Date of filing: 16.05.2018 Date of disposal: 21.01.2020
Complainant: Premangshu Hui, S/o. Mihir Kumar Hui, resident of 11/07, Anandpuri, Co-operative Housing Society Ltd., Durgapur, District: Paschim Barddhaman, PIN – 713 213.
Opposite Party: Oriental Insurance Company Ltd., Durgapur Divisional Office, represented by its Divisional Manager, having its office at Ajit Banerjee Building, Anandgopal Mukherjee Sarani, Bhiringee, Durgapur, District: Paschim Barddhaman, PIN – 713 213.
Present:
Hon’ble President: Smt. Jayanti Maitra (Ray).
Hon’ble Member: Ms. Nivedita Ghosh.
Hon’ble Member: Shri Sailaranjan Das
Appeared for the Complainant: Ld. Advocate, Suvro Chakraborty.
Appeared for the Opposite Party : Ld. Advocate, Saurabh Dey.
J U D G E M E N T
The complaint in brief is that Shri Premangshu Hui, hereinafter complainant, had taken a medi-claim policy for Rs. 5, 00,000=00 in the year 2003 from Oriental Insurance Company Limited, hereafter OP, which included additional benefit coverage which was renewed on year to year basis. During the continuance of the policy, the complainant met with an accident on 17.05.2015 and sustained injuries. He was hospitalized for treatment till 29.05.2015 and was discharged from hospital on that date. However, he remained under treatment at his residence till 14.08.2015. In the process he incurred a total expenditure of Rs. 1, 21,916=00. It has been stated by the complainant that the policy taken by him provided for reimbursement of medical expenses prior to accident up to 10% of the sum insured or 25% of the admissible personal accident claim amount or actual medical expenses incurred whichever should be less.
On receipt of the claim for Rs. 1, 21,916=00, the OP paid all treatment expenses to the hospital as per policy terms and condition. But the OP remained silent regarding payment of additional benefit to the complainant, i.e., 1% of the sum insured per week and 25% of total medical expenses. Thereafter the OP sent a voucher of claim of Rs. 62,832=00 to the complainant in the last week of November 2015 but without any calculation sheet or details of such amount. Complainant sent a letter on 01.12.2015 returning claim voucher to the OP and requested for allowing additional coverage in consonance with calculation details/detailed clarification. Though the OP received the letter, they sent reply by way of e-mail to the complainant only on 07.04.2016 intimating therein that the complainant’s claim has been settled for Rs. 62,832=00 but they did not disclose the details of how the settlement amount had been arrived at. Being aggrieved thereby, the instant complaint has been filed with the following prayers:
- Directing the OP to pay a sum of Rs. 30,479=00 to the complainant towards 25% of the total medical expenses (Rs. 1,21,916) by holding them liable for their deficiency in service and unfair trade practice.
- Directing the OP to pay a sum of Rs. 50,000=00 as compensation for mental pain and agony and harassment suffered by the complainant.
- Directing the OP to pay Rs. 10,000=00 for litigation cost.
The OP has filed written version wherein they have denied all the allegations made by the complainant and prayed for dismissal of the complaint which according to them lack of any merit. In the written version it has been stated that the hospital expenses incurred on account of treatment of the complainant had been fully paid directly to the hospital authorities. They have further clarified that the medical expenses under P.A. (Personal Accident) policy is on actual basis and the same does not fall under benefit policy. As per the medical benefit claim, the complainant was entitled to reimbursement as per Table – III of the benefit table which provides that in case of temporary total disablement, 1% of C.S.I. (Max) Rs. 5,000=00 per week from all policies taken together and a maximum of 104 weeks was admissible. Based on this the calculation for compensation to the complainant was made, i.e., Rs. 5,000=00 /7X88 days which came to Rs. 63=2,832=00. Therefore, no irregularity had been committed by the OP.
It has further been stated that the instant complaint is frivolous and vexatious one; and as such OP is entitled to get a cost of Rs. 10,000=00 for filing such frivolous complaint.
There was a delay of 40 days in filing the instant Consumer Complaint and as suh the complainant filed an M.A. for condonation of delay which was allowed by this Ld. Forum on 21.08.2018 by condoning the delay.
Decision with reasons:-
We have heard the ld. Counsel for both the parties, perused the complaint, written version filed by the OP and the evidence filed by the complainant. This is a very peculiar case wherein OP is willing to pay an amount which the complainant is not ready to accept and prays for a lesser amount, i.e., Rs. 30,479=00 only. It appears from the complaint that the complainant has filed this complaint under the mis-conception that he was covered under the benefit scheme based on which amount comes to Rs. 30,479=00. Whereas it has been clearly stated by the OP that medical expenses under P.A. policy is to be settled on actual basis and the same does not fall under the benefit policy. Therefore, the amount arrived at by the OP cannot be held to be not correct. It is interesting to note that as per page -30 of the Annexure attached by the complainant, the complainant has expressed dissatisfaction on receipt of Rs. 62,832=00 voucher and stated that the final amount was too much less than his expectation. Surprisingly in the complaint he himself has made a calculation and stated that he should be paid only Rs. 30,479=00 and not Rs. 62,832=00 which is higher amount. Therefore, we are of the considered view that the instant complaint has been filed by the complainant purely on mis-conception and improper appreciation of the conditions under which personal accident policy has been issued. Therefore, we do not find any deficiency in service or unfair trade practice on the part of the OP. However, since as per the OP, the complainant is entitled to get Rs. 62,832 whereas the complainant is claiming a lower amount, i.e., Rs. 32,479=00, we direct that the OP shall issue a voucher amounting to Rs. 32,479=00 to the complainant.
Hence, it is
O r d e r e d
that the present Consumer Complaint being No. 79/2018 be and the same is allowed on contest directing the OP-Oriental Insurance Company Limited to pay Rs. 32,479=00 as medical benefit claim amount to the complainant within 30 days from the date of passing of this award. There is no order as to costs.
Let plain copies of this order be supplied to the parties free of cost as per provisions of law.
Dictated & Corrected by me: (Jayanti Maitra (Ray)
President
(Saiaranjan Das) DCDRF, Purba Bardhaman
Member
DCDRF, Purba Bardhaman
(Sailaranjan Das) (Nivedita Ghosh)
Member Member
DCDRF, Purba Bardhaman DCDRF, Purba Bardhaman
