Order No. -30                                       FINAL ORDER                                   Dt.-23/11/2015

Smt. Bina Choudhuri, Member

             Case of the complainant in brief is that he purchased Janata Mediclaim Policy being no.51230434120600000058 from the OP National Insurance Com. Ltd. That policy was valid on & from 19/072010 to 19/07/2011. The complainant and his wife were covered by the said policy. The complainant renewed that policy on 18/17/’12 and the date of coverage of the policy was extended from 20/07/2012 to 19/07/2013. On 02/03/2013 the complainant fell in ill all on a sudden. He went to Kolkata for his treatment getting no relief from local doctors and he was admitted to Mediview Nursing Home 74 Broad Street Kolkata-700019 on 15/03/2013. Under Dr. Rajarshi Banerjee and Cystic Lesion of Mandible was detected  and he was released from that Nursing Home on 18/03/2013 after complete treatment and he had to spend Rs.36,439/- for his treatment. Therefore the complainant submitted his claim of Rs.36,439/- to OP along with all necessary document for settlement of his said claim. After long silence the TPA of the OP most arbitrarily and wrongly repudiated his claim on 01/10/2013. Hence, this case.

               The OP has resisted this case by filing  W/V denying & disputing the claims and contention of the complaint with prayer for dismissal of the case with cost.

                The specific stand of O.P. is that Cystic of  Lesion of Mandible was dental disease and was not covered under the policy in question and as such their TPA has rightly repudiated the claim of complainant by following the provision laid down in the permanent exclusions clause of policy being number 4.4.5

POINTS FOR CONSIDERATION.

1. Is the case maintainable both law and fact?
2. Is the complainant a consumer?
3. Is the repudiation made by TPA of the OP Insurance Com. Of the claim of the complainant was proper?
4. Is the O.P.  guilty for deficiency in service as alleged?
5. Is the complainant entitled to get the reliefs as prayed for?

DECISION WITH REASONS

                 All points are taken up together for consideration and decision for the sake of brevity.

                 We have perused the petition of complaint, the Written Version, evidence on record, written argument filed by both sides and all other documents on record.

    We have also heard the arguments of both sides in full.

               We find that the O.P. has challenged the maintainability of the case in its written version stating that “Cystic Lesion of Mandible” disease was dental disease and it was/is not covered under the policy.

                From the case record we find that the complainant is a bonafide policy holder of the Janata Mediclaim policy for hospitalization benefit of the opposite party. The New India Assurance Co.Ltd. Jalpaiguri Branch, Vivekananda Bipanan Kendra, 1^st Floor, Race Course para, P.S. Kotwali, P.O. and Dist.- Jalpaiguri, Pin.-735101 being policy no. 51230434120600000058 covering the period from 20/07/2012 to 19/07/2013 for a sum assured Rs.50,000/-. So we have no hesitation to hold that the complainant is a consumer. We also find that the case was filed on 10/01/2014 i.e. within the period of limitation of two years from date 15/03/2013 when the complainant got admitted in the Hospital, Mediview Nursing Home (P) Ltd. on which cause of  action has been arisen. In the point of illness and claim of the complainant submitted that the complainant all on a sudden fallen ill on 02/03/2013 and without getting relief from local doctor he went to Kolkata and was admitted to “Mediview Nursing Home” 74, Broad Street, Kolkata-700019 on 15/03/2013 under treatment of Dr. Rajarshi Banerjee. There he underwent surgery for a “Cystic Lesion  of Mandible” and was discharged on 18/03/2013. The expenses of Treatment was Rs.36,439/- and after releasing from nursing home the complainant claimed the amount of Rs.36,439 from O.P. Insurance Company but on 01/10/2013 Medicare TPA Services(I) Pvt. Ltd. repudiated the claim of the claim in writing on the ground that that the dental treatment or surgery is excluded from the coverage of policy, arbitrarily and wrongly.

                  In reply the ld. Lawyer for the Opposite party argued that Dr. Rajarshee Banerjee never opined that “Cystic Lesion of mandible” was not dental disease/problem. The Ld. Lawyer argued that the treatment was done for dental problem and the said disease was not covered under the policy. So the complainant is not entitled to get the benefit under the policy and the O.P. rightly repudiated the claim and there is no Unfair Trade practice or Deficiency in service on the part of the O.P. and TPA of the O.P. But the Ld. Lawyer for the O.P. argued that if any how if the O.P. is found liable then the maximum liability of the O.P. will be Rs.18,999/- as per schedule of payment for other surgeries (Intermediate surgery) as stated in his Written version in paragraph no.12.

                 After due consideration of materials on record, Insurance Policy evidence of doctor Bikram Talukdar BDS Consultant Dental surgeon examined on behalf of complainant, certificate of doctor Rajarshi Banerjee MDS, MOMS RCPS Oral and Maxillo facial Surgeon Registration number 1330 of WBDC, filed by complainant and the arguments of the Ld. Lawyers of both sides we find that the disease of the complainant was Cystic Lesion Mandible at body and gum and no dental surgery of the complainant was performed by Dr. Rajarshi Banerjee, MDS Oral and Maxillo facial Surgeon by applying Maxillo facial procedure. So we opine and hold that the complainant was not a patient of dental problem . We also find that the O.P. insurance company in his Written Version ultimately admitted the part liability of claim of the complainant and is ready to pay Rs.18,999/- only as per schedule of payment for other surgeries (Intermediate surgery) to the complainant. But it is surprising that previously the O.P. clearly denied their liability and they repudiated the claim which is gross deficiency in service and /or Unfair Trade Practice committed by the O.P. Insurance company which causes tremendous pain, sufferings and loss to the complainant.

                 From the aforesaid discussions we are of the opinion that the O.P. Insurance Company is liable to pay the claim amount to the complainant for his Unfair Trade Practice and Deficiency in Service and the complainant is entitled to get the reliefs as specified below.

       All  points are disposed of.

       In the result the case/application succeeds

       Hence, it is

O R D E R E D

                  that the C.C. 05/2014 u/s 12 of C.P.Act filed by the complainant is allowed on contest in part against the O.P. New India Insurance Co.Ltd. with litigation cost  of Rs.2,000/-(Two Thousand) only.

                   The complainant do get an award of Rs.36,439/-(Thirty Six Thousand Four Hundred and Thirty Nine) only for hospitalization benefit from the O.P. Insurance Company Ltd.

                   The complainant do get further award of Rs.3000/- against the O.P. Insurance Company Ltd. for deficiency in service and/or Unfair Trade Practice, mental pain, agony, harassment suffered by the complainant.

                    The O.P. New India Insurance Co.Ltd. is hereby directed to pay the complainant the aforesaid awarded amount alongwith cost (Rs.36,439/- + Rs.3000/- + Rs.2000/-) = Rs.41,439/-(Forty One Thousand Four Hundred and Thirty Nine) only in total within thirty days from the date of this order, failing which it will carry interest @9% p.a. till realization of the amount and the complainant shall be at liberty to realise the same by putting this order into execution in accordance with law.

                     Let copy of this final order be supplied free of cost forthwith to the parties/ their Ld. Advocates/agents on record by hand under proper acknowledgement/sent by general post, in terms of Rule 5(10) of West Bengal Consumer Protection Rules 1987.