Ld Advocates are present. Judgement is ready and pronounced in open Commission in 4 pages and 2 separate sheet of papers

BY -    SRI ASISH DEB, PRESIDENT

Brief facts of the complainant’s case are that the Complainant is a permanent resident under this jurisdiction as described in the cause title. The complainant is a simple, innocent and a peace loving citizen. The Complainant has a mediclaim policy under the Bajaj Alianz General Insurance Co. Ltd. being policy no. OG-18-2422-8429-00000010 valid from 23.06.2017 to 22.06.2018. The complainant was suffering from Hepatitis and got admitted from 15.03.2018 to 22.03.2018 in Dr. G.C. Pal Memorial Nursing Home at Paikpari, Kolaghat, Purba Medinipur. The complainant incurred Rs. 23,292.21 for treatment in the aforesaid hospital. After completion of treatment complainant informed the op for payment of the said medical expenses. Thereafter complainant sent a letter for payment through Advocate and thereafter O.P. Insurance Company repudiated the claim on 12.07.2018. The cause of action arose on 12.07.2018. Therefore the complainant  pays that the op be directed to pay the amount i.e. Rs.23,292.21/- along with interest @ 7% P.A. , to pay compensation of Rs. 1,00,000/- for harassment to the complainant and  to pay litigation cost of RS. 5,000/- to  the complainant for conducting this case.

The op has resisted the claim of the complainant by filing a written version thereof stating inter alia that save and except the statements which are the matter on record all other statements as made in paras No. 5,6,&7 of claim application are very much denied & disputed. The Complainant is put to the strict proof of such statements as made in these paras. It is very much false to state that thereafter completion of treatment complainant informed O.P. for payment of the said medical expenses or that thereafter complainant sent a letter for payment through advocate or the O.P. Insurance Company repudiate the claim on 12.07.2018 or the cause of action arose on 12.07.2018. It has come to the knowledge from the official record of the company that the patient (complainant) is working in the outside of the local area. During hospital visit, no pharmacy purchase record was provided to verify the batch no & expiry details of the billed medicine which has no batch no. & expiry date as such authenticity  of the same could not be confirmed .On the other hand Dr. S. Pal was informed, who had treated the patient, but the doctor did not provide any information regarding the treatment of the patient. A rate chart displayed in the hospital wall, where a bed charges is Rs.350/- day, which has billed of Rs.500/-day. The owner of the hospital Dr. Mrinal Pal confirmed that he does not have any nurses and the aya charges of Rs.150/- per shift day & night but separate charges of nurses being provided in the record. Patient was charged for monitor@ of Rs.500/- day. The owner of hospital did not want to verify his signature. The owner and patient & patient party did not provide any sufficient information about the hepatitis case. The complainant did not provide any document to the O.P Insurance Company and non submission of the same led O.P inconvenience to close the claim. The complaint is not maintainable under the consumer protection act as there is no deficiency of service on the part of the opposite party. The complaint is baseless, false misconceived harassing devoid of merit, not maintainable and is liable to be dismissed. In view of the above circumstances the opposite party prays for dismissal of the complaint with cost.

Upon reading of the pleadings of both parties the following points for determination are framed.

Points for determination are:                                                  

1. Is the case maintainable in its present form and in law?

 2.  Is  the Complainant entitled to the relief(s) as sought for?

Decision with reasons

Both the points, being inter related to each other, are taken up together for discussion  for sake of brevity and  convenience.

We have carefully perused and assessed the complaint supported by affidavit of the complainant, written version filed by op, evidence of both parties and other documents. We have anxiously considered the arguments advanced by the Ld. Counsel of rival parties.

Having regards had to the facts and circumstances of the case and evidence on record, it is evident that the complainant being an insured of a mediclaim policy with the insurer op has alleged deficiency in service against the op ; the bundle of facts indicate that this case is maintainable in its present form and in law.

On scanning the evidence on record, it appears that complainant has stated that the Complainant has a mediclaim policy under the Bajaj Alianz General Insurance Co. Ltd. being policy no. OG-18-2422-8429-00000010 valid from 23.06.2017 to 22.06.2018. The complainant was suffering from Hepatitis and got admitted from 15.03.2018 to 22.03.2018 in Dr. G.C. Pal Memorial Nursing Home at Paikpari, Kolaghat, Purba Medinipur. The complainant incurred Rs. 23,292.21 for treatment in the aforesaid hospital. After completion of treatment complainant informed the op for payment of the said medical expenses. Thereafter complainant sent a letter for payment through Advocate and thereafter O.P. Insurance Company repudiated the claim on 12.07.2018.The complainant has submitted the prescription of doctor maintained in Indoor Sheet of Dr G C Pal Nursing home Discharge certificate and bill ( Annexure 2 to 7) in support of his averments .

The op has repudiated the claim of the complainant by its letter dated 12.07.2018 with the note Verification of claimed documents reveal aforesaid claimant was hospitalized for investigation and treatment of Hepatitis. We have noticed certain discrepancies and lapses in the claim documents on basis of which the claim stands repudiated.

 From the repudiation version of the op it is evident that on verification it could ascertain that aforesaid claimant was hospitalized for investigation and treatment of Hepatitis. So there is no dispute regarding the treatment by doctor at Dr. G.C. Pal Memorial Nursing Home at Paikpari, Kolaghat, Purba Medinipur and discharge thereafter. In course of argument Ld Advocate for the op has pointed out that the complainant has not filed any money receipt as against the bill. It is a fact that complainant has not filed any money receipt as against the bill. But we think that for mere non submission of receipt the weightage of the documents in support of treatment undergone and evidence on oath can not be brushed aside. Preponderance of evidence is in favour of the complainant. It is not the case of the op that the treatment was a complimentary one. As such ,it can well be presumed that complainant got discharged from the nursing home upon full payment of the raised bill. Moreover the op in its repudiation letter has given a vague and evasive ground stating that we have noticed certain discrepancies and lapses in the claim documents. The op ought have mentioned the noted discrepancies and lapses in the claimed documents specifically. As such, we find that the acts of the op amount to deficiency of service. The complainant is entitled to get the amounts incurred for the treatment along with interest in the nature of compensation and litigation costs from the op.

 Accordingly, both the pointsare disposed of.

Thus, the complaint  case  succeeds.

Hence, it is

O R D E R E D

That CC/189 of 2019 be and the same is allowed on contest against the op.

The op is hereby directed to pay Rs.23,292/- to the Complainant.

The op is further directed to pay simple  interest @ 7% P.A. over the said amount of Rs.23,292/- from the date of filing of this case till the date of actual payment in the nature of compensation and to pay Rs.5000/- as towards litigation costs.

The op will comply the above direction within 45 days from the date of this order.

The complainant would be at liberty to put the order into execution as per law.

Let a copy of the judgment be supplied to the complainant and the op of cost.