Ld. Advocate(s)
For Complainant: Debraj Das
For OP/OPs : None
Date of filing of the case :09.12.2020
Date of Disposal of the case :16.03.2023
Final Order / Judgment dtd.16.03.2023
Complainant Piyali Raha Dey filed the present complainant against the aforesaid opposite parties under section 35 of the Consumer Protection Act, 2019 alleging deficiency in service and praying for proper insurance claim, compensation amounting to Rs.10,00,000.00(Rupees Ten lakh) and cost of the case amounting to Rs. 20,000.00(Rupees Twenty thousand).
It is the allegation of the complainants that their predecessor i.e husband of complainant No.1 and father of complainant no.2 had purchased one Medical Insurance Policy from the OPs vide policy no.154302501810001012 valid from 14.09.02018 to 13.09.2019 for him along with complainant no.1 & 2 for the sum assured Rs.2,00,000.00.
Said Praloy Kumar Dey at first purchased the policy on 11.09.2013 and thereafter he continued the said policy by renewing the same.
On 24.04.2019 said Praloy Kumar Dey became seriously ill with a probable diagnosis with CJD i.e one type of neurological disorder and he continued his treatment before institute of neuro-science, Kolkata from 24.04.2019 to 25.05.2019 and also spent Rs.8,26,376.00.
Thereafter said Pralaoy Kumar Dey had further admitted at SSKM Hospital, Kolkata for further treatment and lastly he died on 29.08.2019 living behind the complainant no.1 & 2 as his legal heirs.
Complainant No.1 sent all necessary documents to the OPs on 26.04.2019 and also submitted claim form on 27.08.2019. Complainant no.1 visited the Branch office of OP No.1 for getting Insurance claim but did not get any fruitful reply. Hence, this case.
(3)
On perusal of order no. 7 dated 17.06.2022 we find that OP No.1 did not turn up before this Commission in spite of receipt of the notice on 29.01.2021. We also find that OP No.2 did not turn before this Commission in spite of receipt of Notice on 01.02.2021. As per said order case is running ex-parte against OP No.1 & 2.
Trial
During trial complainant No.1 Piyali Raha Dey filed affidavit in chief. She also produced certain documents.
Documents
Following documents have been produced viz :
- Document of Institute of Neurosciences Kolkata dtd.25.05.2019(Discharge on risk bond).....(Two sheets).....(Xerox)
- Document of IPD Provisional Bill...................(Sixteen sheets).............(Xerox)
- Document of Detailed Bill.........(Four sheets)........(Xerox)
- Document of IPD Provisional Bill.....(Two sheets).....(Xerox)
- Document of Department of Pathology..........(Eight sheets)...(Xerox)
- Document of MRI of Brain............(One sheet)........(Xerox)
- Document of 3D TOF MR Angiogram of Brain.....(One sheet)...(Xerox)
- Document of X-Ray Chest (AP View) Portable....(One sheet)...(Xerox)
- Document of Department of Pathology.....(One sheet)....(Xerox)
10) Document of Rothshield Insurance TPA Ltd....(One Sheet)...(Xerox)
11) Document of Claim Form.....(Two sheets)....(Xerox)
12) Document of Certificate of Death.....(One sheet)....(Xerox)
13) Document of Parivar Mediclaim....(Two sheets)....(Xerox)
14) Document of Tax Invoice.....(One sheet).....(Xerox)
15) Document of Parivar Mediclaim....(Two sheets)....(Xerox)
16) Document of Tax Invoice.....(One Sheet).....(Xerox)
17) Document of Collection Receipt....(One sheet)....(Xerox)
18) Document of National Insurance Company Ltd....(Two sheets)....(Xerox)
19) Document of Receipt of Speed Post.....(One sheet)...(Xerox)
20) Document of Petition under RTI ACT 2005......(Three sheets)......(Xerox)
21) Document of Track Consignment......(One sheet).......(Xerox)
(4)
22) Document of complain letter before CAD.....(One sheet).....(Xerox)
23) Original Copy of Death Certificate of Praloy Kr. Dey......(One sheet)
24) Original Copy of Policy valid from 11.09.2013 to 10.09.2014.....(One sheet)
25) Original Copy of Policy valid from 11.09.2014 to 10.09.2015.....(One sheet)
26) Original Copy of Policy valid from 11.09.2015 to 10.09.2016.....(One sheet)
27) Original Copy of Policy valid from 14.09.2016 to 13.09.2017.....(One sheet)
28) Original Copy of Policy valid from 14.09.2017 to 13.09.2018.....(four sheets)
29) Original Copy of Policy valid from 14.09.2018 to 13.09.2019.....(four sheets)
Brief Notes of argument.
Complainant in support of his case filed Brief Notes of Argument.
Argument
Ld. Adv. for the complainant argued before this commission that deceased Praloy Kumar Dey purchased the aforesaid policy from OP No.1 for the sum assured Rs.2,00,000.00. He continued his treatment before Institute of Neuroscience, Kolkata and spent huge amount relating to said treatment. Complainant No.1 claimed the policy amount from the OP No.1 and deposited all the documents before the OP No.1. She got one reply from OP No.2 dated 02.08.2019 and thereafter, she again submitted claim form but till date she did not get any amount from the OPs.
Decision with Reasons
It is the allegation of the complainant that deceased Praloy Kumar Dey purchased the aforesaid policy from OP No.1 for the sum assured Rs.2,00,000.00. He continued his treatment before Institute of Neuroscience, Kolkata and spent huge amount relating to said treatment. Complainant No.1 claimed the policy amount from the OP No.1 and deposited all the documents before the OP No.1. She got one reply from OP No.2 dated 02.08.2019 and thereafter, she again submitted claim form but till date she did not get any amount from the OPs.
On perusal of original medi-claim policy issued by OP No. l we find that said policy was valid for the period from 14.09.2018 to 13.09.2019. Name of insured persons have mentioned therein as Praloy Kumar Dey, Piyali Raha Dey and Plaban Dey. Floater sum insured is Rs.2,00,000.00. From said document it is clear before us that said policy was valid of the period from 14.09.2018 to 13.09.2019.
(5)
On perusal of discharge on risk bond issued by Institute of Neuroscience, Kolkata, we find that policy holder of the aforesaid policy namely Praloy Kumar Dey continued his treatment before the said Institution for the period from 24.04.2019 to 25.05.2019 under Doctor Hrishikesh Kumar (MD, DM).
On perusal of details bill, we find that complainant No.1 spent Rs.8,78,719.00 relating to aforesaid treatment of said Praloy Kumar Dey.
On perusal of letter issued by OP No.2 dated 02.08.2019 , we find that they directed to submit properly fill up claim form with all details relating to exact claim amount and also directed to produce all documents relating to treatment.
On perusal of claim form, we find that said document has been filed before the office of OP No.2 through the said document complainant No.1 claimed Rs.3,80,000.00.
On careful perusal of the aforesaid policy, we find that policy amount has mentioned therein as Rs.2,00,000.00. We find that complainant No.1submitted bill before the office of OP No.2 who is the representative of OP No.1 praying for policy amount. As per argument of Ld. Adv. for the complainant OP No.1 & 2 not yet paid the policy amount in favour of the complainants nor they assigned any reason as to why they did not allow the claim of complainants. On perusal of Xerox copies of medical bills we find that Institute of Neuroscience, Kolkata claimed bill amounting to Rs.8,78,719.00 relating to treatment of Praloy Kumar Dey for the period from 24.04.2019 to 25.05.2019. But as per aforesaid policy complainant no.1 is entitled to Rs.2,00,000.00 from the OP No.1 & 2.
Having considered the facts and circumstances of this case, evidence of records and documents on record we find that complainants have able to establish that they are entitled to policy amount i.e. Rs.2,00,000.00 from the OP No.1 & 2. In the result present case succeeds.
Hence,
It is
Ordered
that the present case be and the same is allowed ex-parte against OP No.1 & 2 with cost of Rs.3000.00(Rupees three thousands) to be paid by OP NO. 1 &2 in favour of the complainants.
OP No.1 &2 jointly or severally are directed to pay Rs.2,00,000.00 in favour of the complainants within one month from this date failing which complainants shall have liberty to put this order into execution.
(6)
OP No.1& 2 jointly or severally are directed to pay Rs.10,000.00(Rupees Ten thousand) to the complainants as compensation for their physical harassment and for their mental pain and agony within one month from this date of order failing which complainants shall have liberty to put this order into execution.
Let a copy of this order be supplied to the complainant as free of cost.
Let a copy of this order be sent to OP NO.1-2 for compliance.
Dictated & corrected by me
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PRESIDENT
(Shri DAMAN PROSAD BISWAS,) .................................................
PRESIDENT
(Shri DAMAN PROSAD BISWAS,)
I concur,
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MEMBER
(NIROD BARAN ROY CHOWDHURY)
