DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA :  AGARTALA

 

 

CASE   NO:   CC- 42 of 2021

 

1. Sri Dhiraj Dhar,

S/O. Lt. Sudhangshu Ranjan Dhar,,

Of North Joynagar, Agartala, 

P.O.-Agartala, P.S.-West Agartala,

Pin-799001, Dist.- West Tripura …....…....................Complainant.

 

 

-VERSUS-

 

 

1. The Branch Manager,

SBI, General Insurance Co. Ltd., 

Ker Chowmuhani, Agartala,

P.O.- Agartala, Pin-799001, 

 

 

2. Medicare TPA Services(I) Pvt. Ltd.

Paul Mansions, 6, Bishop Lefroy Road, 

Kolkata-700020.............................…....................Opposite parties.

 

 

    __________PRESENT__________

 

 SRI RUHIDAS  PAL

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

DR (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

  WEST TRIPURA,  AGARTALA.

 

SRI SAMIR  GUPTA

MEMBER,

  DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA. 

 

 

C O U N S E L

 

For the Complainant : Sri Kajal Nandi,

  Sri Haridas Datta,

  Advocates. 

For the O.Ps. : Sri Prabal Kumar Ghosh,

  Advocate. 

 

JUDGMENT  DELIVERED  ON: 31/10/2022.

 

J U D G M E N T

The complainant Sri Dhiraj Dhar,  set the law in motion by presenting the petition U/S 35 of the Consumer Protection Act, 2019 complaining deficiency of service committed by the O.Ps.  

  The complainants' case, in brief, is that the Complainant took an Arogya Plus Policy, bearing policy No.0000000011895281, dated 20/02/2019 for himself and for his wife from O.P. Insurance Company. The Policy was issued on 21/02/2019. The Complainant has paid premium amount of Rs.29,143/- on 21/02/2022. As per rules & regulations of insurance company, the Complainant had paid premiums and other payment to the insurance company. Thereafter, O.P. had issued insurance policy No. 0000000011895281 on 20/02/2019 in favour of the Complainant and his wife. But unfortunately on 21/12/2020, the Complainant fell ill and he was admitted to R.N. Tagore International Institute of Cardiac Science in Kolkata for abdominal discomfort. He has incurred expenditure for his medical treatment is Rs.95,036/- only. After discharged from the hospital on 25/12/2020, the Complainant submitted necessary documents i.e. recent prescription and medical bills to the insurance company for reimburse the claim amount of Rs.95,036/- only. But despite of fulfilling all the formalities, the O.Ps. have refused to reimburse the said amount. The O.P. No.2, TPA Pvt. Ltd., Insurance Company have informed the Complainant to submit first prescription along with all related papers since 2019 for further process of claim. It is mentioned here that the Complainant had not consulted to any doctors nor he was being admitted to any hospital since 2019 and there are no such history of deceases or pre-existing disease / symptoms which are violation for cashless claim amount from O.Ps. It is also mentioned here that R.N. Tagore International Institute of Cardiac Science in Kolkata is a TPA Network hospital to avail cashless access. The Complainant had undergone pathological & other test in a pathological laboratory as per desire and direction of the O.P. Insurance Company. Thereafter, the Complainant submitted an application to the insurance company on 27/01/2021 for payment of mediclaim of Rs.95,036/- only. But there are no response from their end. Again the Complainant had submitted an application to the insurance company on 25/02/2021 for payment of mediclaim of Rs.95,036/- only. But O.P. did not take any response in this application also. Thereafter, the Complainant sent a demand notice dated 22/03/2021 and after getting the same the O.P. sent a reply dated 07/04/2021 and inform to the Complainant that due to pre-existing diseases /symptoms he is not entitled to get any cash less benefit from the O.P., the insurer. So, O.Ps. have not yet paid any claim amount although he is having a valid health insurance policy of the SBI General Insurance Co. Ltd. As the Complainant did not get any response from the O.Ps., the complainant  has filed the present complaint before this Commission being the claim amount of Rs.95,036/- and compensation for mental agony and harassment of Rs.85,000/- and Rs.20,000/- for cost of litigation. 

Hence this case. 

The O.P. No.1 SBI, General Insurance Company Ltd. has contested the claim raised by the Complainant by filing written statement refuting the allegations of the Complainant. The O.P. No.1 has denied negligence and deficiency on his part in dealing with the claim of the Complainant. In the written objection it is stated that the Complainant has taken a Arogya Plus Policy bearing No.0000000011895281 for the period between 20/02/2019 to 19/02/2022 and it was a cashless policy. The claim was registered with the O.Ps. through “Medi Assist Insurance TPA Pvt. Ltd under the said policy towards pre-authorization cashless approval for medical management of hypertension, diabetes mellitus from 21/12/2020. That after going through all the claim documents it was found that the insured had history of percutaneous transluminal coronary angioplasty in 2019. Hence considering the past-medical history of the Insured the it was ruled out. That TPA approached the insured several times for asking the exact duration of hypertension, diabetes mellitus in-order to rule out pre-existence and to settle the claim as per policy terms and conditions. That despite of several reminder letters the Insured did not comply with the said requirements as a result claim was denied. It is further stated that there is no deficiency in service on the part of the O.Ps. Insurance Company and alleged by the Complainant and it is prayed to dismiss the complaint. 

        Inspite of receiving notice O.P. No.2 did not turn up.        

 3. EVIDENCE ADDUCED BY THE PARTIES:

The Complainant examined himself as PW-I and submitted his examination in chief by way of affidavit. He has produced 07 documents under a Firisti dated 14/06/2021. On identification the documents are marked as Exhibit-1 series. 

The O.Ps. did not adduce any evidence.  

4.           POINTS TO BE DETERMINED:-          On the basis of contention raised by both the parties following points cropped up for determination:

(I) Whether there is deficiency of service on the part of the O.Ps. towards the Complainant?

(II) Whether the petitioner is entitled to get any compensation?

5. ARGUMENTS OF THE COMPLAINANT SIDE:

      We have heard argument of the Complainant side only. At the time of argument, Learned Counsel Sri Kajal Nandi for the Complainant submitted that O.Ps. have failed to submit any evidence to substantiate their defense. Rather Complainant has submitted examination-in-chief on affidavit and also documentary evidence which are marked Exhibit-1 series. He further submitted that Complainant has been able to prove his claim and the deficiency of service on the part of the O.Ps. So, Complainant is entitled to get compensation as sought for.  

6. DECISION AND REASONS FOR DECISION:

Both points are taken-up together for convenience for decisions. 

We have gone through the pleadings as well as evidence adduced from the side of the Complainant. On perusal of the written objection we found that it is admitted fact that Complainant purchased a Arogya Plus Policy from the O.P. No.1 and period of policy was from 20/02/2019 to 19/02/2022 and it is also admitted fact that Complainant fell ill on 21/12/2020 and he was admitted to R.N. Tagore International Institute of Cardiac Science in Kolkata for abdominal discomfort. He has incurred expenditure for his medical treatment amounting to Rs.95,036/- only. After discharged from the hospital on 25/12/2020 the Complainant submitted necessary documents and the medical bill to the insurance company for reimbursement for the claim of Rs.95,036/- only. 

The reasons for denial is that insured had history of percutaneous transluminal coronary angioplasty in 2019 and TPA approached the insured several times for asking the exact duration of hypertension, diabetes in order to rule out pre-existence and to settle the claim as per policy terms and conditions. 

In the instant case O.P. No.1 submitted written objection but they did not adduce any evidence to justify their denial of the claim. But we found that Complainant in his examination-in-chief on affidavit at Para-1 & 2 stated that before issuing a insurance policy, O.P. No.1 maintained all the necessary formality as well as medical fitness as per desire and direction of them. He had under gone medical test / pathological test in the approved Diagnostic clinic of O.P. No.1 and on being satisfied with the medical report as aforesaid. O.P. No.1 had issued Arogya Plus Policy in his favour. There is no question of pre-existence of any severe disease.  At Para -3 stated that unfortunately he fell ill on 21/12/2020 and was admitted to R.N. Tagore International Institute of Cardiac Science in Kolkata for abdominal discomfort. He had incurred medical expenditure for the above disease amounting to Rs.95,036/- only. After discharged from hospital on 25/12/2020, he submitted all the relevant documents such as recent prescription and medical bills to the insurance company to reimburse the claim amount of Rs.95,036/- only.

        Complainant also submitted the photocopy of the bills voucher and other documents and on perusal of the Exhibit-1 series we find that there are corroborated evidence with the oral evidence and Complainant actually incurred of Rs.95,036/- for the purpose of his treatment but no single farthing was paid by the O.P. No.1 to the Complainant.          

8.         On overall appreciation of the Complainant's evidence we find that the Complainant has been able to prove  his claim and we also found that there are deficiency in service on the part of the O.P. No.1. Hence, it is ordered that O.P. No.1 will pay the medical bill amount of Rs.95,036/-/- as Complainant claimed the amount in the complaint petition and also Rs.20,000/- for causing harassment and mental agony and also litigation costs of Rs.5,000/- i.e. in total of Rs.1,20,036/-(Rs.95,036/- + Rs.20,000/- + Rs.5,000/-). The O.P. No.1 is directed to make the whole payment within 2 month from the date of this judgment and if the payment is not made within 2 month then it will carry interest @ 7% per annum till the payment is made in full. Accordingly, the complaint is partly allowed. 

      Thus the complaint is disposed of.     

  Supply a certified copy of the judgment to both the parties free of cost.    

 Announced.

 

SRI  RUHIDAS  PAL

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA

 

 

DR (SMT)  BINDU  PAL

MEMBER, 

DISTRICT CONSUMER DISPUTES 

REDRESSAL COMMISSION, 

WEST TRIPURA,  AGARTALA

 

 

 

SRI SAMIR  GUPTA

MEMBER,

 DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA.