Present : Sri A.K. Das, President
Sri L.K. Banerjee, Member
Smt. J. Saha, Member
Order no. 14 dt. 03.04.2008
The present case being no.300/2005 was filed u/s 12 of the C.P. Act, 1986 by Sri Debashish Majumder, S/o Late D.L. Majumder, B-7/8, Central Park, Sector-I, Kalyani, Dist. Nadia-741235 against the o.ps. viz (1) National Insurance Co. Ltd., 3, Middleton Street, Kolkata-71 (2) The Sr. Divisional Manager, National Insurance Co. Ltd., Division-III, 1, Shakespeare Sarani, Kolkata-71 and (3) The Golden Trust Financial Services, 16, R.N. Mukherjee Road, Kolkata-1 before the forum praying for various relief as specified at pages 12-13 of the main petitioner. The facts are in brief as follows.
That the complainant took a Group Mediclaim Insurance Coverage under a policy viz. Group Mediclaim Policy by the o.p. no.1 through the proforma o.p. no.3. The petitioner is a member of he Golden Multi Services Club of the Golden Trust Financial Services (GTFS) being the principal insured. Being a member of the club, the petitioner is a facilitated insurance coverage of he o.p. Policy is 100300/46/8500107/02/85/30045. The policy was for a period from 15.12.02 to 14.12.03 (midnight). The capital sum insured was Rs.20,000/-. The petitioner after having chest pain consulted Dr. Sankar Mondal who after examining advised him to take admission in ‘Suraksha’ of Susruta Clinic & Research Institute for Advanced Medicine (P) Ltd. at JC-16 & 17 Salt Lake City, Kolkata-91. The petitioner took admission there on 27.11.03 and after undergoing various tests discharged on 28.11.03. On 2.12.03 the petitioner informed the proforma o.p. no.3 regarding his hospitalization. As per advice of he o.p. no.3 the petitioner submitted a claim of Rs.20196.20 incurred by him towards his treatment to the o.p. no.3 on 8.3.04 for onwards transmission to the o.p. no.1 for settlement of his claim. On inquiry by o.ps. the petitioner clarified all the points to the o.ps. on 29.6.04. The o.ps. after a long gap on 5.2.05 informed the petitioner that his claim has been closed as ‘no claim’ for the reasons that he has failed to comply with the policy condition 5.4 i.e. he has failed to file his claim within 30 days from the date of his discharge from hospital. The petitioner made appeals to the o.ps. to modify, reconsider the decision but it was in vain. The petitioner approached the forum for justice. The petitioner relied upon the annexure marked A-1 to A-13 in support of his claim.
The o.ps. have been contesting the case all along by way of filing w/v denying therein very emphatically the material allegation of the petition of complaint. The o.p. no.3 has stated that the o.p. no.3 has no authority to settle the claim of the petitioner and also he has no power to make comment on the decision of the o.p. nos.1 and 2. Liability to settle the claim of the petitioner rests on the o.p. nos.1 and 2.
The o.p. nos.1 and 2 followed the policy conditions and stuck to their earlier decision and repudiated the claim of the petitioner as ‘no claim’.
Fact reveals that the petitioner is policy holder, undergone medical treatment, incurred expenditure towards treatment, filed claim form but it was not done within the stipulated time frame as envisaged in the policy condition although the petitioner informed the o.p. no.3 about his hospitalization in time.
Fact is that the petitioner could not submit the claim form within the stipulated time of the policy condition but the o.ps. in spite of having well oiled administrative machinery took nearly one year to inform the petitioner about its decision.
Non submission of claim form in time is not a fundamental breach of the policy condition. It is also not a major laches or lapses on the part of he petitioner for not submitting the claim form in time as it does not involve breach of condition of the policy is fundamental and material. The o.ps. could have dealt the matter with a humane touch.
The forum have perused all the materials on record and considered the submissions made by the parties and come to conclusion that the o.ps action smacks of dereliction of duty and deficiency in service as the o.ps. fail to render the service to the petitioner which the petitioner is entitled to have during the time of processing the case. The petitioner has been able to prove his case to the hilt so as to get the benefit within the ambit of C.P. act, 1986. the case succeeds on contest.
Hence,
Ordered,
The o.p. nos.1 and 2 are directed to reimburse the claim amount of the petitioner for Rs.20,000/- (Rupees twenty thousands) only. The o.ps. are also directed to pay a sum of Rs.3000/- (Rupees three 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 inaction, negligence and deficiency. The payment shall be made within 60 days from the date of this order , failing which it will carry interest @ 8% p.a. till realization.
Let copy of this be supplied to the parties free of cost.
Member Member President
