This case has arisen out of an application U/s 35 of the Consumer Protection Act, 2019.
The case of the complainant is that being an employee of Axis Bank Ltd he purchased employee policy being No:124500/48/2019/4056, sum assured Rs.3,00,000/- valid from 01.10.2018 to 30.09.2019, further renewed by paying premium being Policy No:124500/48/202/3052 valid from 01.10.2019 to 30.09.2020, sum assured Rs.4,00,000/-, for safe guard of employee/complainant as well his family members.
That on 07.10.2019 the complainant met with an road traffic accident and sustained blood injury, immediately shifted at local hospital later shifted at North Bengal Neuro Centre Pvt. Ltd on 08.10.2019 & discharged there from on 16.10.2019 and under treatment of many doctors.
That complainant’s relative informed the matter to the Ins. Company through agent as well as Toll Free number. After treatment complainant claimed medical expenses Rs.1,84,846/-, claim ID 20863385 & O.P concern directed the complainant to provide documents which the complainant have provided but in spite of receipt of documents O.P concern did not pay the claim. The complainant prays for direction upon O.P.No:1 & 2 to pay medical reimbursement amount Rs.1,84,846/- along with interest @10% p.a from the date of treatment, compensation of Rs.50,000/- for harassment and mental pain & Rs.10,000/- as litigation cost.
O.Ps contested the case by filing W.V admitting the complainant’s case that complainant is an employee of Axis Bank Ltd, due to safe guard of the employee the bank purchased insurance policy under Group Mediclaim Tailor-made GMC/Policy, issued to cover employees of Axis Bank on Pan India basis and the insured faced an RTA on 07.10.2019.
The case of O.Ps is that the complainant did not submit some information regarding the exact date of incident & how and when incident taken place and also did not supply the original bill voucher medical report and other documents so the O.P unable to settle the matter. There is no deficiency in service on the part of O.Ps concern and the case is liable to be dismissed.
Point for consideration is:-
- Whether there was any deficiency in service on the part of the O.Ps which gives rise cause of action to file the complaint and the complainant is entitled to get the claim?
D e c i s i o n w i t h r e a s o n s
Admittedly, the complainant Chandan Paul is an employee under Axis Bank Limited and for safe guard of its employee Axis Bank Limited purchased insurance policy under Group Mediclaim Tailor-made Policy/GMC being No:124500/48/2019/4056, sum assured Rs.3,00,000/- valid from 01.10.2018 to 30.09.2019, later renewed vide Policy being No:124500/48/202/3052 sum assured Rs.4,00,000/- valid from 01.10.2019 to 30.10.2020.
O.Ps admit that the insured/complainant faced an road traffic accident (RTA) on 07.10.2019. Though defence case is that the complainant did not submit some information regarding the exact date of incident and how & when the incident had taken place but certificate dated 12.11.2019 of North Bengal Neuro Centre Pvt. Ltd found disclosed everything, that Chandan Paul was admitted in that hospital on 08.10.2019 at 05:55 am with alleged H/o sustaining multiple injuries following RTA on 07.10.2019 at around 11 pm and he underwent surgery for the management of his bony injury on 12.10.2019, after management and medication he improved gradually and he was discharged in a stable condition on 16.10.2019. He was hospitalized in an emergency medical condition, on examination at emergency room he was not found to be consumed any substance like Alcohol or Drugs.
There is no denial that after the incident the relative of the complainant informed the matter to the Insurance Company through Agent as well as Toll Free Number.
The case of the complainant is that after completion of treatment he claimed medical expenses of Rs.1,84,846/- and after receiving the claim, the O.P concern create one Claim ID bearing No:20863385 in the name of the complainant, thereafter, O.P concern directed the complainant to provide all pre-numbered cash payment receipt against final hospital bill which he has provided, in spite of receipt thereof O.P concern did not pay his claim.
The defence case is that the complainant did not supply the original bill voucher, medical report and other documents, so O.P was unable to settle the matter.
Claim details depicts Claim ID:20863385, date of admission: 08.10.2019, Hospital:North Bengal Neuro Centre Pvt. Ltd, claim amount:Rs.1,84,846.00, approved amount:Rs.0.0, missing dock one: kindly provide all pre-numbered cash payment receipt against final hospital bill-yet to upload.
The complainant stated that he has provided all documents available with him to the Insurance Company, consequently it is presumed that the document asked for was supplied/uploaded. Consolidated money receipt No:1356, dated 16.10.2019 and bill depicts the name of patient:Chandan Paul, total bill amount:Rs.1,82,312.00, less discount:Rs.50.00, total bill amount:Rs.1,82,262.00 less amount paid:Rs.1,82,262.00/-, net amount payable:Rs.0.00. In addition other two money receipts show that the hospital received Rs.1000/- + Rs.500/- on 25.10.2019 for OPD + Dressing charge and Emergency charge. The complainant answered Question No:4 & 5 that he has already submitted all bill, voucher and medical papers relating to the incident & discharge certificate before the Insurance Company.
Under above facts and discussion, we are of the opinion that in spite of supply of required documents the O.P concern did neither settle the matter nor paid the medical expenses incurred by the complainant & there exists deficiency in service on the part of the O.Ps. But the actual figure of medical expense would be Rs.1,82,262/- + Rs.1,500/-=Rs.1,83,762/- instead of Rs.1,84,846/-. We find that the complainant is entitled to get Rs.1,83,762/- as medical expenditure but we are not inclined to award interest thereon, compensation & litigation cost as prayed for because no receiving seal & date are found from the documents produced by the complainant.
In the result the case succeeds.
Hence, it is
O R D E R E D
that the C.C-45/2020 be and the same is allowed on contest against the O.Ps.
We do direct O.P.No:1&2 to severally & jointly pay Rs.1,83,762/- towards medical expenses within 01 month from the date of order, failing which it will carry interest @6% p.a till final realization and the complainant will be at liberty to recover the same through execution.
Let a copy of this order be given to the parties free of cost.
