Orissa

Cuttak

CC/99/2018

Rabindra Nath Das - Complainant(s)

Versus

Senior Branch Manager,National Insurance Co.Ltd - Opp.Party(s)

P K Das & associates

16 Sep 2022

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

                                 C.C.No.99/2018

 

Rabindra Nath Das,

S/O:Late Sukadev Das,Resident of

At:Panda Sahi,Fakirpur,P.S:Jagatpur,

Dist:Cuttack-754021,State:Odisha.                                                ... Complainant.

 

                                                Vrs.

1.        National Insurance Co. Ltd.,

Cuttack Branch,1^st Floor,A.P.Market Complex,

Allahabad Bank Premises,

Link Road Square,Madhupatna,Cuttack,

Odisha,Pin-753010. Represented through

Its Senior Branch Manager.

 

2.          Medi Assist Insurance TPA Pvt. Ltd.,

“PREMIER COURT”.4^th Floor,

4,Chandinichowk Street,

Kolkota-700072.                                                        ... Opp. Parties.

 

 

Present:               Sri Debasish Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing:    27.08.2018

Date of Order:   16.09.2022

 

For the complainant:          Mr. P.K.Das,Adv. & Associates.

For the O.P No.1      :          Mr. MTJA Baig,Adv. & Associates.

 

Sri Debasish Nayak,President                          

            Case of the complainant as made out from the complaint petition in short is that he had availed a policy for Rs.5,00,000/- for himself and his wife Binapani Das effective from 6.5.17 to 5.5.18 vide policy no. 163104501710000015 with the O.P No.1.  The complainant on 13.10.17 sustained severe pain at his lower abdomen and the physician suspected hernia which required surgery.  The complainant was accordingly admitted to Chandralaya Nursing Home at Cuttack as an indoor patient on 2.11.17 and had undergone surgery on 3.11.17.  He was discharged on 12.11.17.  The total expenses incurred in the said hospitalisation of the complainant was of Rs.41,716/-.  The complainant had made a claim for the said amount with the O.Ps and had thereby submitted all the necessary documents.  On 3.12.17 the complainant sustained a brain-stroke and was treated by the physician at SCB Medical College & Hospital at Cuttack in the medicine ward being admitted as an indoor patient for two days.  For this he had to spent more than Rs.50,000/- by borrowing the said money.  On 22.6.18 the complainant had received a registered letter from O.P No.1 who had repudiated his claim on the ground of violation of condition no.5.11 of the policy on account of fraud.  O.P No.1 through his letter had mentioned that as per the bills as submitted by the complainant that he had taken medicines from Baba medicine store and also from Sai Krupa medicine store, but those two shops had confirmed to the O.P No.1 that the said bills as submitted were not issued from their shops.  The complainant had sent his son to O.P no.1 on 29.6.18, 10.7.18 and on 31.7.18 in order to explain that the medicines administered to the complainant were procured from the person who had delivered those near the bed of the complainant while he was admitted.  Ultimately when the complainant could not get the claim amount settled with the O.P, he had filed this case seeking direction to the O.P to the settle his claim amount of Rs.41,716/- and to provide interest thereon @ 24% per annum with effect from 12.11.17, further, to pay him a compensation amount of Rs.1,00,000/- towards his mental agony and harassment, also to pay the expenses towards his brain stroke to the tune of Rs.50,000/- and to bear his litigation expenses.  He has further  prayed for any other relief as deemed fit and proper.

            In order to prove his case he has filed copies of his insurance policy, about the letters from the O.P regarding the documents wanting and the letter sent to him repudiating his claim.

2.         Out of the two O.Ps as arrayed in this case, O.P no.2 has been deleted as per the order dt.8.8.19.  Thus, it is only O.P No.1 who has contested this case and has filed his written version.  As per the written version of O.P No.1, the case of the complainant is not maintainable, there was no deficiency in service.  The O.P No.1 admits to have issued insurance policy bearing no.163104501710000015 in favour of the complainant and his wife covering risk with effect from 6.5.17 to 5.5.18 to the tune of Rs.5,00,000/-.  The O.P could know that the complainant was under treatment with effect from 2.11.17 to 12.11.17.  O.P No.1 had engaged O.P No.2  to enquired into the claim as made by the complainant and as per the final survey report of the O.P No.2 dt.28.1.18, the hospital expenditure of the complainant was of Rs.25,100/- but the other bills as submitted by the complainant when verified were found that those were not to have been issued by the concerned medicine stores.  Accordingly, the O.P No.1 has mentioned in his written version that the complainant/petitioner has submitted fraudulent bills.  It is for this, O.P no.1 repudiated the claim of the complainant.  O.P No.1 has further mentioned in his written version that the complainant being treated at the SCB Medical College & Hospital of Cuttack for brain-stroke is not within their knowledge.  Thus, the O.P no.1 has prayed to dismiss the complaint petition of the complainant.

3.         Keeping in mind the averments as made in the complaint petition together with the contents of the written version of O.P no.1, this Commission is of a view to settle the following issues in order to arrive at a proper conclusion.

i.          Whether the case of the complainant is maintainable ?

ii.         Whether there was any deficiency in service on the part of the O.Ps.?

            iii.        Whether the complainant is entitled to the reliefs as claimed ?

Issue no.ii.

            Issue no.ii being the pertinent issue is taken up first for consideration here in this case.

            Admittedly, the complainant was treated at Chandralaya Nursing Home and was admitted as an indoor patient with effect from 2.11.17 to 12.11.17.  It is also admitted that the complainant and his wife had a policy coverage to the tune of Rs.5,00,000/- bearing policy No. 163104501710000015 which was effective from 6.5.17 to 5.5.18 with the O.P No.1.  It is seen that the O.P No.1 has not disputed about the surgery and treatment of the complainant at Chandralaya Nursing Home at Cuttack with effect from 2.11.17 to 12.11.17.  They also admit about the complainant paying a sum of Rs.25,100/- in the said Nursinghome.  From the copies of all the medical documents, prescriptions, medicine bills as filed by the O.P No.1 in this case relating to the surgery and treatment of the complainant when perused, those go to show that there were certain pathological test, X-ray bills, medicines as incurred from other shops like Get-Well and HariOmm Drug house of Cuttack etc. which were not paid any heed by the O.P.  When there was surgery and treatment and as per the documents available of the complainant as filed by the O.P No.1 here in this case, those do not show about the provisions of supplying medicine to the complainant free of cost or if the examinations pertaining to the surgery and treatment of the complainant were made free of cost.  Thus, when the complainant had made his claim and the same was repudiated after seven months by the O.P no.1 with the plea that he had engaged a third party surveyor in order to investigate into the medicines as incurred by the complainant, the said third party surveyor had opined that those medicine shops had denied to have issued any such medicine bills as filed by the complainant. One thing is for sure is that when a patient undergoes any surgery and treatment thereto, requirement of certain examinations and medicines will definitely be there.  The enquiry as conducted by O.P No.1 through a third party which failed to appear before this Commission and substantiate his evidence and the simple plea that the third party engaged by O.P No.1 had opined that the medicine  shopkeepers denied to have issued the medicine bills do not hold good here in this case.  Due to such lack of proper evidence being not elucidated by the O.P no.1, this Commission is of an opinion that O.P nol.1 had tried to escape from the liability of settling the claim of the complainant when made.  The O.P No.1 though admits about the Nursing Home where the complainant had paid a sum of Rs.25,100/-, has repudiated the said amount even when the explanation thereto is not available, this Commission is of an opinion that infact there was deficiency in service on the part of O.P No.1 which makes him liable for the same.  This issue is answered in favour of the complainant.

Issues no.i & iii.

            From the discussions as made above, when it is admitted fact that the complainant was under treatment and had undergone surgery and by then he had a valid insurance policy with the O.P No.1 and that when he made his claim, the same was repudiated on a flimsy ground by the O.P no.1, he had to file this case which is definitely maintainable and the complainant is ofcourse entitled to the reliefs as claimed by him but as regards to subsequent treatment of the complainant at SCB Medical College & Hospital at Cuttack since because there is no document putforth, and the same is not within the knowledge of the O.Ps, there can be no relief for the same.  Hence it is so ordered;

 

                                                           ORDER

            The case is decreed on contest against the O.P No.1 who is thus directed to settle the claim of the complainant by paying him the claim amount of Rs.41,716/- together with interest thereon @ 12% per annum with effect from 12.11.17 till the total amount is quantified.  The O.P No.1 is further directed to pay a sum of Rs.60,000/- to the complainant towards his mental agony and harassment and also to bear the litigation expenses of the complainant to the tune of Rs.30,000/-.  This order is to be carried out within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on the 16^th day of   September,2022 under the seal and signature of this Commission.           

                                                                                                                                Sri Debasish Nayak

                                                                                                                                            President

                       

                                                                                                                                                             Sri Sibananda Mohanty

                                                                                                                                              Member