Jharkhand

Bokaro

CC/16/99

Mahendra Kumar Somani - Complainant(s)

Versus

The Branch Manager, The Oriental Insurance co. Ltd. - Opp.Party(s)

Aman Sharma

27 Jul 2018

ORDER

Complainant Mahendra Kumar Somani Filed this case for a claim of Rs. 21,575/- with 18% interest p.a. from the date of intimation of treatment. He also claimed compensation of Rs. 1,50,000/- for business loss and mental harassment and litigation cost of Rs. 20,000/-

2.        The case in short is that the complainant had purchased a Mediclaim policy from O.P. M/S Oriental Insurance Co. Ltd. on 19-08-2014, having Happy family Floater policy No. 311504/48/2015/2541 valid from 22-08-2014 to 21.08.2015 for a sum assured of Rs. 2,00,000/- (Two Lakhs).

            The Complainant due to chest pain was admitted at Rabindranath Tagore Internation Institute of Cardiac Science, Kolkata on 15-06-2015 and underwent the coronary Angiogram and discharged on 16-06-2015. The insurance co. as well as T.P.A. Vipul Medicorp Pvt. Ltd. were informed by the hospital, listed in the insurance Co. for cashless facility. On 25-06-2015 complainant submitted all the bills and the discharge summary to T.P.A. with a letter to condone delay by Insurance Company but the claim was repudiated without any bound ground and no claim.

            TPA had issued two letters dt. 8-07-2015, 11-08-2015 for queries which was replied on 07-08-2015 and 25-08-2015 by the Complainant.

            Then on 14-09-2015, Insurance Company issued a letter regarding clarification with 15 days else the claim would be repudiated. Complainant had also replied on 21-09-2015 but thereafter, there was no reply. Then on 25-04-2016, Complainant send a letter to return the original paper. This is a deficiency in service on minor ground if any.

            Then, legal notice was sent on 23-07-2016 to O.Ps but O.Ps did not reply.

3          Complainant filed following document in support of the claim

Anx-1-           Copy of receipt of payment of the policy.

Anx-2, 2/1,   Copy of part documents of the policy.

Anx-3-           Copy of cashless card.

Anx-4&4/1    Copies of medical prescriptions.

Anx-5 to 5/10- Copies of medical tests & reports.

Anx-6 to 6/3-  Copies of medical Bills hospital.

Anx-7 to 7/2-  Copies of money receipt of hospitals.

Anx-8-            Copy of Discharge summary.

Anx-9 to 9/3-  Copies repudiation letter, reply & queries.

Anx-10- Copy of legal notice.

Axn-11- Copy of claim forms.

4          O.P. No.2, M/S Vipul Medi Corp. TPA Pvt. Ltd. has not appeared in spite of service of the notice. Therefore ex parte proceeding has been initiated against O.P. No. 2

5          O.P. No. 1 M/s Oriental Insurance Co.  Ltd. appears and filed W.S. it is submitted that this complaint is not maintainable the complainant is not a consumer and the claim with interest shows this case has been filed by concealing material facts regarding hypertension. This O.P. has admitted the policy as mentioned in the compliant petition for the period 22-08-2014 to 21-08-2015. It is further submitted that during process of the claim of the complainant while he was under treatment at R.N.T. International institute of cardiac science at Kolkata the complainant has concealed facts of hypertension. This O.P. asked the complainant to submit exact duration of hypertension certified by treating doctor and also to send first detection test of hypertension along with IPD records which were not provided by the complainant and as such the claim of the complainant was closed as “No Claim” and therefore there is no deficiency on the part of the this O.P. and the complainant is not in titled for the claim.

            No documentary evidence has been filed by this O.P.

FINDINGS

6          We perused the record and it appears complainant has taken “Happy family floater policy” from the O.P. Insurance co. on payment of premium and therefore, he is a consumer and dispute is a consumer dispute.

7          The Oriental Insurance Co. Ltd. Appeared and contested by local office, as such the Jurisdiction has not been challenged by O.P. we hold that this case is within territorial Jurisdiction of this Forum.

8          The  O.P. No.1, the insurance co., has admitted the Mediclaim policy of the complainant for the period claimed.  The only objection of the O.P. that the complainant has not submitted the required documents and has not disclosed regarding exact date of hypertension but the documents filed on behalf of the complainant is sufficient to prove the  claim of the complainant and the objection of the O.P.  on a flimsy ground that the complaint has not submitted the exact date of detection of the hypertension this objection cannot be accepted of the O.P. as it is highly technical ground against the principle of the natural justice.

            And therefore, we are of the view that the claim of  the complainant is justified and O.P. No.1 is liable for deficiency in service. And the case is maintainable.

9          Thus we allowed the claim of the complainant of Rs. 21,575/- with interest of 8% per annum from the date of repudiation i.e. 14-09-2015

            Accordingly O.P. No.1 M/S Oriental Insurance Co. Ltd. is directed to pay Rs. 21,575/- with interest of 8% per annum form the date of repudiation to the complainant. O.P. No.1 is further directed to pay compensation of Rs. 5,000/- for mental harassment and Rs. 3,000/- as litigation cost.

            All the payments must be paid within 60 days from this order falling which the rate of interest on the main claim shell be enhanced to 12% per annum till realization.