Hon’ble Mrs. Rumpa Mandal, Member.
The pith and substance of the case is that the complainant Prabhat Singh Sarkar was medically treated for the disease of cysts at Siliguri and subsequently Tata memorial Hospital, Mumbai for better treatment. The Complainant incurred huge medical expense for his treatment. Subsequently, the Complainant submitted a claim as per mediclaim policy no 153901502010000065 and terms & conditions of the OP to the branch Manager, National Insurance Co. Ltd. which the O.P. duly received as per the mediclaim policy the Complainant is entitled to get the amount of mediclaim and the O.P. is bound to pay the same. On 31.12.20 the O.P. issued a letter to the complainant to furnish some information . The Complainant duly answered the same to the O.P. Despite receiving the application & the medical document, the O.P. willfully delayed to settle the mediclaim. Accordingly the complainant suffered in-reparable financial loss which is deficiency in service on the part of the O.P .The cause of action arose on 15.01.21 and on subsequent dates. The complainant prayed for an award for Rs.62,500/- with interest from the O.P. and Rs.50000/- towards deficiency in service.
O.P. contested the case by filing written objection denying all the allegations against them. The positive defence case is that the complainant has not presented the whole fact in specific manner. It is vague and the Complainant is put to this strict proof thereof. The complainant is totally silent about his disease. So the instant case is liable to be dismissed with cost.
The respective case of the Parties demand for ascertainment of the following points.
POINTS FOR CONSIDERATION
- Is the case maintainable in its present form and prayer?
- Is the Complainant entitled to get relief as prayer for ?
- To what other relief if any the complainant is entitled to get?
DECISION WITH REASONS
Point No.1.
The pleading of the parties disclosed that the Complainant purchased mediclaim insurance from the O.P. . There is no denial about the said mediclaim insurance by the O.P.
Accordingly, the Complainant is a consumer under the C.P. Act. Except some evasive denial there is no specific case of O.P. as to why the case is not maintainable.
Ld. Defence Counsel however raised an objection that the present case is filed u/sec.12 of the C.P. Act which ought to be U/sec. 35 of the C.P. Act.
Ld. Advocate for the Complainant strongly objected to the same on the ground that the O.P. has not stated in the W/V about the said objection.
After perusing the case record , it transpires that at the time of admission hearing of this case Ld Advocate submitted that due to inadvertence and typographical mistake of the typist in copy paste manner it was typed as Sec 12 instead of Sec.35 of C.P. Act.
As per the order of the commission it was admitted with the consideration that the case was filed u/Sec. 35 of the C.P. Act.
Ld. Advocate for the complainant also argued that the entire case should be considered as a whole & not on the basis of a particular line or word.
Due consideration is given to the argument advanced by the parties. The said defect is thus considered as is a typographical mistake due to inadvertence, since sec.12 is now obsolete and as such the present case should be considered as Sec. 35 of the C.P. Act.
It is also important to consider that the O.P. never filed any petition for challenging the maintainability of the case. The O.P. has just evasively denied the case of complainant.
Thus ,having perused the pleadings and the evidence on record, the commission is of the view that the case is maintainable in its present form and prayer. Point No.1 is accordingly answered infavour of this Complainant
Point No.2 & 3.
Both the points are taken up together for brevity and convenience of the discussion. It is the admitted fact that the Complainant purchased mediclaim insurance under the O.P. having Policy No.153901502010000065.
The O.P. has not denied the said fact . It is the specific case of the complainant that after treatment at Siliguri for his disease of cysts, the Complainant was medically treated at Tata memorial hospital, Mumbai on 29.12.20. The Complainant proved the final report dt.29.12.20 at Tata Memorial Hospital Mumbai issued by Doctor Kajari Bhattacharjee and Doctor Jeba Nazneen. The Corresponding note of the doctor dt.30.12.20 is also proved .The Complainant categorically stated that he claimed medical insurance against his medical expenses. The letter dt.15.01.21 stands proved which was issued by the Complainant O.P. Company.
The O.P. Company responded to the said letter but did not give any relief. Instead they demanded more information.
The documents proved by the complainant suggest that the complainant had incurred expenses for his treatment at Siliguri and Tata Memorial hospital. The policy is effective from 27.04.20 to 26.04.21. So the treatment of the complainant at Tata Memorial Hospital on 29.12.20 & 30.12.20 is well within the validity of the mediclaim insurance.
Thus the Complainant is entitled to get his claim of Rs.62,500/- towards medical treatment which is reasonable & proper.
Except some evasive denial of the claim of the O.P. could not discard the evidence of the complainant.
Instead questionnaires put by the OP in cross-examination dt 23.08.22,the complainant duly answered that he was admitted on 28.12.20 &discharged on 30.12.20 from Tata Memorial Hospital . He also stated in cross examination that he submitted written complaint to the Medi Assist Insurance TPA Ltd. on 15.01.22.
The complainant categorically answered in cross examination that he spent to Rs.62,500/-.
Answer given in cross-examination has special significance and due weight . So the claim of the complainant for Rs.62,500/- is duly proved.
In the light of the above assessment of evidence the case of the Complainant is considered to have been duly proved.
Point No.2 and 3 are accordingly are answered in positive.
In the result the complaint case succeeds with costs.
Hence, it is
Ordered
That the Complaint case No. CC/8/2022 be and the same is allowed on contest with cost Rs.5,000/- .
The Complainant do get on award Rs.62,500/- against the O.P. The O.P. is directed to pay Rs.67,500/- to the complainant within 30 days from the date of passing the Final Order failing which the award money shall carry an interest of 8% per annum from the date of passing order till realization.
D.A to Note in the trail Registrar.
Let plain copy of this order be supplied to the parties concerned by hand/by post forthwith, free of cost for information and necessary action, if any.
The copy of the Final Order is also available in the official Website www.confonet.nic.in.
Dictated and corrected by me.
