F I N A L   O R D E R

This is a case U/S 12 of the Consumer Protection Act, 1986 for an award directing the O.Ps. to pay Rs.20,000/- for cost of treatment and Rs.20,000/- as compensation for harassment and also litigation cost.

The complainant’s case in short is that the complainant was/is holder of Medicalim  policy under Happy Family Floater Policy with the O.Ps. for himself, his wife and son. The complainant was paid premium of Rs.4,335/- on 23.02.2011 against sum assured Rs.2,00,000/- and the O.Ps. issued policy to the complainant vide policy No.313501/48/2011/2962 valid up to 22.02.2012. Due to sudden illness the wife of the complainant had to admit in Roy’s Clinic at Siliguri on 08.11.2011 for treatment. The complainant was intimated the matter regarding medical treatment of his wife along with documents to the O.Ps. through the agent of the O.Ps. But the O.Ps. did not pay heed to the claim of the complainant as such finding no alternative the complainant was forced to come before this Forum with the prayer mentioned above.

The O.P. No.1 contested the case by appearing on the date of hearing and by filing W.V. denying the allegations of the complainant stating inter alia that the complaint case is not maintainable, the claim was not submitted to the O.Ps. with 48 hrs. of admission of the insured, the complainant was not submitted any clarification of delay in submission of claim, the O.Ps. have no negligence or deficiency in service, the case of the complainant will be dismissed with cost.

The O.P. No.2 is not contesting the case neither by appearing in this case nor by filing any W.V. as such the case heard ex-parte against the O.P. No.2.

DECISIONS WITH REASONS

To establish his case the complainant has filed photocopies of some documents, filed affidavit-in-chief and adduced oral evidence on his behalf.

The O.P. No.1 has filed written version, photocopies of documents and adduced oral evidence on his behalf.

The O.P. No.2 is not contesting the case as such the case is heard ex-parte against the O.P. No.2.

We carefully consider the petition of complaint, W.V., documentary and oral evidence and argument advanced by the both parties.

On perusal of documents in the case record it appears that the complainant was a bonafide mediclaim policy holder under the scheme of Happy Family Floater Policy of the O.Ps. being policy No.313501/48/2011/2962 valid up to 22.02.2012. During existence of said policy the wife of the complainant was admitted one Roy’s Clinic at Siliguri on 02.11.2011 and treated thereon up to 08.11.2011. The complainant intimated the matter of medical treatment of his wife along with some documents to the O.Ps. through the agent of the O.Ps. and knocking the door of the O.Ps. on several times but the O.Ps. did not settled the claim. On scrutiny of documents filed by the O.Ps. the rules and regulations of Happy Family Floater Policy, in item No.5.4 i.e. Notice of claim, clearly mentioned that the claim should be made to the O.Ps. within 48 hrs. of admission at Nursing Home/ Hospital/ Clinic etc. But the complainant did not do so, rather he admitted that he had no knowledge that the claim would be submitted within 48 hrs. of admission in the Clinic/ Hospital. On the other hand as provision of the said rules the O.Ps. have intimated the insured i.e. Smt. Anindita Dutta vide Letter dated 14.12.2011 and 28.12.2011 to clarify or explain as to why the claim could not be submitted to the O.Ps. within 48 hrs. of admission at clinic for medical treatment and the complainant himself also  admitted regarding the acknowledgement of the letters mentioned above but the complainant did not give any answer to the O.Ps. against those letter where there was much opportunity to condoned the delay in submission of claim to the O.Ps. and in this way the claim of the complainant could be entertained by the O.Ps. or he could came before this Forum with clear hand. So, on careful perusal of documentary and oral evidence adduced by the both parties it clearly show that the complainant could not established his case against the O.Ps. and the O.Ps. have no negligence or deficiency in service as a service provider as per Act.

In view of the discussions above we are of opinion that the complainant is not entitled to get any relief as prayed for.

Accordingly the complaint fails.

Fees paid is correct.

Hence, it is

ORDERED,

that the complaint case No. CC-07/2013 be and the same is dismissed on contest against the O.P. No.1 and ex-parte against the O.P. No.2 without cost.

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