In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, 4th Floor, Kolkata-700087.
CDF/Unit-I/Case No. 192/2011 .
1) Smt. Rekha Sikaria,
Flat # 9 D.A., Mani Tower,
31/41, Binod Bhave Road, Kolkata-38. ---------- Complainant
---Versus---
1) Reliance General Insurance Co. Ltd.
38B, Jawahar Lal Nehru Road, 8th Floor,
Kolkata-71, P.S. Shakespeare Sarani.
2) Medi Assist India Pvt. Ltd.
1st Floor, 53A, Rafi Ahmed Kidwai Road, above
Kathleen Shop, Near Eliot Road, Bata More,
Kolkata-16, P.S. Park Street. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member.
Smt. Samiksha Bhattacharya, Member
Order No. 20 Dated 11-06-2013.
The case of the complainant in short is that complainant is the legal heir of Manoj Kumar Sikaria since deceased who was the husband of the complainant. Complainant’s husband is the policy holder under the name and style Reliance Health Wise Policy issued by Reliance General Insurance Co. Ltd. i.e. o.p. no.1. O.p. no.2 is the TPA / service provider of o.p. no.1 as described in the policy schedule.
The said policy of the complainant’s husband covers risk for the period from 27.1.10 to 26.1.11 and the said policy covers the risk for the complainant’s husband. During continuation of the said policy the complainant’s husband under went tongue treatment in Prince Aly Khan Hospital, Mumbai. Complainant’s husband after being discharge from the said hospital submitted claim to o.p. no.2 the TPA / service provider under o.p. no.1 in respect of reimbursement of the medical expenses incurred for the treatment of the complainant’s husband.
Said claim being numbered 5102290 and policy no.1313/282510617115 was submitted by the complainant’s husband. O.p. no.2 being TPA accepted the said claim and processed the matter and during process of the said claim submitted by the husband of the complainant he became died leaving the complainant and two daughters Tanushka Sikaria and Yastica Sikaria.
O.p. no.2 ultimately repudiated the claim on 25.3.11 on the ground that said claim cannot be exceeded due to exclusion clause no.10. Complainant requested the o.ps. to reconsider the claim and to make payment of the claimed amount of Rs.2,18,847.41 but without any result. Hence the case was filed by the complainant with the prayer contained in the petition of complaint.
O.p. no.1 had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case. Ld. lawyer of o.p. no.1 in the course of argument submitted that the case has got no merit and the same is liable to be dismissed. O.p. no.2 did not contest the case by filing w/v and matter was heard ex parte against o.p. no.2.
Decision with reasons:
We have gone through the pleadings of the parties, evidence and documents in particular and we find that complainant is the legal heir of Manoj Kumar Sikaria since deceased who was the husband of the complainant. Complainant’s husband is the policy holder under the name and style Reliance Health Wise Policy issued by Reliance General Insurance Co. Ltd. i.e. o.p. no.1. O.p. no.2 is the TPA / service provider of o.p. no.1 as described in the policy schedule.
We further find that the said policy of the complainant’s husband covers risk for the period from 27.1.10 to 26.1.11 and the said policy covers the risk for the complainant’s husband. During continuation of the said policy the complainant’s husband under went tongue treatment in Prince Aly Khan Hospital, Mumbai. Complainant’s husband after being discharge from the said hospital submitted claim to o.p. no.2 the TPA / service provider under o.p. no.1 in respect of reimbursement of the medical expenses incurred for the treatment of the complainant’s husband.
It is seen from the record that said claim being numbered 5102290 and policy no.1313/282510617115 was submitted by the complainant’s husband. O.p. no.2 being TPA accepted the said claim and processed the matter and during process of the said claim submitted by the husband of the complainant he became died leaving interested the complainant and two daughters Tanushka Sikaria and Yastica Sikaria.
It transpires that o.p. no.2 ultimately repudiated the claim on 25.3.11 on the ground that said claim cannot be exceeded due to exclusion clause no.10. Complainant requested the o.ps. to reconsider the claim and to make payment of the claimed amount of Rs.2,18,847.41 but without any result.
In view of the findings above and on perusal of the entire materials on record we find that o.p. no.1 had sufficient deficiency in service being service providers to their consumer / complainant and complainant is entitled to relief since this Forum is of opinion that complainant made premium duly and merely for violation any clause of policy the bonafide claim of the complainant should not be denied.
Hence, ordered,
That the case is allowed on contest with cost against the o.p. no.1 and ex parte without cost against o.p. no.2. O.p. no.1 is directed to pay Rs.1.25,000/- (Rupees one lakh twenty five thousand) only (on non standard basis) towards the claim of the complainant and are further directed to pay compensation of Rs.20,000/- (Rupees twenty thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
