F I N A L   O R D E R

This is a case U/S 12 of Consumer Protection Act, 1986 with the prayer for a direction upon the O.P. to pay sum of Rs.1,00,000/- for medical treatment, to pay Rs.50,000/- as compensation for harassment and mental pain and agony, Rs.5,000/- as litigation cost and other relief if any.

The complainant’s case in short is that the complainant was purchased one mediclaim policy from the O.P. vide policy No. 31350/48/2012/488 valid from 31.05.2011 to 30.05.2012. During the subsistence of said policy the complainant felt seriously ill and suffered from chest pain and she was at first treated by doctor at Raiganj who referred her B. M. Birla Heart Research Centre, Kolkata wherein she was under gone “Coronary Angiography and Pecutaneous Transuminal Coronary Stent Angioplasty” and for that she had to admit thereon from 20.10.2011 to 24.10.2011. For the said operation the complainant had to spent Rs.2,34,072,24/-. Thereafter the complainant submitted claim before the O.P. with the medical documents for reimbursement of her medical expenses. On several occasions the complainant knocked the door of the O.P. for getting her claim but the O.P. did not pay heed. Then the complainant sent the legal notice to the O.P. and in reply of legal notice the O.P. further required some documents which were also send to the O.P. as per their requirements but the O.P. on various pretext avoided to pay the claim of the complainant. Finding no way the complainant was forced to come before the Forum.

The O.P. has appeared in this case and submitted W.V. denying the allegations of the complainant stating inter alia that it is a premature case, the complainant did not put her claim in time, there is no deficiency of service on the part of the O.P. and this O.P. pray to dismiss the case with cost.

DECISIONS WITH REASONS

The complainant to prove her case submitted memo of evidence, adduced oral evidence and submitted some photocopies of documents regarding medical treatment, the mediclaim policy in favour of the complainant and copy of legal notice, letter etc.

The O.P. to prove their case submitted W.V., oral evidence and documents as per list.

We carefully perused the complaint petition, W.V., evidences and documents submitted by the parties and considered the hearing of arguments of both sides.

On scrutiny of the documents in which the complainant relied upon, which appears that the complainant was/ is bonafide consumer of O.P. and the complainant was the holder of a mediclaim policy and during subsistence of said policy the complainant suffered from severe chest pain and was primarily treated by local doctor at Raiganj, who referred her at B. M. Birla Heart Research Centre, Kolkata, where she had to admit on 20.10.2011 and had to under gone an operation of “Coronary Angiography and Percutaneous Transminal Coronary Stent Angioplasty” and was discharged from the said hospital on 24.10.2011. Thereafter, the complainant was submitted claim for her medical treatment expenses along with medical documents to the O.P. and repeatedly knocking the doors of the O.P. for reimbursement for medical expenses but the O.P. did not pay heed. Then the complainant sent legal notice through Advocate on 23.08.2013 to the O.P. and in reply of legal notice the O.P. was asking for some documents which were also sent to the O.P. through Advocate on 26.09.2013 with the request to settle the claim as early as possible but the O.P. did not settle the claim till date.

The O.P. stated in W.V. that the claim was not lodged within 48 hours of admission or before discharge from hospital and it is the mandatory provision in the policy condition but the complainant did not comply the said provision. But there is also provision for clarification of delay information.

In the oral evidence in cross examination by the O.P., the complainant stated that “I had intimated the clarification for delay information of my illness to the O.P.”. But the O.P. could not rebut her evidence, only gave mere suggestion to the witness. In oral evidence the complainant established her case. In the oral evidence of the O.P., it is admitted, that the Branch Office of the O.P. received documents relating to medical treatment with the lawyer’s letter dated 27.08.2013. From the documents of medical expenses it revealed that Rs.2,34,072.24/- have already expensed by the complainant at the time of hospitalization at said hospital but in the policy sum assured was only Rs.1,00,000/-. No doubt that the complainant was treated in a reputed hospital there should not be question regarding expenses and other related documents and as a cardio patient the movement of laborious work can be restricted as per medical science. The O.P. should also consider this aspect and should process the settle of claim without any delay. But in the instant case the O.P. in various pretexts was/ is killing time for settling the claim, harassed the complainant. It is fact that for the treatment of the complainant mentioned above had spent huge expenses and for that the complainant is suffering monetary loss and suffering mental pain and agony where the policy was valid and claim was also genuine. The O.P. vide their letter, dated 05.12.2011 asking the complainant to provide documents mentioned in para-3 of the said letter most of them are answered in the bill of medical treatment dated 24.10.2011 as the complainant was treated under package charges of the said hospital and the package includes the operation, medicines and other charges of the hospital. But the O.P. repeatedly asking for individual treatment records which were/ are in the matter of hospital authorities as such they are handover the bill including the package charges to the patient partly not in details.

We think that the O.P. either unable to understand the status of treatment of the patient or willfully harassed the complainant for avoiding to pay the claim.

In view of the discussions hereinabove this Forum is of opinion that the act of the O.P. is proved that the O.P. was/ is negligent and deficiency of service for harassment of the complainant. The complainant is entitled to get her policy assured amount, compensation and litigation cost.

Fees paid is correct.

Hence, it is

ORDERED,

That the case being No.CC-34/2014 is allowed on contest against the O.P. without cost.

Accordingly the O.P. is directed to pay Rs.1,00,000/- (Rupees One Lakh) only as sum assured of the policy, to pay Rs.20,000/- (Rupees Twenty Thousand) only for harassment, financial loss, mental pain and agony and to pay Rs.3,000/- (Rupees Three Thousand) only as litigation cost to the complainant within one month from the date of this order, failing which the total amount of Rs.1,23,000/- (Rupees One Lakh Twenty Three Thousand) only will carry interest @ 9% p.a. from the date of filing of the claim application till the date of full realization. The complainant is at liberty to put this order in execution as per law.

Let copy of this order be supplied to each parties free of cost.