The instant case was instituted on the basis of a written complaint filed by one Tapati Mandal, W/O. Sri Malay Kr. Sarker and Sri Malay Kr. Sarker, S/O. Late Mahendra Nath Sarkar, P.O & P.S. Raiganj, District Uttar Dinajpur u/s.12 of Consumer Protection Act, 1986 which was registered as Consumer Case No. 14/18 in this Forum.
The fact of the case as revealed from the petition of complaint as well as the evidence is that the complainant No.1.a purchased Mediclaim policy from the O.P.No.1 since long to safe guard their family and after the inception of the policy the complainant No.1.a was regularly paying the insurance premium. It is to be mentioned that the policy was Happy Family Floater policy in which the name of her husband Malay Kr. Sarkar , daughter Madhurima Sarker dependent child and Mani Shankar Sarker, dependent child was shown in the policy. Coverage of the policy was Rs.2,50,000/-. The policy was valid from 22.11.14 to 21.11.15 bearing policy No.313001/48/2015/2075. From the petition of complainant as well as the evidence it is further revealed that the complainant No.1.b) Malay Kr. Sarkar suddenly become ill in the month of May, 2015 and he was treated by the local doctor Dr. Sushil Biswas and advised complainant No.1b to go outside of Bengal for treatment preferably at Hyderabad. As per advice of the local doctor the complainant went to Asian Institute of Gastroenterology, Hyderabad for treatment. Wherein the complainant No.1.b was examined by the doctor of Asian Institute of Gastroenterology, Hyderabad on01.06.15 and the doctor advised him to do some medical test. Accordingly all the medical test was done by the doctor in the same institution and the petitioner No.1.a expend all the expenses for the medical test. Thereafter the said report was produced before the chief doctor on the next date i.e. on 03.06.15. The said doctor further advised him for another medical test. As per advice of the said doctor the medical test was done and all the reports were produced before the doctor and on perusal of the reports the doctor of Asian Institute of Gastroenterology, Hyderabad came to conclusion that the complainant No.1.b was suffering from “Gastrointestinal stromal Tumor”. Thereafter the complainant No.1.a contacted with her insurance agent for cashless treatment as per insurance policy but the Asian Institute of Gastroenterology authority informed the complainant No.1.a that there sis no provision for cash less treatment. Accordingly the complainant No.1.a collected money from her well wishers. Ultimately on 16.06.15 the said operation was done. For such operation the complainant No.1.a expend a huge amount of money. After discharge the complainant No.1.a returned back with her husband i.e complainant No.1.b to her native place at Raiganj and submitted a prayer before the Insurance Co. for reimbursement of the medical expenses incurred by her for the operation of her husband in the month of August 2015. The total medical expenses was Rs.1,86,000/-. But ultimately the insurance co. did not give any positive reply for which the complainants were compelled to file the case before this Forum claiming compensation of Rs.1,86,000/- for medical reimbursement, Rs.50,000/- for harassment and metal pain and agony and Rs.5,000/- as litigation cost.
The petition has been contested by the O.P. Nos.1 & 3 i.e Oriental Insurance Co. by filing written version denying all the materials allegation as leveled against the Insurance Co. contending inter alia that the instant proceeding was not maintainable. The application is barred by waiver, estoppels, acquiescence and also barred by law of limitation.
The definite defence case of the Insurance Co after discharge from the hospital on 23.06.15 the claimants submitted the documents on 26.10.16 i.e after lapse of long period and there was delay for filing the claim documents near about 476 days. According to the policy the complainant should inform the insurance Co. within 15 days from the date of discharge from the hospital. As the complainant did not inform the Ins. Co. within 15 days as such Insurance Co. is not liable to pay any compensation to the complainants. As the complainants have violated the mandatory provision of the Insurance Policy, the complainant is not entitled to get any compensation. Moreover, the amount is highly excessive and without any basis. Considering such facts and circumstances the complainants’ case is liable to be dismissed.
In order to prove the case the complainant No.1.b was examined as P.W.1 and he was cross examined. The complainant files some documents as per firisti. No other witness was examined on behalf of the complainants. On the other hand no other witness was examined on behalf of the O.P./Ins. Co.
On perusal of the record it is found that on 19.02.19 the complainant filed a petition to call for documents from the Insurance Co. which was submitted by the complainant to the Insurance Co. On hearing in presence of both sides the petition was allowed by which the O.P was directed to produce all the documents as prayed for on the next date. But no documents were produced by the Insurance Co. inspite of definite direction of this Forum.
Now the point for determination whether the complainants are entitled to get any money as reimbursement for medical expenses which was incurred by the complainants.
DECISION WITH REASONS:
It is not disputed that the complainant No.1.a Tapati Mandal purchased Happy Family Floater policy and that policy was valid from 22.11.14 to 21.11.15 and during the continuance of the policy the petitioner No.1.b Malay Kr. Sarker was undergone treatment at Asian Institute of Gastroenterology, Hyderabad and there is also no dispute that Sri Malay Kr. Sarker was treated at Asian Institute of Gastroenterology, Hyderabad. The main defence of the Insurance Co. is that the matter was not informed to the Insurance Co. within the time as mentioned in the policy. It is fact that the patient Malay Kr. Sarker was released from the Asian Institute of Gastroenterology, Hyderabad on 23.06.15. According to the policy 1) claim is to be reported within 48 hours of admission but before discharge. 2) claim documents to be submitted within 7 days of discharge. It is fact that from the letter filed by the complainant it is revealed that on 6th August 2015 by a letter to the Branch Manager, Oriental Insurance Co. Ltd., Raiganj Branch the complainant No.1.a informed the Insurance Co. in the language “we have mentioned in our previous application” and prayed for payment as soon as possible. That letter indicates that before 6th August 2015 the complainant informed the Insurance Co. The complainant calls for the document from the Insurance Co. but no documents have been produced by the Insurance Co. So adverse presumption will go against the Insurance Co. that the complainants informed the Insurance Co. about their claim. Moreover, it is to be mentioned that when a husband is seriously ill and confined to bed whether the wife rushed to the Insurance Co. for payment? So, considering the facts and circumstances that the Insurance Co. did not file any document inspite of specific order for production of the document on the basis of a prayer of the complainants. So it can be easily presumed that the complainant informed the Insurance Co. previously before 06.08.15.
Now the next point is to be considered what the amount of cost of treatment is.
On perusal of the documents it is found that the complainant undergone medical test for which they had to expense money and also purchased medicine from the medicine shop. The cost of medicine is Rs.1,375/-. Total cost for operation is Rs.1,35,673/-. So, the total amount comes to Rs.1,35,673 + Rs.1,375/- = 1,37,248/-. But we did not find any receipt to substantiate the claim of Rs.1,86,000/-.
As the policy was valid on the date of operation and the coverage was Rs.2,50,000/- , so the Insurance Co. is liable to pay the compensation for medical treatment of Rs.1,37,248/-. Besides that the complainants are entitled to get compensation of Rs.30,000/- for harassment and mental pain and agony and Rs.5,000/- for litigation cost. So total awarded amount comes to Rs.1,72,248/-.
C.F paid is correct,
Hence, it is
ORDERED
That the complaint case being no. CC-14/18 be and the same is allowed on contest against the O.P No.1 & 3 with cost and ex parte against the O.P.No.2 without any cost.
The complainants are entitled to get total awarded amount of Rs.1,72,248/-. The O.P.Nos.1 and 3 are directed to make the payment within 45 days from the date of this order by issuing an account payee cheque in the name of complainant No.1.a Tapati Mandal who is the insured of the policy failing which it will carry interest at the rate of 5% per annum from the date of filing of this case. In case of default in making payment the complainants are at liberty to execute the order as per provision of law.
Let certified free copy of this order be supplied to the parties free of cost on proper application.
