Order No. -28 Dt.-02/04/2015
Shri Prabin Chettri, Member
The record is placed before me for passing final order.
Brief fact of the case is that the complainant Smt. Paromita Roy, W/O Sri Debmoy Roy is a housewife and resident at Pandapara Road, Opp.- Bowbazar, P.S.- Kotwali, Dist.- Jalpaiguri. Complainant is a policy holder jointly with her husband and thus a consumer of the Oriental Insurance Co. Ltd. (Health Insurance) vide policy no. 1) 313201/48/2010/292, 2) 313201/48/ 2011/411, 3) 313201/48/2013/313. The said policies were taken out firstly on 07/07/2009 and renewed vide policy no. 313201/48/2013/313 dated 08/07/2012 valid till 07/07/2013 midnight. That the complainant fallen ill and was treated by Dr, Jaya Bhattacharjee who examined the complainant at her chamber at Siliguri on 24/03/2012 and referred the patient/ Complainant to Ranchi IVF and Infertility Research Centre at Ranchi for Myomectomy operation to be carried out by the specialist surgeon Dr. Shoba Chakraborty. The said operation was carried out by Dr.Shoba Chakraborty on 20/04/2012 who had been referred to by aforesaid Dr. Jaya Bhattacharjee at Ranchi. The expenditure as per official bill communication of the said medical institution was for a sum of Rs. 41,688/- only. The complainant’s husband intimated the O.P. (Oriental Insurance company) vide through letter vide dated 28/03/2012 for favour of information and necessary action regarding said operation but no reply was given from the O.P. Oriental Insurance company. The complainant’s husband also intimated the insurance company regarding the claim after discharge of his wife through letter dated 02/07/2012 after operation to settle the claim, on the other hand insurance company was delaying the claim of the complainant after completing the more or less formalities of the insurance company.
The complainant issued notice through Advocate to the O.P. Oriental Insurance Company vide notice dt. 20/05/2013 but no reply was given by the O.P. Oriental Insurance Company. The O.P. Oriental Insurance Company repudate the claim of the complainant on 18/03/2013. Hence this case.
The complainant has prayed for Rs.66,688/- in total as cost of treatment, cost of litigation, compensation for mental agony, harassment, etc.
The O.P. has contested this case by filing Written Version denying and disputing the claims and contention of the complainant. The specific stand of the O.P.is that the complainant’s matter was referred to MD INDIA Health Care Service (TPA) for settlement of the claim. The O.P. Oriental Insurance Company also states in para 8 of the Written Version that as per condition of the policy the Insurance Company shall not be liable to make any payment under this policy in respect of any expenses what so ever incurred by any insured person in connection with or in respect of pre-existing diesase when the cover inceptsfor the first time are excluded upto 4 years of this policy. And O.P. Oriental Insurance Company also states in para 10 and 11 of W/V that the complainant did not supply those documents with TPA asked for, which are mandatory to decide the eligibility of the claim. The TPA closed the claim on 18/03/2013 on the ground of non-compliance of the required documents. Thus O.P. states that the O.P. is not liable to pay any claim to the petitioner as the petitioner failed and followed the terms and condition of the policy and prays for dismissal of the case with cost.
POINTS FOR CONSIDERATION
- Is the complainant a consumer as per provision of the C.P.Act(1986)?
- Is the case maintainable by both law & facts?
- Was there any deficiency of service on the part of the O.P. as alleged?
- Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
All points are taken up together for consideration and decision.
Seen and perused the pleading of both the parties which are supported by Affidavit and the documents annexed and filed by both the parties.
Now after due consideration of the arguments of Ld Lawyers of both sides, the written arguments filed by the parties and the material on record, we find that the complainant is a policy holder jointly with her husband of Health Insurance under Oriental Insurance Co. Ltd. Since 07/07/2009 vide Health Insurance Policy No. and the last Insurance Policy was valid from 08/07/2012 to 07/07/2013 by renewing every year. That the petitioner suffered from Gynological problem covered by said insurance and was operated for tumor in the uterus. The complainant was treated by one Dr. Jaya Bhatterjee at Shiv Mandir Siliguri on 24/03/’12, and referred the patient(complainant) to Ranchi IVF and Infertility Research where at Ranchi for operation and was operated on 20/04/’12 at Ranchi by Dr.Sobha Chakraborty for Myomectomy (i.e., tumor in uterus). The total cost of the operation and the total cost including medication came to Rs.41,688/-. The complainant have made all due of her insurance policy and her claim is valid and the insurance company has all relevant records and premium payment records.
That the decease of the petitioner/complainant is clearly cover by insurance vide condition 4.3 (IX) of the Insurance Policy document page 10 SecIX(under Happy Family Floating Policy).
Now after due consideration of arguments of Ld.Lawyers and the materials on record we find that the complainant’s claim is substantiate by sufficient evidence, we find nothing adverse against the maintainability of the case. Therefore we find and hold that the case is maintainable and the complainant is a consumer as per the provision of the C.P.Act 1986, as the complainant is a policy holder jointly with her husband and thus a consumetr of Health Insurance under Oriental Insurance Co.Ltd. vide Health Insurance Policy no. 1) 313201/48/2010/292, 2) 313201/48/ 2011/411, 3) 313201/48/2013/313 and valid till 07/07/2013 midnight. The act of the Insurance Company prove that they delay to settle the claim and repudated the same, instead of settling the claim on several request by the complainant through letters and the relevant medical papers and bills were submitted by the complainant as queries from the O.P.(Oriental Insurance Company) to settle the claim.
In this view of the matter we find and hold that the complainant is consumer as per provision of the C.P.Act 1986 and as such this case is maintainable and accordingly the O.P. (Oriental Insurance Company) is guilty for deficiency in service as alleged by the complainant and the complainant is entitled to get some reliefs.
All points are disposed of accordingly.
Hence, it is
O R D E R E D
that the case is allowed on contest with cost of Rs.2000/-. The complainant do get an award of Rs. 35,000/-(Thirty-five Thousand) Complainant do get further award of Rs.3000/- for her mental agony and harassment. The total amount of Rs.40,000/- has to be paid by O.P.(Oriental Insurance Company) to the complainant within 30 days from this day failing which the O.P. shall have to bear interest @ 8 % p.a. till realization of the same and the complainant shall be at liberty to realize the same by putting this order into execution in accordance with law.
Let copy of this final order be supplied to the parties free of cost forthwith in terms of Sec.5(10) of West Bengal Consumer Protection Rules 1987.
