In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No. 42 / 2011.
1) Mr. Alok Kumar Jhumjhunwala,
543, Rabindra Sarani, Baghbazar, 1st Floor, Kolkata-700003. ---------- Complainant
---Versus---
1) Sr. Branch Manager, The Oriental Insurance Co. Ltd.,
CBO-II, A & B Block, 2nd Floor, 212, Rashbehari Avenue, Kol-19.
2) Vipul MedCorp TPA Pvt. Ltd.,
16/2, Lord Sinha Road, Kolkata-700071.
3) Vipul MedCorp TPA Pvt. Ltd.,
515, Udyog Vihar, Phase-V, Gurgaon, Haryana-122016. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri ,Member
Smt. Sharmi Basu ,Member
Order No. 13 Dated 09/05/2012.
The petition of complaint u/s 12 of the C.P. Act, 1986 has been filed by the complainant Mr. Alok Kumar Jhunjhunwala against the o.ps. The Oriental Insurance Co. Ltd. and others. The case of the complainant in short is that complainant purchased a mediclaim policy commonly known ‘Mediclaim Insurance Policy (Individuals)’ bearing policy no.311604/48/2010/790 for the period 25.6.09 to 25.6.10 with a yearly premium of Rs.9916/- from o.p. no.1 and complainant from the very inception i.e. from 25.6.04 onwards has been paying the yearly premium regularly without any interruption. Complainant’s daughter Miss Nandini Jhunjhunwala has been suffering from continuous pain on the back associated with discharge of pas and immediately consulted Dr. (Prof) Eken Ghosh who has examined her on 14.9.09 and diagnosed a ‘Pilonidal Sinus’ and prescribed her some medicine, suggested operation and referred to Dr. D.K. Ghosh and as per advice of Dr. D.K. Ghosh, complainant’s daughter underwent all pathological tests and medical examination and admitted to Belle Vue Clinic on 1.10.09 and then operated on 2.10.09 under the supervision of Dr. D.K. Ghosh. Complainant incurred a total expenditure of Rs.90,307/- for the medical treatment of his daughter. Accordingly, he submitted the claim of Rs.90,307/- with o.p. no.2 towards reimbursement as against policy referred to above. O.p. no.3 without evaluating and assessing properly the genuine claim of complainant, has sanctioned wrongly and malafidely an amount of Rs.32,500/- on discharge voucher dt.21.1.10 with the list of deductions. In response to complainant’s letter dt.28.12.09, o.p. no.1 has communicated to complainant on 5.2.10 stating that they shall revert as soon as they get the details from the o.ps. but unfortunately o.p. no.1 has not reverted to. Thereafter, o.p. no.3 has sent the aforesaid amount of Rs.32,500/- by cheque no.815870 dt.4.5.10 to complainant who in turn, has sent back the same with strong objection and again o.p. no.3 sent another cheque no.846212 dt.4.10.10 for the same amount as aforesaid which has been turned back by complainant with strong protest. Hence, the case lodged by complainant with the prayer contained in the prayer portion of the petition complaint.
O.ps. had entered their appearance in this case by filing w/v and denying all the material allegations labeled against them. In their w/v o.ps. stated that after giving due consideration to the bill raised by complainant, the instant o.ps. after dividing the said claim under the various sub-groups disallowed the claims calling under certain heads and approved the rest portion of the claim which fell within four corners of the insurance policy and were duly paid. The portion of the claim which was not approved and was not such reimbursed amount to (1) Rs.21,807/- towards excess room rent and non-payable items, (2) Rs.36,000/- towards fees paid to doctor as the complainant did not provide proper number receipt in spite of reminding the same. Hence the total amount Rs.32,500/- was reimbursed. However, complainant refused to accept the said cheque and the said was returned by complainant to o.p. no.2 vide letter dt.17.9.10. O.ps. have stated that there has been no deficiency of service on their part as they have already showed bonafide intentions of paying the amount that the complainant is really entitled to under the four corners of the insurance policy. Accordingly, o.ps. prayed for dismissal of the case.
Decision with reason:
We have gone through the pleadings of the parties, evidence and documents in particular. It is an admitted position that complainant had mediclaim insurance policy (individuals) bearing no.311604/48/2010/790 for the period 26.6.09 to 25.6.10 with a yearly premium of Rs.9916/- with o.p. no.1 and complainant was going on making payment of renewal of policy without any interruption from 26.6.04 onwards. Further case of the complainant’s daughter himself Nandini Jhunjhunwala fell sick from continuous pain on her back associated with discharge of pas and she was consulted Dr. Eken Ghosh and was examined by the said doctor on 14.9.09 as diagnosed as ‘Pilonidal Sinus’ and prescribed medicine and suggested operation and referred to Dr. D.K. Ghosh. Accordingly, as per advice of Dr. D.K. Ghosh the said daughter of complainant underwent all pathological tests and examinations and was admitted at Belle Vue Clinic on 1.10.09 and operated on 2.10.09 under Dr. D.K. Ghosh. Finally complainant lodged a claim of Rs.90,307/- towards reimbursement as against policy referred to above, but o.ps. sent a cheque of Rs.32,500/- on 21.1.10 and the said cheque was returned by complainant vide letter dt.28.1.10 and thereafter so many correspondences went on between the parties to this case, but o.ps. refused to consider the claim of the complainant and on being aggrieved complainant has put forward before this Forum for redressal.
Ld. lawyer of complainant in the course of argument submitted that the claim of complainant was not bonafide one and the portion which was considered bonafide to o.ps. i.e. for Rs.32,500/- was sent to complainant by cheque, but unfortunately complainant sent back the cheque to o.ps. and claimed the full amount as referred to above which is not admissible by o.ps. as per their terms and conditions. Now we find on perusal of the entire materials on record and the documents in particular that it is the attending doctor who underwent operation got the daughter of complainant admitted in the Belle Vue Clinic as the said attending doctor considered fit and proper in the context of the medical ethics wherein complainant did not have any scope to interfere with the suggestion and/or advice of the doctor and it was a life saving situation wherein no one had any control over the same. It is settled principle of law that complainant went on making payment of premium regularly and he was no longer defaulter at any stretch of imagination as it appears from the materials on record.
That being the position we do not find any justification on the part of o.ps. not to entertain the entire claim of complainant and this act on the part of o.ps. amounts to deficiency of service to its consumer / complainant and complainant is entitled to relief.
Hence, ordered,
That the petition of complaint is allowed on contest with cost against o.p. no.1 and without cost against o.p. nos.2 and 3. O.p. no.1 is strictly directed to pay a sum of Rs.90,307/- (Rupees ninety thousand three hundred seven) only together with interest @ 9% p.a. from the date of filing of this case i.e. 3.2.11 till the date of realization and is further directed to pay compensation of Rs.25,000/- (Rupees twenty five 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 @ 9% 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.
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MEMBER MEMBER PRESIDENT
