In the District Consumer Disputes Redressal Forum,

Murshidabad at Berhampore.

Case No. CC/06/2014

Date of filing: 06 /01 /2014                                                                             Date of Final Order:15/07/2015

 Tanmoy Das,

 S/O- Late  Gajanan Das.

 48/A,Joychand Road.

 P.O.- Khagra., P.S.- Berhampore.

 Dist- Murshidabad, PIN.-742103.(W.B.)………………………………………………………...Complainant             

                                                  Vs

 1).The Branch Manager, The New India Assurance Co. Ltd.

     37A, R.N.Tagore Road.,P.O.+ P.S.- Berhampore,

     Dist. Murshidabad.PIN.-742101.

2). The Manager, Heritage Health TPA PVT. LTD.

      Nicco House ( 5^th Floor),2 Hare Street, Kolkata-700001……………………….   Opposite Party

Mr.Tanmoy Das In Person.

Mr.Subhanjan Sengupta. Ld. Advocate…………………for the Opposite Party.

                      Present:   Hon’ble President, Anupam Bhattacharyya.           

                                        Hon’ble Member, Samaresh Kumar Mitra.           

                                        Hon’ble Member, Pranati Ali.           

FINAL ORDER

Samaresh Kumar Mitra, Presiding Member.                  

                 The brief facts of the complainant is that he purchased a Mediclaim Policy (Hospitalization Policy) being No.51290034130100 00 0010 that started on 08.4.2011 and  coverage period till 07/04/2014 under the New India Assurance Co. Ltd , 37A, R.N. Tagore Road, Berhampore, Murshidabad. The complainant submitted a medi-claim amounting to Rs.56, 763.00 on 10.7.13 for the treatment of her wife namely Sonali Das as her left femur was operated. The said medi-claim has been refused i.e. claim file closed by the Insurance Company. The complainant came to know on 16.5.2015 that left neck femur of his wife has broken after conducting Ex-Ray . An operation took place in the left Femur of Mrs. Sonali Das on 4.6.2013 at Rameswara Nursing Home Pvt. Ltd at Ultadanga, Kolkata, he filed all necessary documents with prescribed format to the Company by the concerned agent. As he was denied by the receiving section to the Insurance Company so he compelled to file his claim by the concerned agent. On the false pretext the company refused the medi-claim of the complainant and a letter in this subject was sent to this complaint on 10.09.2013 by Heritage Health TPA Pvt. Ltd, Nicco House, Hare street Kolkata-700001.So, this complainant in a helpless situation came to this Forum for getting Redressal in different heads as stated in the Redressal heads amounting to Rs.95,923.00.

               The OP No.1 after getting notice from the Forum appeared by its advocate and filed written version in which he denied the allegation as levelled against him. Despite receiving notice OP No.2 did not turn up so the proceeding runs ex-parte against the Op No.2.

            The case of the Opposite Party, in brief, is that the complainant had procured one medicliam policy and  as per the mediclaim policy condition, the Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist Fees are reimbursable but the payment shall be reimbursed provided the insured pays such fees through cheque and the Surgeon/Anaesthetist provides a numbered bill. Bills given on the letter-head of the Surgeon, Anaesthetist would not be entertained. The TPA shall upon getting the related medical information from the insured person/network provider, verify that the person is eligible to claim under the policy and if satisfied, will issue a preauthorization letter to the Hospital/Nursing Home mentioning the sum  guaranteed . The TPA reserved the right to deny pre-authorization in case the insured person is unable to prove the relevant medical details as required by the TPA. The complainant was asked for several times through letters dated 20.7.13, 05.08.13, 24.08.13 to comply the necessary requirements and to supply all the relevant documents but the complainant failed to supply the required documents. Ultimately, the TPA vide letter dated 10.09.2013 opined the claim as closed. The OPs have no negligence or deficiency in service. The complainant’s case is liable to be dismissed with cost. 

         The complainant filed evidence on affidavit in which he demanded that by filing written version the OP No.1 tried to turn the case from its actual way, leaving the key points. He also averred that all the expenditures as mentioned in petition are reasonable and justified rather it is less than actual expenditure. He also made all possible correspondence with opposition by giving reply with supplying documents with his best effort.

        The complainant was absent since 30.10.2014 and no steps taken on his behalf till date so this Forum directed him to file show cause as to why the complaint should not be dismissed due to non prosecution but no show cause filed by him.

        That on 26.06.2015 the advocate on behalf of the OP No.1 advanced argument which is heard as ex-parte and taken up the case record for passing Final Order on 8.07.2015 on merit.  As the final order is not ready on 08.07.2015 so another date is fixed on 15.07.2015 for passing final order.

From the discussion herein above, we find the following Issues/Points for consideration.

ISSUES/POINTS   FOR   CONSIDERATION

1).    Whether the Complainant Tanmoy Das is a ‘Consumer’ of the opposite party?

2).    Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?

3).    Whether the O.P. carried on unfair trade practice/rendered any deficiency in service towards the Complainant?

4).   Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to him?

5).   Whether the complainant is entitled to relief(s) as prayed for?

                                                     DECISIONS WITH REASONS

                    In the light of discussions herein above we find that the following issues/points should be decided based on the above perspectives.

  1).Whether the Complainant Tanmoy Das is a ‘Consumer’ of the opposite party?

                From the materials on record it is transparent that the Complainant is a “Consumer” as provided by the spirit of section 2(1)(d)(ii) of the Consumer Protection Act,1986. As the complainant herein being the customer of OP is entitled to get service from the OPs.

 (2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?

              Both the complainant and opposite party are residents/carrying on business within the district of Murshidabad and cause of action took place at Berhampore, Murshidabad. The complaint valued at Rs.95923.00 ad valorem which is within Rs.20,00,000/-limit of this Forum. So, this Forum has territorial/pecuniary jurisdiction to entertain and try the case.            

    (3).Whether the opposite party carried on unfair trade practice/rendered any deficiency in service towards the Complainant?

              After perusing the Complaint Petition, Written version and Evidence on Affidavit  as filed by the complainant and OP and the documents as filed by the complainant during the time of filing the complaint petition and hearing the argument as advanced by the agent of the OP No.1 it appears that  the complainant availed of mediclaim policy before the OP No.1 and within the coverage period the wife of the complainant suffered injury in neck femur and at the advice of the treating doctor she was operated in the Rameswara Nursing Home Pvt. Ltd. at C.I.T.Scheme-VIIM(Ultadanga), Kolkata-700054. She was operated by the treating doctor namely Dr. N.C. Ghosh on 04.06.2013 by implanting gadgets like screw, barrel & plate which is termed as Titanium DHS implantation and instrumentation.  During & after the operation a lot of investigation required for the patient and he/complainant purchased a lot of medicines and operation equipments for which he compelled to expend money and the bill/receipts are annexed herewith. The treating doctor also received the fees and operation charge from the complainant and the receipt is given in his letter head which is used as bill. The complainant deposited the claim form along with bills of medicines and other expenditures before the OP No.2 regarding the operation of his wife who was also insured before the OP No.1 but the OP No.2 by a letter dated 10.09.2013 informed this complainant that the claim submitted by him has been found to inadmissible as per the terms and condition of his policy. And the reasons for closure as, after sending several letters to the insured, the insured is not submitting the required documents, so the claim will be closed. But also stated that he/complainant has right to appeal against the rejection to the Insurance Company whose decision in this regard will be final and binding.  After perusing the Mediclaim Policy(2007) it appears that the reasonable, customary and necessary Surgeon fee and Anaesthist fee would be reimbursed, limited to the maximum of 25% of sum Insured. The payment shall be reimbursed provided the insured pays such fee (s) through cheque and the Surgeon / Anaesthetist provides a numbered bill. Bill given on the letter head of the Surgeon, Anaesthetist would not be entertained.

       So the OP No.2 refused the claim of the complainant in accordance with the provisions of the policy but advised to approach before the OP No.1 as an appeal whose decision is final regarding this claim. 

         After perusing the documents and others and hearing the argument of the advocate of the OP No.1 we are in a considered opinion that the complainant could not produce papers as per the requirements of the OP No.2 but it is transparent that her wife was operated before an Orthopaedics namely Dr. N.C.Ghosh and as per his advice the complainant followed pre, par and post operative measures for which a lot of money have to expend and the bills were furnished but not numbered one and the complainant meet the fees of the doctor on cash which is received by the doctor in his  letter head. The bonafide of the complainant cannot be questionable and the bill of the doctor is trustworthy and his claim amount is not exorbitant so we cannot disbelieve the claim of the complainant.

          Inspite of the bar as referred by the Ld. Advocate for the OP NO.1 as payment of fees by cash on the basis of above discussion as well as considering the meagre amount of operation fees and receipts of the same by the own hand of the doctor we have no alternative but to conclude that the complainant is entitled to get the actual medical expenditure amounting to Rs.70,923/- supported by documents already filed  and cost of Rs.1,000/-.  

4.  Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to him?

            The discussion made herein before, we have no hesitation to come in a conclusion that the Complainant is entitled to get the insurance claim as mediclaim from the OP No.1 as he made expenditure for the treatment of her wife who was insured before the OP No.1 insurance company.

 5. Whether the complainant is entitled to relief(s) prayed for?

               As it is already proved in the discussion at point No. 3, the deficiency in service by the Opposite Party cannot be ousted as such the Complainant is entitled to get relief(s).

               Hence, it is ordered that the complaint be and the same is allowed on contest against OP No.1 Insurance Company and be dismissed against the OP No.2 with Rs.1000/- as to cost to be paid by the OP No.1 to this complainant.

                The OP No.1 is directed to pay a sum of Rs.70,923.00 to this complainant, the money which is incurred for the treatment of her wife within 45 days from the passing of this order.

The OP No.2 is exonerated from his liability. 

            No other relief (s) is awarded to the complainant.

            At the event of failure to comply with the order the Opposite Party No.1 shall pay fine @Rs.50/- for each day’s delay, if caused, on expiry of the aforesaid days if any, in the ‘Consumer Legal Aid Account’.

            Let plain copy of this order be made available and be supplied, free of cost, to the parties on contest in person, Ld. Advocate/Agent on record, by hand under proper acknowledgement/ be sent forthwith under  registered post to the concerned parties as per rules, for information and necessary action.

Dictated and Corrected by me.

      Member,                                                 Member,                                                     President,

   District Consumer Disputes              District Consumer Disputes                    District Consumer Disputes                                      Redressal Forum, Murshidabad.     Redressal Forum, Murshidabad             Redressal Forum, Murshidabad.