C.F. CASE No. : CC/10/76
COMPLAINANT : Kanailal Halder
S/o Subodh Halder,
of B.D. Mukherjee Lane,
Beside Ramkrishna Pathagar,
P.O. Krishnagar, P.S. Kotwali
Dist. Nadia
OPPOSITE PARTIES/OPs : 1) The Branch Manager
Life Insurance Corporation of India
Krishnagar Branch – II (42 F)
Padia Market Building,
R.N. Tagore Road,
P.O. Krishnagar,
P.S. Kotwali, Dist. Nadia
2) The Branch Manager
Medicare TPA Services (I) Pvt. Ltd.
6, Bishop Lefroy Road,
Kolkata – 700 020
PRESENT : SHRI KANAILAL CHAKRABORTY PRESIDENT
: SMT SHIBANI BHATTACHARYA MEMBER
: SHRI SHYAMLAL SUKUL MEMBER
DATE OF DELIVERY
OF JUDGMENT : 07th December, 2010
: J U D G M E N T :
In brief, the case of the complainant is that he purchased one LIC Health Plus Plan policy being No. 427039812 on 26.06.08 for a sum of Rs. 50,000/- from the OP No. 1. That the OP No. 2, Medicare TPA Services (I) Pvt. Ltd. is enlisted by the LIC to assist LIC in processing Health Insurance Claims and accordingly health card was issued by the TPA. On 09.03.10 the complainant became ill and as per advice of Dr. S. Mitra he was admitted at Bellona Nurshing Home & Diagnostic Centre for treatment / operation and at that Nursing Home he was treated and undergone operation from where he was released on 13.03.10. To that extent the Nursing Home issued a discharge certificate also. Thereafter, he submitted the bill issued by the Nursing Home before the LICI on 08.04.10 for settlement of his claim. The total expenditure was Rs. 22,560/-. On 15.05.10 the OP No. 2 sent a letter asking him to submit some papers which he already submitted before the OP No. 1. From this letter he learnt that LIC submitted those documents before the OP No. 2 on 05.05.10, i.e., beyond the stipulated period of 30 days of discharge from the Nursing Home. On 04.06.10 the OP No. 2 sent a letter to him asking for submission for condonation of delay letter and some other documents also. The alleged delay was caused by the OP No. 1 in sending the documents before the OP No. 2 which the complainant duly informed the OP No. 2 by another letter. In spite of that the OP No. 2 did not settle his claim though the complainant submitted all the papers to the LIC in due time. So having no other alternative he has filed this case praying for the reliefs as stated in the petition of complaint.
The OP No. 1, LIC of India, Krishnagar Branch has contested this case by filing a written version, inter alia, stating that this complainant submitted the hospital treatment form along with other relevant documents at Krishnagar Branch on 08.04.10 and after collecting those papers he forwarded to the OP No. 2 on 05.05.10 who duly received the same. There is no negligence on the part of this OP in sending the documents before the OP No. 2. He further submits that the delay has been condoned by the competent authority on 21.07.10 and that paper of condonation of delay was sent to TPA on 23.07.10. Further this OP sent a letter to the complainant on 15.05.10 and 25.05.10 asking to submit some documents such as ailment to be conformed by treating doctor and need for hospitalization from 09.03.10 to 15.03.10 along with justification of prolonged stay there which is required to settle the claim. But the complainant has not supplied the reply till to-date. So no question of negligence on the part of this OP in settling the claim does arise. Hence, the complainant has no cause of action to file this case and the same is liable to be dismissed against him.
OP No. 2 has not appeared before this Forum on receipt of notice and has not contested this case by filing any written version.
POINTS FOR DECISION
Point No.1: Has the complainant any cause of action to file this case?
Point No.2: Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
Both the points are taken up together for discussion as they are interrelated and for the sake of convenience.
On a careful perusal of the petition of the complaint along with the annexed documents filed by the complainant and the written version filed by the OP No. 1 and after hearing the arguments advanced by the ld. lawyers for the parties it is available on record that this complainant purchased one LIC Health Plus Plan policy from the OP No. 1 with a sum assured of Rs. 50,000/-. Regarding this purchase of policy there is no denial on the part of the OP No. 1. It is also available from the written version that the complainant submitted all medical papers before the OP No. 1 on 08.04.10 with a prayer to settle his medical claim as he was treated at a Nursing Home from 09.03.10 to 07.04.10. The OP No. 1 sent all those documents before the OP No. 2 for settlement of the claim on 05.05.10 which caused delay in sending the documents and not within 30 days from the date of discharge. Thereafter, this OP No. 1 again sent a letter to the OP No. 2 stating that the delay was condoned by the appropriate authority of the OP No. 1 with a request to settle the claim of the complainant. At the time of argument ld. lawyer for the OP No. 1 submits that the complainant has claimed Rs. 22,560/- and from the medical papers issued by the nursing home it is available that operation charge of the complainant in that Nursing Home is Rs. 11,000/- which the complainant is not entitled to get as he was operated for complication of piles which is not included in the list of surgical procedures of Health Plus Policy of the LIC. Perused the documents filed by the OP No. 1 from which it is available that the operation of piles is not included in the list of surgical procedures. Ld. lawyer for the complainant has also endorsed this submission at the time of argument and has submitted that the complainant is entitled to get the medical expenditure only which the OP No. 1 is ready to pay. But she submits for compensation as the OP No.1 has not settled the claim prior to filing of this case which is a harassment to the complainant also and negligent work on the part of the OP No. 1.
After hearing the arguments advanced by the ld. lawyers for both the parties and after a careful perusal of facts of this case along with annexed documents, our considered view is that the complainant is entitled to get Rs. 11,560/-, the amount which is spent for his treatment at the Nursing Home along with compensation of Rs. 3,000/- for the harassment caused to him and litigation cost also. In result the case succeeds.
Hence,
Ordered,
That the case, CC/10/76 be and the same is allowed on contest against the OP No. 1 and exparte against the OP No. 2. The complainant is entitled to get Rs. 11,560/- + 3,000/- as compensation for along with Rs. 1,000/- as litigation cost. The OP No. 1 is directed to pay the decretal dues amounting to Rs. 15,560/- to the complainant within a period of one month since this date of passing this judgment, in default, the decretal amount will carry interest @ 10% per annum since this date till the date of realization of the full amount.
Let a copy of this judgment be delivered to the parties free of cost.
