West Bengal

Paschim Midnapore

CC/29/2013

Sri Lila Dhar Jhanwar - Complainant(s)

Versus

The Branch Manager, National Insurance Company Limited - Opp.Party(s)

30 Jul 2014

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                                                                                 

 Complaint case No.29/2013                                                         Date of disposal: 30 /07/2014                               

 BEFORE : THE HON’BLE PRESIDENT :  Mr. Sujit Kumar Das.

                                                      MEMBER : 

                                                      MEMBER :  Mr. Kapot Chattopadhyay.

  

    For the Complainant/Petitioner/Plaintiff : Mr. S. Bhattacharya, Advocate.

    For the Defendant/O.P.S.                           : M. Md. G. Chowdhury & Mr. S.B Das, Advocate.                                   

          

    Sri  Lila Dhar Jhanwar, S/o Late Pransukh Jhanwar, At Rangamati Tantigeria, P.O.  Vidyasagar University, Dist- Paschim Medinipur…………..Complainant

                                                           Vs.

1. The Branch Manager, National Insurance Company Limited, at Inda, P.O. Kharagpur,    P.S.  Kharagpur (T), Dist- Paschim Medinipur
2. Md. India Health Care service (TPA) Pvt. Ltd., S. No. 46/1, E-Space, A2 Building, 3^rd Floor, Pune Nagar Rd., Vadgaonsheri, Pune  411014 (India) Maharashtra………………Ops.

 

          The case of the complainant Sri Lila Dhar Jhanwar, in short, is that a claim of Rs. 7,500/- is demanded from the Op-National Insurance Company on account of surgery cost under mediclaim policy of sum assured Rs. 2 lakhs but an amount of Rs. 28,380/- was paid  which the complainant objected to.  Being aggrieved by and dissatisfaction with such payment the complainant has come before us for relief as categorically mentioned in her petition of complaint.  In this connection, some documents are filed in order to support the claim from the end of the complainant.

            The claim case of the complainant as above is challenged by the Op-Insurance Company by filling written objection stating therein that the case is not maintainable for want of cause of action and the same is barred by principles of estoppels, waiver and acquiescence.  The specific case of the Op is that there were no due correspondences with relevant documents before the Op. The complainant violated the condition of the policy and as such she made a frivolous, fictitious and excessive claim amount.  Since in the light of total expenditure on account of Eye Surgery for correction of vision, cost of lense etc., the alleged claim was duly considered and a rightful,

Contd…………..P/2

 

 

- ( 2 ) -

reasonable and just amount of cost of Rs. 28,380/- has been paid.  Thus, there was no occasion of deficiency in service held against the Ops.    

             

                     Upon the case of both parties the following issues are framed.

 

Issues:

1. Whether the case is maintainable in its present from?
2. Whether the complainant has any cause of action for presentation of this petition of complaint?
3. Whether the case is barred by the principles of estoppels, waiver and acquiescence?
4. Whether the complainant is entitled for getting relief as prayed for.?

 

Decision with reasons

Issue Nos.1 to 4:

              All the issues are taken up together for discussion as those are interlinked each other for the purpose of arriving at a correct decision.

              Ld. Advocate for the complainant made his argument that the terms and conditions as in the medical policy the complainant has incurred an amount of Rs. 57,500/- on account of cost of Eye Surgery and accordingly claim was made in support of all relevant documents.  But the amount so incurred was not properly considered but just a cheque of Rs.28,380/- was given to the complainant.  This is highly irregular and not under the terms and conditions of the policy.  Moreover, the Op failed to assign any bona fide reason as to why the complainant was debarred from getting the actual cost incurred.  It is very clear upon the medical documents that the amount claimed is genuine and not suffered otherwise.  Thus, the complainant is entitled to get rest amount of Rs. 28,500/- with compensation and litigation cost.

              The claim exposed as in the argument on behalf of the complainant is strongly opposed by the Ld. Advocate for the Ops.  It is pointed out in the medical documents that the lense implanted for the complainant is unnecessarily highly cost price which was not essential for the purpose.  In this connection, there is no medical evidence on the point of essentiality so as to accept the lense allegedly implanted for the patient/complainant.  Apart from that, it is the rules of insurance that in case of any medical treatment undertaken by the insurer, the prior information should be given to the Insurance Company for due approval and the Estimate will be sent to the TPA for approval. There is no such steps in terms of the policy regulation was taken by the complainant.  Lastly, the claim settlement was finally held on full satisfaction of the

Contd…………..P/3

 

 

- ( 3 ) -

claimant.  In this connection, the document of claim payment settlement is pointed out by the Ld. Advocate in order to conclude his argument that there is no deficiency in service against the Ops and thereby the case should be dismissed.

                  In reply on law point, it is submitted by the Ld. Advocate for the complainant that the precondition clause relating to the claim for medical reimbursement cannot be imposed, in case of, the same having nor duly communicated to the claimant at the time of purchasing the policy.  In this connection, decision reported in AIR 2012 (NOC) 217 (P&H). 

                   We have carefully considered the case of both parties also in the context of the basic principles laid down in the decision as elaborately explained by the Ld. Advocate for the complainant.  It appears that there exists no legal evidence on behalf of the Op showing that the claimant was duly intimated with the conditions for any claim under the mediclaim policy from the end of Insurance Company at the time of its introduction and initiation. So, question of application of the technical obligations lately indicated is nothing but to deprive of the benefit which the complainant being the policy holder expects from the Insurance Company by virtue of maintaining the same.  This attempt of Insurance Company goes to amount unfair, unreasonable and unjustified towards the bonafide customer.

                      Considering the facts and circumstances it is held and decided that the complainant should get the rest amount of Rs. 29,112/- with litigation cost of Rs. 1,000/-.  Thus, the issues are disposed of in favour of the complainant.             

               Hence,

                           It is Ordered,    

                                               that the case be and the same is allowed  on contest  without cost.

        The complainant do get an award of Rs. 29,112/-(Twenty nine thousand one hundred twelve) only & litigation cost of Rs. 1,000/-(One thousand) only payable by the Ops within 60 days from this date of order in default the complainant will be entitled to get interest thereon @ 9% for the period till its payment.  

Dic. & Corrected by me

              Sd/-                                                Sd/-                                                   Sd/-

         President                                         Member                                             President

                                                                                                                       District Forum

                                                                                                                 Paschim Medinipur.