The instant case was started on the basis of a petition under Section 12 of the Consumer protection act, 1986 which was registered as Consumer Case No. 72/16 in this Forum.

The fact of the case as revealed from the petition of complaint is that the complainant/petitioner is the holder of Medi-claim policy being no-313501/48/15/00134.

That during the continuance of the said policy the complainant became ill with serious pain in both hip joints and he was treated by Dr. N.R. Halder at Siliguri (MD medicine), DM(Neurology) and subsequently for the better treatment he went to Kolkata where it was detected that he was suffering from Osteomecrosis both femoral heads and accordingly both the hips of the petitioner/complainant  were operated at Baksi orthopedics Trauma and Rehabilitation Center Pvt, Ltd at Baliaghata, Kolkata and for the said operation purpose the complainant was admitted in the said Nursing Home on 29/08/2014 and discharged on 23/09/2014.

The matter of admission of the complainant to the said Nursing Home was duly communicated to the office of the OP on 29/08/2014 through the agent of the OP namely Subrata Chaki.

After operation and after discharged from the Nursing Home the complainant submitted all prescriptions, cash memo, money receipts, reports and other claim related documents with the office of the OP for claiming medical reimbursement on 30/09/2014.

That subsequently on 14/11/2014 MD India Healthcare Service (TPA) Pvt. Ltd requested the petitioner/complainant to submit additional documents.

There after the complainant/petitioner comply with the directions of TPA as far as possible. Thereafter, on 19/1/2015 MD India Healthcare Service (TPA) Pvt. Ltd again send a letter requesting the complainant/petitioner for providing the duration of multiple sclerosis. From the petition of complaint it is found that the complainant already submitted all documents but the OP did not paid the amount. As such the complainant was compelled to file the petition before this Forum for reimbursement of Rs.187491/- (rupees one lakh eighty seven thousand four hundred ninety one only) and for medical treatment with a prayer for compensation of Rs. 20000/- for harassment and mental pain and agony.

The petition has been contested by the OP by filling the written version denying all the material allegations as leveled against the OP contending inter alia that the case is not maintainable, the case is bad for non joinder of necessary parties as MD India Healthcare Service (TPA) PVT. ltd who is the TPA in this case. The claim is barred by Law of Limitation and that the defence case is that the complainant/petitioner was suffering for his hip joint for a long time. The complainant obtained the policy by suppressing the said disease. Further defence case is that the Insurance Company sent several letters for supplying necessary documents but the complainant/petitioner did not reply of those letters.

There is no deficiency or negligence on the part of the OP Insurance Company. Considering such facts and circumstances the case is liable to be dismissed with cost.

In this case it is to be mentioned that the complainant/ petitioner filed the examination in chief but he did not reply to the questionnaires as asked by the OP. On perusal of the order sheet it is found that more than 11 days were lapsed for giving reply to the questionnaires given by the OP. In this case the OP did not adduce any evidence to his defence.

Now the point for determination whether the complainant/petitioner is entitled to get any relief or not as prayed for.

DECISION WITH REASONS:

At the time of argument the Learned Lawyer of the complainant argued that in this case the complainant filed the examination in chief but neither the OP cross examined the complainant nor put any questionnaires by writing to the Court for this reasons the OP took several times. As such the evidence adduced by the complainant remains unchallenged and the learned lawyer of the OP did not cross examine. The OP was ordered to put questionnaires by writing before this Forum on the basis of its petition. On perusal of the record it is found that the complainant Arup Kumar Mukharjee filed the examination in chief on 4-5-2017. Copy was served to the other sides and the next date is fixed for cross examination on 25-6-2017. The complainant filed a petition and the OP filed hazira and the prayer was allowed and the forum fix the date on 19-6-2017 for cross examination. The Op  prayed for filling questionnaires before this forum which was fixed on 27-6-2017. There after several dates have been lapsed on and form 12-12-16 to 27-6-2017. At that time the OP did not file the questionnaires. On perusal of the record it is found that the forum rejected the prayer for filling questionnaires and fixed OPW on 19-1-2018. The Op did not produce any evidence, so the next date was fixed on 20-12-2017 for argument. On 20-12-2017 the argument was not done as per resolution of the local bar. On 3-5-2018 the argument of the case was heard and final order is passed today. So on perusal of the record it is found that there was  serious latches on the part of the OP. Neither the OP cross examined and the complainant nor submitted the questionnaires. So the evidence of the complainant remains unchallenged. On perusal of the evidence it is found that the complainant has claimed Rs. 187491/- for medical reimbursement. But on perusal of the record it is found that the complainant has expend Rs. 97490/- and it is the final bill of the Baksi Orthopedics Trauma And Rehabilitation Center Pvt. Ltd. Thereafter, the Learned Lawyer of the OP on the date of the final order filed some documents for showing that huge amount was expend. For which he is entitled to get more money and the complainant is also entitled to get the amount of ambulance charges from Raiganj to Kolkata and Kolkata to Raiganj is Rs. 20000/- and professional charges is Rs. 80000/-. Despite that he is entitled to get pathological charges is Rs. 2400/- and cost of medicines are Rs. 242/-, Blood bank charges is Rs. 150/-, Dr. Dipesh Modal’s fee is Rs. 2000/-and Dr. Ashock Paul’s Charges is Rs. 500/-and the total amount comes to Rs. 200000/- and the complainant claimed Rs. 187491/-. As such the OP is liable to paid the amount but the amount was Rs. 197491/-. It is admitted that the complainant is the medical policy holder of the OP so there is no doubt that the operation of the complainant was done due to the continuance of the policy.

Fees paid are correct,

Hence, it is

                                         ORDERED

That the complaint case being no. CC-72/16 be and the same is allowed on contest against the OPs but without any cost.

The complainant is entitled to get compensation of Rs. 187411/- for medical expenses and also entitled to get Rs. 5000/-as litigation cost and Rs. 5000/- for unnecessary harassment and deficiency in service of the ops and the total amount comes to Rs. 197411/-. The OP is directed to pay the amount within three months on the date of order failing which it will carry interest the rate of 5% per annum from the date of default of payment till recovery.

Let a copy of this order be given to the parties free of cost.