Govt. of West Bengal
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION -NADIA
170, DON BOSCO ROAD, AUSTIN MEMORIAL BUILDING
KRISHNAGAR, NADIA, PIN 741101, Telefax (03472) 257788
______________________________________________________________________
PRESENT : Shri dAMAN pROSAD BISWAS, PRESIDENT
: SHRI NIROD BARAN ROY CHOWDHURY MEMBER
: SMT MILLIKA SAMADDAR MEMBER
Case No. CC/18/2022
COMPLAINANT : 1. Minor Rupsa Ghosh
D/O Sir Bimal Chandra Ghosh,
Minor represented by guardian father:
Sri Bimal Chandra Ghosh,
Of Ram J.Road, Chasapara,
P.O Krishnagar, P.S. Kotwali,
Dist. Nadia, PIN. 741101.
V-E-R-S-U-S
OPPOSITE PARTIES / OPs 1) The Branch Manager,
National Insurance Company Ltd.
Krishnagar Branch, 17,M.M.Ghosh Street
P.O Krishnagar, P.S. Kotwali, Dist. Nadia, PIN. 741101.
2) The Manager,
Safeway Insurance TPA Pvt. Ltd
2nd Floor, 84 Rashbehari Avenue Kolkata-700026,
Email kolkata@safewaytpa.in
Ld. Advocate(s)
For Complainant: Swapan Ghosh
For OP/OPs : Rajkumar Mondal
Date of filing of the case : 22.02.2022
Date of Disposal of the case : 31.08.2023
Final Order / Judgment dtd. 31.08.2023
Complainant above name filed the this case against the aforesaid OPs u/s 35 of Consumer Protection Act 2019 praying for direction to Ops to pay Rs. 4,35,000/- as compensation along with other relief. He alleged in the petition of complaint that he purchased one Mediclaim Policy namely Parivar Mediclaim. On August 21 his daughter Rupsha Ghosh became ill due to her abdomen and appendix disorder. She was treated under Spectrum Clinic & Endoscopy Research Instituteat 6 A 26 F Neelamber 28 B, Shakespeare Sarani , Kolkata-17. He informed the matter to OP no. 1 with the hope that he would get back incurred expenses amounting to Rs. 4,00,000/- but OP no. 1 refused to pay the same hence he filed this complaint.
Case is running ex-parte against OP no. 2 vide order dtd. 27.07.2022. OP no. 1 contests the case by filing W/V. He denied the entire allegation of the complaint and further contended that National Insurance Company Limited , Krishnagar Branch issued National Parivar Mediclaim Plus Plan in favour of the complainant vide police no. 154001/50/2110000240 for the period from 15.06.2021 to 14.06.2022 subject to terms and conditions, limitations and expedition to the policy. On 14.09.2021 complainant intimated to the OP that her daughter Rupsa Ghosh aged about 16 years was admitted at Spectrum Clinic & Endoscopy Research Institute, Kolkata with diagnostic of pathological appendix, double uterus within non communication horn and underwent diagnostic, Laparoscopy –hysteroscopy- appendectomy during hospitalization and after receiving the said intimation and claim of RS. 1,01,261/- OP no. 1 forwarded same to the OP no. 2 for inquiry and assessment. Thereafter OP no. 2 started inquiry and assessment process and wrote a letter to the complainant on 16.09.2021 with the request to provide some documents but he did not provide the same within the next 10 days Thereafter the OP no. 2 submits his reports before the OP no. 1.
He stated that aforesaid hospital has 5 inpatient beds so this hospital does not fulfil the definition of hospital as per National Parivar Mediclaim Plus-Plan hence they refused the claim.
TRIAL
During trial complainant filed affidavit-in-chief, OP filed questionnaire complainant gave answer OP no. 1 filed affidavit-in-chief complainant filed questionnaire op gave answer.
DOCUMENTS
Complainant produced following documents:
- Copy of collection Receipt dtd. 11.06.2021( five sheets Xerox).
- Copy of advocate letter issued by Swapan Kumar Ghosh addressed to the Manager National Insurance Company Limited, 17, M.M. Ghosh St. Krishnagar-741101, Dist, Nadia. dtd. 12.11.2021 ( two sheets Xerox )
- Copy of letter issued by Branch Manager National Insurance Company Limited addressed to Bimal Chandra Ghosh. Dtd. 25.10.2021. ( one sheet Xerox).
- Copy of letter issued by Bimal Ch. Ghosh addressed to Branch Manager National Insurance Company Limited dtd. 10.08.2021.
- Copy of letter issued by Bimal Ch. Ghosh addressed to Branch Manager National Insurance Company Limited dtd. 20.09.2021.
- A copy of letter issued by SAFEWAY INSURANCE TPA PVT LED addressed to Bimal Chandra Ghosh.
OP produced following documents :
- National Parivar Mediclaim Policy of National Insurance Company Limited.(two sheets Xerox copy).
- Copy of letter issued by Branch Manager National Insurance Company Limited addressed to Bimal Chandra Ghosh. Dtd. 25.10.2021. ( one sheet Xerox).
- A copy of letter issued by SAFEWAY INSURANCE TPA PVT LED addressed to Bimal Chandra Ghosh dtd. 05.10.2021. ( one sheet Xerox).
BNA
Complainant filed BNA. OP filed BNA.
DECISION WITH REASONS
It is admitted position that complainant purchased one policy namely National Parivar Mediclaim Plus Plan from OP no. 1 vide policy no. 154001/50/2110000240 which was valid for the period from 15.06.2021 to 14.06.2022. During the validity of the said policy complainant’s daughter was ill and he was treated as Spectrum Clinic & Endoscopy Research institute and complainant submitted a bill amounting to Rs. 1,01,261/- before the OP no. 1 and OP no. 1 forwarded the same to OP no. 2 and OP no. 2 during the period of his investigation asked the complainant to provide some documents but complainant did not provide the same within 10 days, moreover aforesaid hospital have five beds as per definition of hospital aforesaid Treatment Centre is not a hospital at all.
On perusal of the document dtd. 10.08.2021 we find that complainant informed the OP no. 1 that his daughter namely Rupsa Ghosh will be admitted on 11.08.2021 before the Spectrum Clinic & Endoscopy Research institute. On perusal of letter dtd. 20.09.2021 we find that complainant submitted some documents before the OP no. 1 and OP no. 1 received the same by giving receiving the endorsement. We also find that complainant submitted documents such as x-ray plate, USG film etc. Accordingly we find that complainant complied the direction of OP no. 2. So it is established that the complainant submitted documents as per requirement of OP no. 2.
On perusal of letter d td. 25.10.2021 we find that OP no. 1 repudiated claim and they refused the claim of aforesaid treatment costs as number of inpatient beds were 5 and accordingly, said treatment centre will not be treated as hospital. In the aforesaid document it has mentioned that hospital shall have at least 10 inpatient beds as per section 56(1) of Clinical Establishment Act ( registration and regulation ) but OP no. 1 failed to provide any documents in support of the fact that aforesaid Spectrum Clinic & Endoscopy Research institute has 5 inpatient bed. Even they did not take any initiative to call for any documents from the aforesaid treatment centre. Accordingly it is clear before us that OP no. 1 has failed to prove that aforesaid Spectrum Clinic & Endoscopy Research institute has 5 inpatient beds.
Accordingly, we find that OP no. 1 has failed to assign any cogent reasons in support of refusal of aforesaid claim of Rs. 1,01,261/-.
On perusal of the record we find that complainant is a consumer and OP no. 1 and 2 are the service provider.
Having regard to the aforesaid discussion it is clear before us that complainant has able to established his grievance and he is entitle to relief as per his prayer.
In the result present case succeeds.
Hence,
It is Ordered
that the present case be and the same is allowed on contest against the OP no. 1 and allowed ex-parte against OP no. 2 with cost of Rs. 5,000/- to be paid by OP no. 1 in favour of the complainant.
OP no. 1-2 jointly or severally are directed to pay Rs. 1,01,261/- ( one lakh one thousand two hundred sixty one) in favour of the complainant within 45 days from this date failing which complainant shall have liberty to put this order into execution.
OP no. 1 and 2 jointly or severally are directed to pay Rs. 20,000/- in favour of the complainant for his harassment , metal pain and agony.
Let a copy of this final order/judgment be supplied to both the parties as free of cost.
Dictated & corrected by me
............................................
PRESIDENT
(Shri DAMAN PROSAD BISWAS,) .................................................
PRESIDENT
(Shri DAMAN PROSAD BISWAS,)
We ,concur,
........................................... ............................................................
MEMBER MEMBER
(NIROD BARAN ROY CHOWDHURY) ( MILLIKA SAMADDAR )
