This complaint U/S 35 of C.P. Act, 2019 was initially filed against the Opposite Party (O.P.) 1) Senior Divisional Manager, National Insurance Co. Ltd., Debi Jhora Building, Thana More, P.S. - Kotwali, P.O. & Dist. - Jalpaiguri, Pin Code- 735101 and O.P. 2) Medi Assist India TPA Pvt. Ltd., Kolkata CRO- II, Thappar House, 8^th Floor, 25^th Brabourne Road, P.S. - Hare Street, Kolkata- 700001 who contested the case by filing Written Version (W.V.).

The case of the complainant as per her complaint is as follows-

The complainant argued in her plaint that she had a mediclaim policy being no. 153900502010000962 with coverage up to Rs. 2, 00, 000/- (Rupees Two Lac) only and her husband, Sri Subrata Nandi, was also covered under the said policy. The complainant added that on 08/08/2021 her husband was admitted at Touch Nursing Home with severe respiratory distress under the advice and supervision of Dr. Sumanta Mukherjee and was admitted there up to 14/08/2021 for which the total bill incurred Rs. 1, 32, 986/- (Rupees One Lac Thirty Two Thousand Nine Hundred and Eighty Six) only. The complainant also argued in her plaint that she placed all bills along with relevant documents before the O.P. No.1 as her claim and the same was placed before the O.P. No.2 by O.P. No.1 but said claim being no. 104917667 was reimbursed and paid Rs. 97, 751/- (Rupees Ninety Seven Thousand Seven Hundred and Fifty One) only to the complainant on 21/01/2022 by illegally deducting of Rs. 28, 900/- (Rs. Twenty Eight Thousand Nine Hundred) only and it was intentionally paid through NEFT in her account without intimating her so that she could not raised any objection.

The complainant also argued in her plaint on 05/02/2022 she received a mail from O.P. No.2 mentioning that the amount of Rs. 28, 900/- (Rs. Twenty Eight Thousand Nine Hundred) only was deducted as consultation charges however the breakup of the said amount had shown that the amount was for ventilator, oxygen, intubation etc. The complainant also argued that she separately paid a sum of Rs. 6, 000/- (Rupees Six Thousand) only to Dr. Sumanta Mukherjee as his fees and the illegally deducting amount of Rs. 28, 900/- (Rs. Twenty Eight Thousand Nine Hundred) only was not the consultancy fees of the attending doctor. The complainant also argue that the said ventilator,       oxygen, intubation resources were asserted and advised by the attending doctor, Dr. Sumanta Mukherjee, as a necessary for treatment of the patient.

The complainant also argued that on 15/02/2022 she met with O.P. No.1 for reimbursement of the deducted amount but did not get any result and subsequently on 18/06/2022 the complainant sent a legal notice to the O.P.s but again after receiving the same the O.P.s remained silent.                         

 The prayers of the complainant are as follows-

1. Admit the complaint filed by the complainant.
2. To pass an order directing the O.P.s to settle the claim amounting to Rs. 28, 900/- (Rs. Twenty Eight Thousand Nine Hundred) only.
3. To pass an order directing the O.P.s to pay a sum of Rs. 50, 000/- (Rupees Fifty Thousand) only to the complainant for mental harassment and monetary loss.
4. Any other relief/ reliefs as your honour may deem fit and proper.
5. Total claim amount is Rs. 78, 900 (Rupees Seventy Eight Thousand and Nine Hundred) only.

         List of documents filed by the complainant:

1. Photocopy of Mediclaim Policy being no. 153900502010000962 in the name of Smt. Bhabani Chakrobarty Nandy.
2. Photocopy of mail communication, dated 05/02/2022 from Medi Assist.
3. Photocopy of letter dated 15/02/2022 from the complainant to the O.P. No.1.
4. Photocopy of letter dated 10/02/2022 issued by Dr. Sumantra Mukherjee.
5. Photocopy of legal notice dated 18/06/2022, issued by L. Advocate to O.P. No.1 and O.P. No.2

6. Photocopy of postal receipt of legal notice, dated 18/06/2022.   

             Regarding this instant case, the Opposite Party (O.P.) 1) Senior Divisional Manager, National Insurance Co. Ltd., Debi Jhora Building, Thana More, P.S. - Kotwali, P.O. & Dist. - Jalpaiguri, Pin Code- 735101 and O.P. 2) Medi Assist India TPA Pvt. Ltd., Kolkata CRO- II, Thappar House, 8^th Floor, 25^th Brabourne Road, P.S. - Hare Street, Kolkata who contested the case by filing W.V. and as per the W.V. the case is as follows.

In his W.V. the O.P. No.1 denied all the facts of the complainant and argued that the allegations contained in different paragraphs of the complaint are fabricated, manufactured and concocted and the complainant should give strict proof thereof. The O.P. No.1 also argued in his plaint that when the complainant received the compensation amount at that time she did not raised no objection and did not deny to receive the payment and when the complainant received the compensation amount without giving any objection then it was well established that the complainant received the same as full and final settlement. The O.P. No.1 also argued that the presence of the attending doctor of the complainant is required before this Commission for clearing confusion related to the type of treatment provided by him to the complainant and whether that type of treatment was required or not.        

List of documents filed by the O.P. No.1:

1. Original copy of National Mediclaim Policy Prospectus.
2. Original copy of National Senior Citizen Mediclaim Policy Prospectus.

Having heard, the Ld. Advocate of the complainant and on perusal of the Complaint and documents filed by the complainant the following points are taken to be decided by this Commission.

Points for consideration

1) Whether the complainant is a consumer?

2) Whether the case is maintainable under the CP act 2019?

3) Whether this Commission has its jurisdiction to decide this case? 

4) Whether there is any deficiency in service in the part of the O.P. as alleged by the complainant?

5) Is the complainant is entitled to get any award and relief as prayed for? If so, what extent?

Decision with reason:-

            All the points are taken up together for consideration and decision.

Seen and perused the complaint petition filed by the parties, supported by the affidavit, documents filed by the parties. We are also heard argument of both sides in full length.

In this case the complainant had a mediclaim policy of National Insurance Co. Ltd (O.P. No.1) being policy no. 153900502010000962 with coverage up to Rs. 2, 00, 000/- (Rupees Two Lac) only and her husband, Sri Subrata Nandi, was also covered under the said policy. The complainant added that on 08/08/2021 her husband was admitted at Touch Nursing Home with severe respiratory distress under the advice and supervision of Dr. Sumanta Mukherjee and was admitted there up to 14/08/2021 for which the total bill incurred Rs. 1, 32, 986/- (Rupees One Lac Thirty Two Thousand Nine Hundred and Eighty Six) only. In this specific point the O.P. No.1 did not raise any objection and so, this Commission has no doubt to hold that the complainant is a very much consumer under the C.P. Act 2019.

The complainant resides in Jalpaiguri and the O.P. No.1 is also carrying his business in Jalpaiguri. Thus, there is no doubt that this Commission has its territorial jurisdiction to decide this case.

In this instant case, in support of his claim the complainant filed a letter of Dr. Summantra Mukherjee who was the treating doctor of the patient clearly stated that in his letter dated 10/02/2022 that ventilation, intubation Central Lining and Oxygen inhalation was necessary for the recovery of the patient and subsequently he was discharged from this Nursing Home on 14/08/2021. The O.P. No.1 insurance company did not challenge the genuineness of this letter. In absence of any objection this Commission relays upon this letter. The O.P. No.1 filed the National Mediclaim Policy Prospectus and the National Senior Citizen Mediclaim Policy Prospectus but the O.P. No.1 failed to establish his defense by not referring any relevant point of the prospectus and that the complainant was not entitled to get ventilation charges and also not filed any documents in favour of his defense. So, this Commission holds that there is a deficiency of service from the part of the insurance company and the complainant is entitled to get Rs. 28, 900/- (Rupees Twenty Eight Thousand and Nine Hundred) only for ventilation charge and Rs. 2, 500/- (Rupees Two Thousand and Five Hundred) only for litigation cost from the O.P. No.1 within 30 days failing which the complainant is entitled to get @ 6% simple interest per annum from the date of this order. The O.P. No.1 is also directed to deposit Rs. 2, 500/- (Rupees Two Thousand and Five Hundred) only in the Legal Aid Account of this Commission within 30 days from the date of this order.        

Hence, it is therefore,

ORDERED

That the Consumer Case No. 70/2022 be and same is allowed in contest against the (O.P. No.1) National Insurance Co. Ltd.

The (O.P. No.1) National Insurance Co. Ltd is directed to pay Rs. 28, 900/- (Rupees Twenty Eight Thousand and Nine Hundred) only to the complainant. The O.P. No.1 also directed to pay Rs. 2, 500/- (Rupees Two Thousand and Five Hundred) only for litigation cost within 30 days from the date of this order failing which the complainant is entitled to get @ 6% simple interest per annum from the date of filing of this case, i.e., 18/08/2022. The O.P. No.1 is also directed to deposit Rs. 2, 500/- (Rupees Two Thousand and Five Hundred) only in the Legal Aid Account of this Commission within 30 days from the date of this order.    

Let a copy of this judgment be given to the parties directly or through their representative Ld. Advocate for compliance free of cost.