In  the  Court  of  the

Consumer Disputes Redressal Forum, Unit -I, Kolkata,

8B, Nelie Sengupta Sarani, Kolkata-700087.

CDF/Unit-I/Case No. 427 / 2010.

1)                   Master Aditya Poddar,

Represented by Sri Vivek Poddar,

12, Bamacharan Roy Road,

P.S. Behala, Kolkata-34.                                                                                      ---------- Complainant

---Versus---

1)                   The New India Assurance Co. Ltd.

Regd. office at 87, Mahatma Gandhi Road,

Fort, Mumbai-400001.   and

Having its Calcutta Divisional-IV office at

23, Ganesh Chanda Avenue (1st floor),

P.S. Bowbazar, Kolkata-13.     

2)       Medicare TPA Services (I) Pvt. Ltd.

      Represented by its Manager,

       6, Bishop Lefroy Road,

P.S. Bhowanipore, Kolkata-20.                                                                           ---------- Opposite Parties.

Present :           Sri Sankar Nath Das, President.                                                        

                        Dr. Subir Kumar Chaudhuri ,Member

                        Smt. Sharmi Basu ,Member

Order No.   21    Dated  08-02-2013.

            The case of the complainant in short is that complainant is represented by the father and natural guardian of policy holder Master Aditya Poddar and presently residing at 12, Bamacharan Roy Road, P.S. Behala, Kolkata-34.

            Complainant’s father had taken Hospitalization benefit policy in the year 2007 from the New India Assurance Co. Ltd. for self and his family consisting of his minor sons bearing no.510100/ 34/07/20/00000875 was issued to him for the period from 2.5.07 to 1.5.08 and accordingly to the demand of o.p. no.1 he paid the premium of Rs.3509/-. Thereafter, complainant again renewed the said policy for the period 2.5.08 to 1.5.09 by paying the requisite premium of Rs.3858/- for the same and accordingly o.p. no.1 issued a hospitalization benefit policy certificate bearing no. 510402/34/08/11/00000471 for the said period. Thereafter, complainant again renewed the said policy for the period 2.5.09 to 1.5.10 by paying the requisite premium Rs.5093/- for the same and accordingly, o.p. no.1 issued a hospitalization benefit policy certificate bearing no. 510402/34/09/11/00000487 for the said period. Thereafter complainant again renewed the said policy  for the period 2.5.10 to 1.5.11 by paying the requisite premium  Rs.5029/- for the same and accordingly o.p. no.1 issued a hospitalization benefit policy certificate bearing no. 510400/34/10/11/00000541 for the said period.

            It can be said the complainant’s son is covered in the hospitalization benefit policy by o.p. no.1 since May 2007. Some time in May 2010 the complainant’s son had some pain in groin area and after consulting with the doctor the ailment was properly diagnosed to be a case of Inguinal Hernia and was advised for surgery by his physician.

            Complainant in terms of the hospitalization benefit policy duly filed a mediclaim form issued by o.p. no.1 for the period of treatment and all the treatment papers and medical papers including bills, discharge summary and other medical reports submitted by him with the insurance company along with claim form on 9.6.10  and original bills amounting to Rs.21,740/- for the aforesaid treatment in respect of his claim and asked o.ps. to process his claim.

            Complainant received a letter dt.19.6.10 from o.p. no.2 stating that the claim submitted by him has been found to be inadmissible as per terms and condition  of his mediclaim policy and the reason for such  repudiation was clause (4.4.1) Disease excluded in first four years of insurance.  Thereafter, complainant by a legal notice dt.13.7.10 challenged the repudiation on the ground that the clause (4.4.1)  of the terms and conditions of the  mediclaim policy. 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’s father took hospitalization benefit policy in 2007 from o.p. no.1 for himself and his family consisting of his minor son bearing no.510100/34/07/20/00000875 which was issued to him for the period from 2.5.07 to 1.5.08 and according to the demand of o.p. no.1, complainant paid premium of Rs.3509/- and thereafter complainant renewed the policy from 2.5.08 to 1.5.09 paying premium of Rs.3858/- and o.p. no.1 issued a hospitalization benefit policy certificate bearing no.510402/34/08/11/00000471 for the said period. Further we find that complainant again renewed the said policy for the period from 2.5.09 to 1.5.10 by paying premium of Rs.5093/- and o.p. no.1 issued hospitalization benefit policy certificate bearing no.510402/34/09/11/00000487 for the said period and further complainant renewed the said policy for the period from 2.5.10 to 1.5.11 by paying premium of Rs.5029/- and o.p. no.1 issued hospitalization benefit policy certificate bearing no.510402/34/10/11/00000541 for the said period and complainant’s son was covered under hospitalization benefit policy by o.p. no.1 since May 2007 and we again find that the son of the complainant in May 2010 fell sick and consulted doctor for his ailment and was diagnosed to be a case of Inguinal Hernia and was advised surgery by the physician and complainant filed mediclaim form in terms of hospitalization benefit policy with o.p. no.1 for the treatment of his son amounting of Rs.21,470/- and complainant received a letter on 19.6.10 from o.p. no.2 stating that the claim submitted by complainant found to be inadmissible for violation of th e clause of insurance policy.

            In view of the findings above and on perusal of the entire materials on record we are of the view that for mere breach of policy condition insurance company cannot deprive the claim of the complainant and this is the view of the Hon’ble Supreme Court published in CTJ May 2010 Vol-18 No.5 Page 66.

            That being the position we hold that the o.ps. had sufficient deficiency being service provider to its consumer / complainant and complainant is entitled to relief.

            Hence, ordered,

            That the case is allowed on contest with cost against o.p. no.1 and ex parte without cost against o.p. no.2. O.p. no.1 is directed to pay  sum of Rs.21,740/- (Rupees twenty one thousand seven hundred forty) only to the complainant for the treatment of the complainant’s son and is further directed to pay compensation of Rs.25,000/- (Rupees twenty five thousand) only for harassment and mental agony and litigation cost of Rs.7000/- (Rupees seven thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 9% 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.