Home. Doctor’s fees were also paid and all the other charges were also meted with. The complainant had a mediclaim covering all the family members from National Insurance Co. Ltd. having Card No.HHS1 0101574890 and policy no.102000/48/09/8500003609 covering upto Rs. 1 lakh. And Heritage Health TPA Pvtl Ltd. is the third party administrator for the National Insurance Co. Ltd. After the discharge of the complainant, a claim of Rs.42340/- had been issued under the Hospitalization Benefit Policy. But surprisingly a refusal letter came from Heritage Health TPA Pvt. Ltd. repudiating the said claim saying that the said disease is excluded in the first two years of insurance as per clause 4.3 of the mediclaim policy. Complainant again issued a notice through her advocate by speed post confirming the claim as a rightful claim but no reply came against the said notice. 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 a mediclaim covering of the family members from National Insurance Co. Ltd. having card no.HHS1 0101574890 and policy no.102000/48/09/8500003609 covering upto Rs.1 lakh and Heritage Health TPA Pvt. Ltd. was 3rd party administrator for the National Insurance Co. Ltd. Further we find that complainant fell sick and was admitted in Arogya Maternity Nursing Home for various ailments as well as operation of appendicitis and removal of left cyst which was conducted on 3.1.11 and operation was successful and it was done by Dr. Deb Charan Ghosh and Dr. Tirtha Mukherjee and she was discharged on 6.1.11 and complainant paid the entire cost and subsequently complainant after discharge submitted a claim of Rs.42,340/- under hospitalization benefit policy, but o.p. no.2 repudiated the claim stating that the said claim was contrary to the provision of clause of mediclaim policy. It is an admitted position that complainant was not at all defaulter at the relevant point of time i.e. at the time of submitting claim. It has been observed by Hon’ble Supreme Court of India that mere breach of policy condition cannot be a ground for repudiation of any bonafide claim of a claimant / complainant and this view of the Hon’ble Supreme Court of India has been published in CTJ May 2010 Vol-18 No.5 Page 66. In view of the above position and on perusal of the entire materials on record we are of the view that o.ps. had deficiency in service being service provider to its consumer / complainant and complainant is entitled to relief. Hence, ordered, That the case is allowed on contest against o.p. no.1 with cost of Rs.10,000/- (Rupees ten thousand) only and ex parte without cost against o.p. no.2. O.p. no.1 is directed to pay a sum of Rs.42,340/- (Rupees forty two thousand three hundred forty) only being the claim amount as against the mediclaim policy to the complainant and is further directed to pay interest @ 18% p.a. from the date of repudiation of claim of the complainant by o.ps. till the date of liquidation of the same and litigation of Rs.5000/- (Rupees five thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 10% 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. | 
