Date of filing: 05/10/2021                                                    

Date of Judgment: 27/06/2023

Mrs. Sashi Kala Basu, Hon’ble President.

This complaint is filed by Sri Sunil Kr. Paul under section 35 of the Consumer Protection Act, 2019, against opposite parties (referred as OPs hereinafter) namely (1) National Insurance Co. Ltd. and (2) M/s. Heritage Health Insurance TPA Pvt. Ltd. alleging deficiency in rendering of service on the part of OPs.

The case of the complainant in short is that he obtained a PARIVAR MEDI-CLAIM POLICY initially on 20/12/2017 and the same was renewed every year and lastly it was renewed on 31/01/2020 which was valid up till 12/01/2021. The policy was being no. 03000501910003262 and the sum insured was Rs. 2,00,000/-. OP 2 is the third party administrator and approves the claim lodged by the policy holder. On 17/09/2020 the complainant’s wife namely Smt. Bula Paul accidently fell down in the kitchen. She was taken to a local Dr. namely Dr. Sishir Das and ultimately as per his advise she was admitted at Lab Baik Medical Centre on 06/11/2020 wherein she was operated on 08/11/2020. The wife of complainant was discharged from the said nursing home on 10/11/2020. She is still bedridden and has not recovered fully. On 21/12/2020 complainant submitted the claim for reimbursement towards cost of the treatment of his wife of Rs. 1,12,176/- before the OP 1 the National Insurance Company. Thereafter on receiving the intimation dated 13/01/2021 from OP 2, complainant submitted declaration about the claim. In spite of lapse of long period, reimbursement has not been made and thus the present complaint has been filed for directing the OP to pay sum of Rs. 1,12,278/-, to pay Rs. 60,000/- as compensation and Rs. 25,000/- as litigation cost.

On perusal of the record it appears that in spite of the receipt of notice steps were not taken by the OPs and thus the case has been heard exparte.

So the only point requires determination is whether the complainant is entitled to the relief as prayed for?

DECISION WITH REASONS

In order to substantiate his claim, complainant has filed the policy along with the medical prescriptions, bills and also letters sent by the complainant to the OPs.

At the very outset it may be pertinent to point out that during the pendency of this proceeding, complainant filed a petition praying of certain amendment to bring the fact that the total sum of Rs. 3,50,000/- to 4,00,000/- has been spent towards the treatment of his wife and thus to allow the complaint to file those vouchers. The same was allowed. However, when the amended version of the complaint has been filed by the complainant, complainant restricted the prayer / relief to the extent of the claim of Rs. 1,12,278/- which was originally claimed by the complainant in the original complaint and compensation of Rs. 60,000/- and Rs. 25,000/- as litigation cost. So it has to be considered whether the complainant is entitled to said sum of Rs. 1,12,278/- towards medical expenses borne by the complainant towards treatment of his wife. It is evident from the petition praying for amendment as well as the amended complaint that after filing of this complaint, in the month of November, 2021 an amount of Rs. 95,160/- has already been paid to the complainant by the OPs. So out of Rs. 1,12,278/- an amount of Rs. 95,160/- has already been paid. It may be pertinent to point out that the complainant has not filed the complete policy document. He has filed only some pages. The terms and conditions therein entered into between the parties has not been filed. So it is not cleared towards which charges the deduction out of Rs. 1,12,278/- has been made by the OPs. Complainant has also not filed any document that he tried to seek information as to on what ground the full amount of Rs. 1,12,278/- was not paid and instead Rs. 95,160/- only has been paid. So towards the cost of the treatment as claimed by the complainant of Rs. 1,12,278 we find no justification for any further direction to pay the balance amount. However, since it is apparent that the complainant had made the claim on 21/12/2020 and had also submitted the requisite document required by the OP 2 on 20/02/2021, but in spite of the same OPs remained silent and did not pay the amount, complainant is entitled to the compensation for such harassment and mental agony suffered by the complainant. There is absolutely no contrary material before this commission to the claim of complainant that in spite of him submitting all the relevant documents, OPs did not intimate anything as to why there has been delay. Same is also substantiated from the fact that immediately after the complaint was filed by the complainant, OPs deposited the sum of 95,160/- in November, 2021. This complaint was filed on 05/10/2021. So we find an amount of Rs. 30,000/- as compensation and Rs. 10,000/- as litigation cost will be justified.

Hence,

           ORDERED

CC/492/2021 is allowed exparte. Opposite parties are directed to pay Rs. 30,000/- as compensation within 45 days from the date of communication of this order. OPs are further directed to pay Rs. 10,000/- as litigation cost within the aforesaid period of 45 days. In default of payment the entire sum shall carry interest @ 7% p.a. till realisation.