FINAL ORDER/JUDGEMENT

SHRI ASHOKE KUMAR GANGULY, MEMBER

This is an application u/s.12 of the C.P. Act, 1986.

The complainant had a Group Mediclaim policy with the OP 1 under Policy No. 154400/50/17/10002979. The complainant got his wife admitted in Kothari Medical Centre from  06.10.2018 to 15.10.2018 and 24.10.2018 to 30.10.2018. Kothari Medical Centre charged fees for 15.10.2018 and 30.10.2018 being the days of discharge. Total Bill amount was Rs. 84, 939.39. They have taken Rs. 34, 780/- from the complainant by pressure. OP did not sanction Rs.34,939.39. The OPs sanctioned Rs.53,658/- against Rs.68,258.15. Rs. 14,600/- was not sanctioned. Another claim of Rs.21,000/- was also refused by the OP 1. The treatment was in connection with Retlna.

Since the complainant was not allowed reimbursement of the expenses incurred for the treatment of his wife Smt. Rita Das in the Kothari Medical Centre and in the Disha Eye Hospital. He has no other option but to approach the commission for relief as mentioned in the complaint petition.

The OP 1 have contested the case by filing  their WV contending inter alia that the case is not maintainable since  the complainant has suppressed the material facts and submitted as follows. The Kolkata Police Force purchased the Group Mediclaim Policy from the OP 1 bearing No. 154400501710002979 for a period from 16.08.2017 to 15.08.2018 which was subsequently extended to 15.09.2018 with certain conditions. The floater sum assured was Rs. 2,00,000/- per family. The complainant and his family members are covered under the scheme. Complainant’s wife Smt. Rita Das was admitted to Kothari Medical Centre, Kolkata for various ailments from  06.10.2018 to  15.10.2018 and again from 24.10.2018 to 30.10.2018. As such, the complainant is not entitled to get any claim or benefit for the treatment whatsoever beyond the period of the policy year. There is no privity of contract in force between the insurer and the  insured while she got admitted in the said hospital for treatment and there is no renewal of policy in question. As such, there was no sanction of any amount from any quarter under the above circumstances. Further the complainant’s wife namely Rita Das took treatment at Disha Eye Hospital Pvt. Ltd., Gariahat Branch, on 24.08.2018 and had incurred an expenditure of Rs.  21,000/-. But the complainant is not entitled to  any reimbursement  since the total limit of Rs 2,00,000/- had already been exhausted. The OP has further stated that the complainant has availed of treatment for his wife Smt. Rita Das at various hospitals and made claims thereof beyond the policy coverage  and accordingly, the full coverage got exhausted while taking treatment for his wife at the eye hospital and Kothari Medical Centre. The complainant has therefore, no right to get any relief of the claim as prayed for.

The OP 2 has also contested the case by filing their WV and submitted that the complainant is not a consumer to the OP 2. There is no contractual relationship between the complainant and the OP 2. The allegation is mainly against the OP 1.  The answering OP 2 denied all allegations against them. No prayer is there against the OP 2 in the entire complaint petition. As such, the complaint should be dismissed in limini against the OP 2. 

Points for Determination

In the light of the above pleadings, the following  points necessarily have come up for determination.

1)  Whether the OPs are deficient in rendering proper service to the Complainant?
            2)  Whether the OPs have  indulged in unfair trade practice?

           3)  Whether the complainant is entitled to get relief or reliefs as prayed for?

Decision with Reasons

Point Nos. 1 to 3 :-

The above mentioned points are taken up together for the sake of convenience and brevity in discussion.

            We have travelled over the documents placed on record. The complainant  and the OP 1 have submitted their respective evidence supported by affidavit. The Complainant and the OP-1 have filed replies to be questionnaire set forth by their adversaries. The Complainant and the OP 1 have also submitted their BNAs.

            Facts remain that the wife of the complainant was admitted to Kothari Medical Centre, Alipore, Kolkata being the OP  2 for treatment of various ailments and got treated during the period from 06.10.2018 to 15.10.2018 and also for the period from 24.10.2018 to 30.10.2018.  The complainant and his family was under the coverage of a group medical policy bearing No. 154400501710002979 which was in force for the period from 16.08.2017 to 15.08.2018 and thereafter, it was extended to 15.09.2018 subject to certain terms and conditions.  While perusing the WV of the OP 2 it is observed that the complainant is not a consumer to the OP 2 as per the CP Act, 2019 in the instant case and the OP 2 is no way responsible for non-payment of the benefit of the impugned group insurance policy. The complaint petition itself is very much confusing. On perusal of the petition it is somehow understood that the OP 1 has not settled the full amount  of claim placed  by the complainant in respect of treatment of his wife in Kothari Medical Centre and Disha Eye Hospital. The OP 1 has clearly stated that the total limit for the family of Rs. 2,00,000/- has already been exhausted during the policy year. Since no money is left in his account the balance reimbursement could not be made.  The OP 1 has repeatedly raised the question that since the total limit of benefit is exhausted, no more reimbursement is possible. Against this question the complainant has not replied properly. The complainant has cleverly avoided the questions simply mentioning to get the reply from his evidence. No evidence has been produced by the complainant to establish that he is eligible for the balance expenditure incurred in the two hospitals. Moreover, there is no privity of contract in force between the insurer and the insured while the wife of the complainant got admitted in the said hospital for treatment and there has been no renewal of policy in question after the expiry of validity period. The policy was in force up to 15.09.2018 while the beneficiary Smt. Rita Das got admitted during the period from  06.10.2018 to  15.10.2018 and thereafter from 24.10.2018 to 30.10.2018. So, it is quite clear that the treatment taken by the wife of the complainant is beyond the validity period of the said group insurance policy. Moreover, the full limit of Rs.  2,00,000/- has already been availed of by the complainant during the validity  period of the said policy.

In view of the above, we are of the considered view that the complainant has not be able to establish his case against  the OPs.

In the result, the consumer complaint fails.

Hence,

Ordered

That the complaint case be and the same is dismissed on contest against the OPs without any cost.