The complainant has filed this case against the OP under section 11/12 of the Consumer Protection Act, 1986 and praying for the relief/order :-

1. Direction against the OP to pay the complainant a sum of Rs. 11,401/- (eleven thousand four hundred one) only being a part of the amount filed by the Hospital which was not paid by the OP along with interest @ 10%  per annum.
2. Direction against the OP to pay a sum of Rs. 10,000/- (ten thousand) only to the complainant for the agony suffered by the complainant.
3. Direction against the OP to pay a sum of Rs. 10,000/- (ten thousand) only to the complainant as litigation cost.
4. Direction against the OP for making payment of Pendente lite expenses.

The brief fact of the case is that the complainant purchased a family health policy from the OP on 16.01.2015 for a period from 16.01.2015 to the midnight of 15.01.2016, renewable yearly and thereafter the policy has been renewed each year on payment of renewal premium which went on increasing with the passage of time. It is also the case of the complainant that, on 04.10.2022 the wife of the complainant namely Smt. Gopa Sarkar got admitted at Neotia Getwel Healthcare Centre, Siliguri for her illness/that matter of admission of Smt. Gopa Sarkar in the Neotia Getwel Healthcare Centre Hospital was duly intimated to the OP/ She was discharged on 07.10.2022 from that hospital when the hospital charged a sum of Rs. 70,868/- for the treatment which was duly sent to the OP on 07.10.2022 and bill was duly sent to the OP for making payment but the OP only paid a sum of Rs. 57,459/- and the complainant was compelled to pay a sum of Rs. 11,401/- to the hospital prior to discharge of Smt. Gopa Sarkar. Further case is that the complainant had to pay a sum of Rs. 11,401/- as the OP did not pay the entire claim amount of Rs. 70,868/- though the hospital allowed a discount of Rs. 2008.30 /that being aggrieved by default made by the OP the complainant sent an e-mail to the OP requesting the OP to give details reason/reasons of non-payment of part of the bill i.e. Rs.11,401/- but received no reply to the said mail and again on 11.10.2022, 05.12.2022 the complainant made some queries through mail to the OP, when the OP stated that the deduction/non-payment was made as per terms and conditions in the policy documents and the said reply of the OP is miss conceive having no basis, it caused harassment to the complainant and thereafter the complainant has filed this case.

          In support of the complaint the complainant filed some documents by a firisti which are stated as follows:

1. Certificate of Insurance as annexure-1,
2. Doctor’s prescription advising admission in hospital as annexure-2,
3. Bill of supply cum receipt as annexure-3,
4. Money receipts evidencing payment by complainant as annexure-4,
5. Print out copy of email done by complainant as annexure-5,
6. Print out copy of email done by the OP as annexure-6.

          Notice was issued from this Commission for servicing the same upon the OP which was duly served. But the OP did not turn up before this commission to contest this case. Accordingly the case is proceeding ex-parte against the OP.

          Having heard the Ld. advocate of the complainant and on perusal of the entire record including the documents filed the following points are taken for determination by this commission:

POINTS FOR CONSIDERATION

1. Whether the complainant is a consumer as per the provision of C.P. Act. ?
2. Whether the case is maintainable in its present form and prayer under the provision of the C.P. Act. ?
3. Whether there is any cause of action to file this case by the complainant?
4. Whether there was deficiency in service on the part of the OP as alleged by the complainant?
5. Is the complainant has able to prove this case and entitled to get any relief as prayed for?

                   DECISION WITH REASONS

All the points are taken up together for discussion to avoid unnecessary repetition and for the sake of convenience and brevity of this case.

         The complainant was given opportunity to prove its case and thereby the complainant filed its evidence in chief in the form of an affidavit. In the written deposition-in-chief complainant has corroborated the contest of the complaint by disclosing on each copy on which day she was admitted in the Neotia Getwel healthcare Centre Hospital  and on which day she was discharged from the hospital and what amount was charged by the hospital and how the complainant make payment of the charge amount. From the documents filed by the complainant it reveals that the bill which was generated on behalf of hospital was charged for a sum of Rs. 70,868.69. Ld. advocate of complainant by filing WNA has specifically stated that the Neotia Getwel healthcare Centre Hospital charged a sum of Rs. 70,868.69 but the OP make payment only a sum of Rs. 57,459/- and make no reply when the complainant requested the OP for clarification of the said non-payment of Rs. 11,401/-. He also argued that on several occasions the complainant sent mail to the OP requesting for making payment of Rs. 11,401/- but they make no such payment and only to evading of making payment, the OP stated that the deduction/non-payment was made as per terms and conditions contained in the policy documents.

          Having heard the Ld. advocate of the complainant and on perusal of the complaint, written deposition-in-chief, WNA including documents filed by the complainantit is admitted fact that the complainant is a consumer who purchased a policy which was valid till the midnight of 15.01.2016, renewable yearly.  From the record it also reveals that the policy was duly renewed time to time by the complainant and after making proper payment of premium renewed the policy. From the documents which are submitted by the complainantit is also admitted fact that Smt. Gopa Sarkar, wife of the complainant got admitted in the Neotia Getwel healthcare Centre Hospital of 04.10.2022 and she was discharged on 07.10.2022. From the medical bills which was issued by the hospital it is admitted fact that the hospital charged a sum of Rs. 70,868/- from the complainant but the OP did no pay the entire amount to the complainant and the OP make no such reply regarding non-payment of such sum of Rs. 11,401/-. It is also admitted fact that the complainant on several occasions sent mail to the OP but the OP deliberately flouted the queries made by the complainant.

          Thenon-payment of the charge bill amount by the Neotia Getwel healthcare Centre Hospital by the OP is nothing but deficiency in service of the OP who issued family health policy in favour of the complainant which is still valid but the OP ignored to make payment of the bill amount to the complainant.

          Considering the unchallenged evidence of the complainant and considering the documents filed by the complainant we are of the view that the complainant has been able to prove its case against the OP and he is entitled to get the relief.

Hence,

ORDERED,

That the instant consumer case no. 34 of 2023 is herby allowed on ex-parte but in part against the OP.

          The OP is directed to pay a sum of Rs. 11,401/- (eleven thousand four hundred one) only to the complainant within 1 month from this day and further directed to pay interest @ 9% per annum with effect from 07.10.2022 till making payment of the entire amount I/d the complainant is at liberty to preferred execution application as per law.

          The OP is also directed to pay a sum of Rs. 5,000/-(five thousand) only as compensation to the complainant for mental agony suffered from due to harassment by the OP.

          The OP is also directed to pay a sum of Rs. 5,000/- (five thousand) only the complainant as litigation cost and OP is further directed to pay Rs. 10,000/-(ten thousand) only to the Consumer Legal Aid Account of this Commission.

          Let a copy of this order be given to the parties free of cost.