This is a complaint U/s 12 of the Consumer Protection Act, 1986 praying for an order directing the O.Ps. to pay Rs.18,728/- with interest and for order of compensation of Rs.25,000/- for harassment and mental pain and Rs.10,000/- for litigation cost.

The case of the complainant in brief is that he is a businessman of Islampur, Uttar Dinajpur and he purchased the policy namely Reliance Group Mediclaim and Group Personal Accident being policy No.1503302812000028 under Reliance Group Mediclaim Policy for the period covering from 05.04.2010 to 04.04.2011 at a premium of Rs.1340/- and purchased through O.P. No.3. The coverage of the individual insured person is Rs.50,000/- each with his wife and total sum assured is Rs.1,00,000/-. The complainant was on tour in South India and on the way of Kanyakumarika, suddenly became seriously ill with severe abdominal pain and chest pain and was immediately admitted to nearest Kovai Medical Centre and Hospital Limited on 17.08.2010. He had undergone various tests over his body. He informed the matter to the insurance company at Kolkata for the purpose of getting medical re-imbursement, but was not replied with by the O.Ps. After recovery and to get the medical re-imbursement, he submitted the claim form along with medical documents like medical bills etc. On 26.05.2011 O.P. No.1 then sent a letter asking to submit all documents for getting claim amount and petitioner submitted and waited for response, but with no result. He personally visited O.P. No.2 also. Then on 26.05.2011, he sent a letter to the O.Ps. and as the O.P. did not pay the claim amount made within the policy coverage period, he suffered mental pain and agony along with financial loss. Therefore, he filed this petition in this Forum with the above mentioned prayer.

O.P. No.1 & 3 appeared and contested this case by filing W.V. separately. On prayer of petitioner O.P. No.2 was expunged vide order No.05, dated 24.06.2015.

O.P. No.1 in the written statement stated that, the case is not maintainable, has no cause of action, barred by limitation etc. and tried to deny that the complainant purchased the said policy with total sum assured Rs.1,00,000/- and individual Rs.50,000/- by paying premium of Rs.1340/-. He also put the petitioner to strict proof that he was seriously ill and was admitted at Kovai Medical Hospital on 17.08.2010. O.P. No.1 stated that petitioner made a fabricated and false claim and is not entitled to any relief from this Forum and prays for dismissal of this case.

O.P. No.3 in its written version stated that the said contract of the policy is a bipartite contract between complainant and O.P. No.1 and this O.P. has no role or authority regarding the settlement or repudiation of claim. That, the petitioner submitted Claim Form before O.P. No.1 and O.P. No.3 forwarded the same vide letter dated 19.01.2011 and 02.06.2011 and copies of the letters are annexed. That, O.P. No.3 has no latches on his part and no authority to settle the claim and the matter is left to the discretion of the Forum.

To establish the case the complainant has relied upon an affidavit-in-chief sworn by him as P.W.-1 and documents filed some documents like copies of the policy certificate, the medical bills, Claim Form submitted to the office of the O.P. and copies of letter dated 26.05.2011 and 22.05.2013 and also copy of letter of Insurance Company dated 26.05.2011 and 21.02.2013.

O.P. No.1 and 3 did not adduce any evidence but they cross examined P.W.-1, O.P. No.1 prayed for time for filing questionnaires but did not filed the same.

DECISIONS WITH REASONS

The complainant as P.W.-1 deposed that, he purchased the policy at a premium of Rs.1340/- and period covered from 05.04.2010 to 04.04.2011 and coverage of individual insured sum is Rs.50,000/-. That, during the tour at South India with severe pain in abdomen and in chest and he was admitted in Kovai Medical Centre and Hospital on 17.08.2010. The discharge summery of the hospital is also filed. That he was discharged from the hospital on 19.08.2010 and undergone various tests and received treatment as indoor patient. The medical bills, various tests’ report are also filed herewith. That he was suffering with severe epigastric and lower abdominal pain is also reveals from the discharge certificates and medical papers. On 08.09.2010 the claim Form was submitted before O.P. No.1 with all such documents to prove that he had incurred expenses of Rs.18,728/- for his treatment in the Kovai Medical Hospital. The letter dated 21.02.2011 of O.P. to this petitioner regretting the repudiation of the claim, the ground stated that “there is no active line of treatment necessitating stay in hospital and the said treatment can be done on an OPD basis”. From the evidence of the complainant and the documents filed, the petitioner has been able to prove that he is a consumer under the O.P. Insurance Company and he purchased the said mediclaim policy with Rs.1340/- premium. The policy paper goes to show that the period of insurance coverage under the policy was 05.04.2010 to 04.04.2011. It is also proved that the complainant became seriously ill when he was in a tour in South India, which necessitated him to get admitted in said Kovai Medical Centre and Hospital at Coimbatore and remained there admitted from 17.08.2010 to 19.08.2010 for his treatment and he received necessary treatment for which he has to incur expenditure of Rs.18,728/-. The medical documents, cash memo and receipts proves the same. Therefore, the O.P. Company cannot repudiate the claim on the ground that said treatment can be done on OPD basis. It is only on the advice of the doctor attending him that he was admitted in the hospital to receive treatment and not in the suit will or whims of the complainant. Therefore the treatment he received during the coverage of the insurance policy entitles the petitioner to receive the claim amount under the policy. The O.P., therefore, is negligent and deficient in service in repudiating the legitimate claim of the petitioner without any valid reason or ground. O.P. necessarily caused mental harassment and pain to the complainant denying the claim. Thus the petitioner has been able to prove his case by sufficient oral and documentary evidence and in his cross examination by the O.P. No.1. O.P. No.1 failed to make out any defence case to repudiate the claim of the petitioner.

Fees paid are correct.

Hence it is,

ORDERED

That the case being No.CC-11/2015 is allowed on contest against O.P. No. 1 and dismissed against O.P. No.3. O.P. No.1 is directed to pay the claim amount of Rs.18,728/- as medical expenses incurred by the petitioner. O.P. is further directed to pay compensation of Rs.5000/- for harassment, mental pain and Rs.2000/- as litigation cost to the complainant within one month failing which the total sum will carry an interest @9% per annum from the date of passing of this order till realization, otherwise complainant is at liberty to proceed with law.

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