Ld. Advocate(s)

                                    For Complainant: Prodip Banerjee

                                    For OP/OPs : Joydip Mitra

            Date of filing of the case                      :16.03.2017

            Date of Disposal  of the case              :16.05.2024

Final Order / Judgment dtd.16.05.2024

The concise fact of the case of the complainant is that the complainant  Goutam Ganguly insured a policy  namely family floater plan no. 0200242637 in the name of Goutam Ganguly, Purabi Ganguly and Aritra Ganguly  on 04.12.2014 complainant Goutam Ganguly  suffered diarrhoea and was admitted  to Central Nursing Home, Krishnagar. He was examined  by the doctor  of Central Nursing Home and discharged  on 06.12.2014. The complainant  spent Rs.7033/- for his medical treatment  in the Nursing Home. The complainant  paid insurance  premium  for Rs.18288/-. Thereafter,  the complainant  submitted  the said bill  for Rs.7033/- to the OP along with  all  documents  but the OP TATA AIG General Insurance Company repudiated  the claim in their letter dated 23.04.2015. The OP has thereby  adopted unfair trade practice  for which the complainant suffered mental pain and agony. So, the present case is filed.  The cause of action for the present case arose  on 23.04.2015. The complainant  prayed for an award for Rs.7033/- towards cost of medical treatment  Rs.50,000/- towards mental pain  and agony and harassment  and litigation cost.

          The OP No.1 contested the case . As per the  case record the case is running ex-parte  against OP NO.4. OP NO.2 expunged . OP NO.1 challenged  the case as not maintainable  on the ground that  it is bad for law and not maintainable. The positive defence  case of OP No.1 is that the insurance  policy  was issued  by OP No.1 in favour of the  insured for the period 12.09.2014 to 11.09.2015. The complainant  lodged  a claim  to the OP  for the treatment  taken in Central Nursing  Home.  It was  observed  that the complainant  was a known diabetic  and heart patient.  Earlier  he  had undergone coronary angioplasty procedure  and on that basis the TPA limited issued one letter  to the complainant    on 23.01.2015 with a request  to  furnish  some documents  to process  the claim request and finding  no response  the TPA again  issued two reminders on 31.01.2015 and 10.02.2015 to the  complainant  to furnish  the required  document  but the complainant  did not submit  the documents. The TPA limited again issued one letter  on 23.04.2015 to the complainant stating inter-alia that due to  non-submission  documents the case is closed as no claim. The present  case is filed prematurely , so  it should be  dismissed.

          On the basis  of the pleadings  of the parties  the Commission   considered  it necessary  to ascertain  the following points for proper adjudication of the case.

Points for Determination

Point No.1.

Whether the  present case is maintainable  in law and fact.

Point No.2.

Whether the complainant  is entitled to get the relief as prayed for.

Point No.3.

          To what other relief if any the complainant is entitled to get.

Decision with Reasons

Point No.1.

Although the OP No.1 challenged  the case as not maintainable yet in course of argument. Ld. Defence Counsel  did not  advance  any argument as to why  the case is not legally maintainable.

However, having  perused  the pleadings of the parties  and the evidence  in the case record  the Commission  is of the view that the present case  is not barred by  any provisions of law.

So, the point no.1 is answered  in affirmative  in favour of the complainant.

Point No.2&3.

Both the points are  closely interlinked with each other and accordingly,  these are taken up together  for brevity and convenience of discussion.

It is the admitted  case of the parties  that the complainant  was admitted to the  hospital  following an attack  of Diarrhoea. There is no denial to the fact that the complainant  spent Rs.7033/- for the purpose of his medical treatment.

The complainant  pleaded and led specific evidence  that he submitted  all the documents to the opposite parties .

Ld. Defence Counsel  argued that the complainant  has not filed  the original policy.

The said  argument  has no force  in as much as  the OP No.1 has categorically  admitted  that the complainant  insured the policy  as per the complaint.

The OP No.1 mainly  raised  the point in dispute  that the  complainant was  asked to deposit  several times  but he did not  submit  the documents. Either  in policy  or in the letters there is no  existence  of the said Abhijit Karmakar being the OP No.3 who is claimed  have been  agent of TATA AIG General Insurance Company.

The said OP NO.3 did not contest the case . Since the insurance policy is  an admitted fact , so  existence  of agent  comes  into fore.

Be that  as it may  the OP No.1 did not  deny  that the said insurance  was not registered with the OP No.1.

The complainant  proved  the vital documents  in course  of the trial.

No.1 is the Central Nursing Home  approval  slip  dated 04.12.2014.

No.2 is the Central  Nursing Home Money receipt  showing  payment  of cash.

No.3 is the Pathological test  at Central Nursing Home the complainant. The complainant also proved  all the medical bills of the said nursing home . The discharge certificate  of the complainant also discloses  that the complainant was admitted and discharged  from the said  nursing home.

There is no  denial  by the OP No.1 that the  complainant was  not medically treated  in the said hospital.

The complainant also  proved the  receipt for payment of insurance premium, Tax benefit  letter policy  schedule.

The OP No.1 claimed that they issued  several reminders  to the complainant  but the OP No.1 could not  file  any document to show that they have  demanded  the said document from the complainant.

However,  the claim closure letter dated 23.04.2015 issued by the OP NO.1 to the complainant discloses  that the claim  was repudiated  due to non-submission  of the necessary documents.

The complainant  in his evidence  categorically  stated that he filed  all the  documents  as per demand of the  OP No.1 for realisation of his claim. The complainant  filed  reply  to the interrogatories  wherein  he categorically stated  that he filed  all the required  documents  to the OP No.1 through OP No.3.

The OP No.3 did not file  any  W/V denying the specific  submission  of the complainant  that  he filed  the documents  through  OP No.3.

The complainant also specifically  asked the  OP No.1 that he  submitted all the documents  to the OP No.3 agent of  TATA AIG General Insurance Company. The OP No.1 could not deny  the said affirmation  of the complainant. On the contrary  the OP No.1 answered that  he did not know  it .This is matter of record.

Ld. Defence Counsel  for OP No.1 argued that  the documents  have to be submitted  within 30 days from raising  the claim  but the  complainant did not comply  with that provisions.

From the aforesaid  analysis  we have previously  found that  the complainant  submitted  the documents  to the OP No.1 through their agent  OP No.3. There is nothing  to show  that OP No.3 did not receive  the said  document. So,  the denial  of the claim by the OP No.1 against the  complainant  is not proper and justified .

Thus after attending  the entire evidence  it is found that the  complainant fulfilled all the conditions  for obtaining  the insurance  money.

In the light  of the aforesaid  observation  it  stands  well proved that the opposite parties  have acted  in a manner  which tantamounts  to deficiency  in service.

Accordingly,  point no.2&3 are answered  in affirmative  and decided  in favour of the  complainant.

Consequently , the complaint case succeeds on contest  with cost.

Hence,

                              It is

Ordered

that the complaint case no.CC/27/2017 be and the same is allowed on contest against OP No.1 and ex-parte against OP No.2,3 &4  with cost of Rs.5,000/- (Rupees five thousand). The complainant do get an award for a sum of Rs.7033/- ( Rupees   seven  thousand   thirty  three ) towards  cost  of medical treatment (medical bill), Rs.20,000/- (Rupees twenty thousand) towards  mental pain and agony and harassment and Rs.5,000/- (Rupees five thousand) towards litigation cost against all the OPs. The liability is jointly and severally. The OP No.1 is directed  to pay Rs.37,033/- (Rupees thirty seven thousand  thirty three) to the complainant  within  30 days  from the date of passing the final order  failing which  the entire award money shall carry an interest @8% p.a  from the date of passing  the final order till the date of its realisation.

All Interim Applications  (I.A) stand disposed of  accordingly.

D.A to note in the trial register.

The case is accordingly disposed of.

Let a copy of this final order be supplied to both the parties at free of costs.    

Dictated & corrected by me

 ............................................

                PRESIDENT

(Shri   HARADHAN MUKHOPADHYAY,)                                  ................ ..........................................

                                                                                                                          PRESIDENT

                                                                                                (Shri   HARADHAN MUKHOPADHYAY,)

I  concur,

 ........................................                                                  

          MEMBER                                                                

(SHRI NIROD  BARAN   ROY  CHOWDHURY)