Annex Building, Kolkata-68.                                                                  ---------- Opposite Party

Present :           Sri Sankar Nath Das, President.                                                        

                        Dr. Subir Kumar Chaudhuri ,Member

Order No.   19    Dated  27-02-2013.

            The case of the complainant in short is that complainant has initially insured his name along with the name of his wife, Mamata Dutta, under mediclaim insurance policy bearing no.030800/48/02/01483 with United India Insurance Co. Ltd. for the period from 20.8.02 to 19.8.03 without making any restriction to pay expenses of any specified disease or illness providing those terms and conditions.

            Complainant has renewed his insurance policy along with the name of his wife in each year continuously without break from the year of 2002 to till submission  of this application and o.p. United India Insurance Co. Ltd. has never denied those initially accepted or contracted terms and conditions of the policy.

            Subsequently o.p. has imposed certain restrictions upon payment of expenses incurred over certain specified disease or illness of insured persons under four heads during the calendar year of 2007-08 and onwards without giving any prior intimation or offering option to this policy holders at the time of renewal of their policies and on the other hand the insured person or the complainant in course of renewal of his own and his wife’s mediclaim insurance policy has never raised any objection relying on the reason or ground that those restrictions as imposed under four heads normally were never applicable for those who renew their earlier mediclaim insurance policies; as and when those restrictions as imposed subsequently shall be applicable for subsequent new comers under fresh contract of mediclaim insurance policy.

            Complainant’s name Bimal Kr. Dutta and the name of his wife Manata Dutta have also been renewed as the first and second insured person of the mediclaim insurance policy no. 030800/48/08/00002801 covering of 20.8.08 to 19.8.09 with the o.p. being combined with TPA or third party administrator, Heritage Health Service Pvt. Ltd. with the sum insured of Rs.1,50,000/- for each of two individuals, husband and wife, in making payment of insured premium of Rs.10,315/- for both  individuals on the date of 18.8.08.

            Complainant’s wife being second insured of the mediclaim policy number 030800/48/08/00002801 renewed during the period of the year from 20.8.08 to 19.8.09 with sum insured of Rs.1,50,000/- has been admitted with acute pain in abdomen under advice of a Dr. Santanu Nandy, Kolkata-29 at night of 9-00 p.m. on the date of 18.3.09 at nursing home, Mohan Clinic, 46, Lake Temple Road, P.S. Tollygunge, Kolkata-29 and thereafter various investigation s were made there to find out the cause of acute pain and finally detected one big size of tumor twisted on ovaries that along with uterus were removed by opening abdomen of Mamata Dutta through the procedure of major surgery done at evening on the date of 21.3.09 and thereafter the patient, Mamata Dutta remained hospitalized within the nursing home, Mohan Clinic, until she was discharged on the date of 26.3.09 (F.N).

            At the time of discharge of patient, Mamata Dutta, from Mohan Clinic Nursing Home, the o.p. through  their agent third party administrator, the Heritage Health Services Pvt. Ltd. h as paid Rs.30,000/- being 20% of the sum insured of Rs.1,50,000/- during the period of hospitalization of the patient, Mamata Dutta, without making further payment of genuine outstanding claim of Rs.27,641.28.

            Complainant being insured person, has issued one letter dt.25/28^th May, 2009 to the Heritage Health Services Pvt. Ltd. as third party administrator, with copy to the insurer, o.p. under receipt of acknowledgement of 28.5.09 wherein the amount of Rs.34,755.28.

            Against the claim amount of Rs.34,755.28 as mentioned earlier, o.p. through their agent Heritage Health Services Pvt. Ltd. has paid the amount of Rs.7114/- on two occasions; firstly by making payment of Rs.2614/- as to reimburse expenditure incurred during pre and post hospitalization period under letter dt.1.7.09 and secondly by making payment of Rs.4500/- to reimburse expenditure of C.T. Scan under letter dt.30.8.09.

            Therefore, by payment of Rs.7114/- as made against claim amount of Rs.34,755/-.28 preferred under letter dt.25/28^th May, 2009 marked ‘C’ the balance amount remains at Rs.27,641.28 as unpaid or outstanding claim. Outstanding claim of Rs.27,641.28 which remains without being reimbursed. 

            Being highly aggrieved and harassed complainant has filed this case with the prayer contained in the petition of complaint.

            O.p. 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. in the course of argument stated that the case has got no merit and the same is liable to be dismissed.

Decision with reasons:-

            We have gone through the pleadings of the parties, evidence and documents in particular and we find that complainant had mediclaim insurance policy along with his wife under o.p. and the policy was valid one. Further we find that the wife of complainant viz. Mamata Dutta being second insured of the mediclaim insurance policy having insured of Rs.1,50,000/- admitted in acute pain in abdomen on 18.3.09 in the nursing home and it was duly valid insured policy and was discharged on 26.3.09. Further we find that complainant submitted claim of Rs.34,755.28 and o.p. paid Rs.2614/- and received Rs.4500/- towards repayment as against the claim and outstanding amount of Rs.27,641.28 remained undisbursed and this action on the part of o.p. amounts to gross negligent and deficiency in service being service provider to its consumer / complainant and complainant is entitled to relief.

            Hence, ordered,

            That the case is allowed on contest with cost against o.p. O.p. is directed to pay to the complainant Rs.27,641.28 (Rupees twenty seven thousand six hundred forty one and twenty eight paise) being the outstanding claim amount 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% shall accrue over the entire sum due to the credit of the complainant till full realization.

            Complainant is at liberty to file execution case before this Forum in case of non execution of the aforesaid order in its entirety within the stipulated period under the provision of the COPRA, 1986.

            Supply certified copy of this order to the parties free of cost.