J U D G E M E N T         

              The door of this Forum has been knocked by the Complainant, for redressal arising out of the consumer dispute as per the Consumer Protection Act, 1986.

                In laconic, the case stated in the complaint, is that, the Complainant had obtained a Medi Claim Policy being No. U 149023771, with cashless benefit  under the Opposite Party  and the said Policy was/is duly continuing by paying regular premium without any default.  Suddenly the Complainant became seriously ill due to heart blockage and as per advice of the recognized Doctor the Complainant firstly admitted to the ‘Kamala Roy Hospital’ and thereafter was referred to the ‘Rabindranath Tegore  Institute of Cardiac Science’  wherein her open heart surgery was done on 08.11.2011 and for the said treatment and surgery the Complainant had to spend a sum of Rs. 4,35,987/- only.  

               After taking admission at ‘Rabindranath  Tegore  Institute of Cardiac Science’ the Complainant initiated for cashless facilities to pay the Bill and operation charges but the same was denied by the Opposite Party on the ground of some technical problem but assured to disburse the same after the claim was submitted. After being discharge from the hospital the complainant duly submitted the claim for disbursement of the said amount of Rs. 4,35,487 which she incurred for her treatment and surgery before the Opposite Party on 13.01.2012.

                Thereafter the Opposite Party settling the matter and disbursed a sum of Rs. 77,400/- only out of the total claimed amount of Rs. 4,35,487/- only. Being the housewife and ailing lady the Complainant severally went to the Opposite Party to ask the reason of not getting the cashless facilities and requested them to re-consider her claim in total and the officials of the Opposite Party further assured the Complainant for the same on  February, 2012. But after waiting up to April, 2012 and getting no response from the Opposite Party, the Complainant sent a legal notice on 02.05.2012 to the Opposite Party for reconsidering the said claim but after receiving the same the Opposite Party remained/remains silent till date, what amounts deficiency and/or negligence in rendering service towards him, for which he has to suffer harassment and mental agony and prayed for compensation. Hence, this case is filed seeking adequate redressal.

               Resisting the complaint, the Opposite Parties filed the Written Version denying each and every allegation made by the Complainant in the petition of complaint contending inter alia, that the Complainant has no cause of action and is not maintainable either in fact or in law.

             The specific case of the Opposite Party, in terse, is that, the Complainant had obtained a Medi Claim Policy named “Invest Assure Health Policy” for herself, being Policy No. U 149025771,  issued on 04.05.2009 which required to pay the yearly premium of Rs. 10,106/- only. In November, 2011, the Complainant lodged a claim for Rs. 4,35,487/- only with Left main TVD, postero inferior wall MI with moderate mitral regulation, moderate tricuspid regulation with RV systolic function – CABG done and incision wound infection and gone through surgery. It is found from the documents submitted by the Complainant along with her claim that she was hospitalized for 36 days for which she is entitled to get the claim of Rs. 19,800/- (36 days X Rs. 550/- ) only, for Surgery benefit the Complainant is entitled to get Rs. 11,000/- only, the Complainant was admitted in ICU for 12 days for which is entitled to get Rs. 6,600/- (12 days X Rs. 550/- ) only, the Complainant has the Surgical Benefit Rider attached to the Policy under which she is entitled to get Rs. 40,000/- only and as such the Complainant is entitled to get a sum of Rs. 77,400/- only in total for her such alleged treatment and surgery as per the terms and conditions defined in the said Policy which was duly disbursed to the Complainant by a cheque, being No. 637270,  dated 08.02.2012  as full and final satisfaction and the same was duly received by the Complainant. In spite receiving the legitimate claim amount from the Opposite Party the Complainant has initiated this false and frivolous case.

               Thus the Opposite Parties never intended to deceit the Complainant by any means, therefore there was no negligence or deficiency on part of the Opposite Party in rendering the service towards the Complainant. Thus, the Opposite Party prayed for dismissal of the case.

                           Points for Consideration

  1. Is the complaint maintainable under the C. P. Act ?

  2. Was there any negligence or deficiency in service on the part of the O.P ?                            

  3. Is the complainant entitled to get the relief as prayed for ?

                                         Decision with reasons

               All the points are taken up together for consideration for convenience and brevity.

               The main dispute between the Complainant and the Opposite Party is that whether the Complainant is entitled to get the entire claim amount  and the Opposite Party Insurance Company is liable to disburse the said claim amount in total of the treatment and surgery in favour of the Complainant or not.

               In coming into conclusion regarding the present dispute we have gone through the Complaint and Written Version and also critically appreciated the material documents on record and we have gathered that admittedly Complainant is a consumer under the Opposite Party Insurance company by obtaining a Medi Claim Policy being No. U 149025771, issued on 04.05.2009.

               On overall evaluation of the argument advanced by the Ld. Advocate for the Complainant and of the argument advanced by the Ld. Advocate for the Opposite Party and on critical appreciation of the case record, it is clearly evident that admittedly the Complainant had obtained a Medi Claim Policy under the Opposite Party, vide Policy No. U 149025771, since 04.05.2009 and the said Policy was/is duly renewed time to time by paying the due yearly premium amounting to Rs. 10,106/- only to the Opposite Party and was still in force at the time of submitting the said claim.

             Admittedly the fact remains that suddenly the Complainant became seriously ill due to  blockage in her heart and as per advice of the recognized Doctor the Complainant firstly admitted to the ‘Kamala Roy Hospital’ and thereafter was referred to the ‘Rabindranath Tegore  Institute of Cardiac Science’  wherein her open heart surgery was done on 08.11.2011.

             It is revealed from the photocopies of the documents filed by the Complainant that for the said treatment and Open Heart Surgery the Complainant had to spend a sum of Rs. 4,35,987/- only in total which was never denied by the Opposite Party. 

              The record reveals from the photocopies of the documents filed by the Complainant that after releasing from the hospital the Complainant had duly submitted her claim along with all relevant documents before the Opposite Party and admittedly the Opposite Party after considering the said claim of the Complainant had actually disbursed the amount of Rs. 77,400/- only by a cheque being No. 637270, dated 08.02.2012 in favour of the Complainant and the Complainant had received the same.

              But the fact remains that neither in the complaint filed by the Complainant nor in the Written Version filed by the Opposite Party and/or nowhere in the said Policy Certificate (photocopy of which was submitted by the Complainant) it if found that the amount of sum assured of the said Policy (named “Invest Assure Health Policy” , being Policy No. U 149025771) was actually and ever and specifically written in the said Policy Certificate.

              Moreover, the Opposite Party never denied and/or challenged the ‘claimed amount’ which claim was submitted by the Complainant on the ground that the Complainant is not entitled to get such claimed amount in total as because the said claimed amount was/is not covered by the said Policy.

               On the contrary, the Opposite Party stated that such claim for Rs. 4,35,487/- only with Left main TVD, postero inferior wall MI with moderate mitral regulation, moderate tricuspid regulation with RV systolic function – CABG done and incision wound infection and gone through surgery. It is found from the documents submitted by the Complainant along with her claim that she was hospitalized for 36 days for which she is entitled to get the claim of Rs. 19,800/- (36 days X Rs. 550/- ) only, for Surgery benefit the Complainant is entitled to get Rs. 11,000/- only, the Complainant was admitted in ICU for 12 days for which is entitled to get Rs. 6,600/- (12 days X Rs. 550/- ) only, the Complainant has the Surgical Benefit Rider attached to the Policy under which she is entitled to get Rs. 40,000/- only and as such the Complainant is entitled to get a sum of Rs. 77,400/- only in total for her such alleged treatment and surgery as per the terms and conditions defined in the said Policy which was duly disbursed to the Complainant by a cheque (being No. 637270,  dated 08.02.2012)  as full and final satisfaction and the Complainant had received the same with full satisfaction.

              But the Opposite Party miserably failed to produce any document and/or scrap of paper to show that the Complainant has received the said amount through cheque on her full satisfaction.

            It is appeared from the record that the Complainant just accepted the said cheque dated 08.02.2012 and she sent the legal notice on 02.05.2012  intimating her objection and requesting the rest amount of the said claim.

               So from the above fact and circumstances it should be reasonably hold by the Forum that the Complainant accepted the said disbursed amount with objection and intimating such objection through the legal notice which was duly received by the Opposite Party on 05.05.2012 (which is evident from the AD Card filed by the Complainant as material evidence) but the Opposite Party preferred to remain silent.

             Moreover, the Opposite Party miserably failed to submit the IRDA Guidelines regarding the terms and conditions of any Insurance Policy and the ‘Terms and Conditions’ as stated by the Opposite Party in the Written Version seems some discrepancies in logical deduction. As the Opposite Party stated that the sum allowed/sanctioned by the Opposite Party (Insurance Company) is shown that the rate of normal bed for hospitalization is of Rs. 550/- only per day and the rate for ICU bed is same with normal bed rate i.e. of Rs. 550/- only per day, which is not reasonable and justified at all.

              Manifestly, the purpose of purchase the Mediclaim Policy by the customer/consumer is for getting benefit, when the said customer after his/her medical treatment may get the benefit of adjustment of the medical expenses. But it is not possible for any customer to guess forehead that he has been suffering from any disease, unless it is detected by any doctor, due to sudden exposer of any problem suffered by the customer/ consumer.

              In fact, the MediClaim Policy is a welfare policy and the said Policy is purchased by the customer/consumer, to get protection in his days of treatment and any customer can never predict that, from what type of disease he has suffering at the time of purchasing the Policy and signing the application for purchasing the said Policy.

              No doubt, the MediClaim Policy is a contract or agreement in between the customer/ purchaser and the Insurance Company and so it is the liability of the Insurance Company to accept such proposal form duly filled by the applicant/ customer and it is the duty of the Insurance company to show the amount of sum assured in a prominent place and in prominent letter in the front of the ‘Policy Certificate’ issued by all Insurance company in favour of their consumer/customer and/or Complainant  in this particular case. But they are spreading their trade and collecting huge premium from the customers and have been running their business by adopting an unfair trade practice to determine the claim in a doubtful manner, when the claim is being placed by the applicant before the Insurance Co. for which the said Insurance Company got such ample scope to determine or to settle the claim by observing all relevant papers/documents submitted by the Insured person.

              In such a situation no prudent or reasonable person can believe that the claim of the Complainant which made on the basis of the medical documents/ papers issued by the recognized Medical Institute was/is not true or doubtful one. Moreover the Opposite Party never challenged the said material evidences produced by the Complainant.

                Therefore, in the light of the above discussion, we are of the opinion that the Complainant is entitled to get the relief as prayed for and consequently the points for consideration are decided in affirmative.

                In short, the complainant deserves success.

                In the result, we proceed to pass

                                                                                            O R D E R 

                That the complaint be and the same is allowed on merit against Opposite Party with cost of Rs. 10,000/- only payable by the Opposite party to the Complainant within one month from the date of this order.

                That the Opposite Party is directed to pay a sum of Rs. 3,58,087/- only to the Complainant as the rest claimed amount along with 9 % interest from the date of actual payment,  i.e. from 08.02.2012  till its realization within one month from the date of this ‘Order’.

                That the Opposite Party is further directed to pay a sum of Rs. 20,000/- only to the Complainant as compensation for harassment and mental agony to within one month from the date of this ‘Order’.

                In the event of non compliance of any portion of the order by the Opposite Party within a period of one month from the date of this order, the Opposite Party shall have to pay a sum of Rs. 200/- per day, from the date of this order till its realization, as punitive damages, which amount shall be deposited by the Opposite Party in the Consumer Legal Aid Fund.

                Let copies of the order be supplied to the parties free of cost when applied for.

                 Written & Typed by me.  Chandrima chakraborty, Member.