Date of filing: 13.04.2018 Date of disposal: 15.03.2023
Complainant: Anirban Kumar Jash, S/o- Amiya Kumar Jash, residing at Hazra Math, Near College More, Post Office-Sripally, P.S.-Bardhaman Sadar, District-Purba Bardhaman, Pin-713103.
Opposite Party: 1. The Branch Manager, National Insurance Company Ltd. having its office at Kundu Mansion, 1st Floor, 548, G.T. Road, Bhangakuthi, Burdwan, West Bengal-713101.
2. The Regional Manager, National Insurance Company Ltd. having its office at 8, National Insurance Building, India Exchange Office, Opposite Tea Board, Dalhousie, Kolkata-700001.
Present : Mohammad Muizzuddeen -Hon’ble President.
: Mrs. Lipika Ghosh - Hon’ble Member.
: Mr. Atanu Kr. Dutta. - Hon’ble Member.
Appeared for the Complainant: Santi Ranjan Hazra Ld. Advocate
Appeared for the Opposite Party Nos. 1 & 2: Somnath Banerjee Ld. Advocate
F I N A L O R D E R
On 13.04.2018, the complainant Anirban Kumar Jash has filed an application u/S 12 of the C.P. Act, 1986 against the O.Ps.
The case of the complainant, in brief, is that the complainant subscribed into the Mediclaim Policy of the O.Ps-Insurance Company through his office (Office of the Burdwan University) on 30.03.2014 and used to renew the said policy year to year. He took the said Mediclaim Policy for himself, his spouse and also for his parents. The complainant has paid Rs.1556/- towards the annual premium of the policy being Policy No. 154100/48/17/850000274 and the policy was covered up to Rs.1,00,000/- and valid from 05.04.2017 to 04.04.2018. Mrs. Sudeshna Konar, the wife of the complainant, became pregnant and subsequently on 25.12.2017 she was admitted into the Eveland Nursing Home at Nababhat More, G.T. Road, Burdwan where she gave birth of a male child on the same day under the treatment of Dr. Kanchan Mukherjee & LUCs were done by the said doctor. On 29.12.2017 she was discharged from the said nursing home. The complainant paid a total amount of Rs.28,777/- towards the treatment of his wife i.e., Rs.9300/- towards hospital main bill, Rs.2000/- towards anesthesia, Rs.11, 000/- towards fees of doctor and Rs.6477/- towards pharmacy bill.
On 04.01.2018 the complainant lodged the claim towards the medical expenses of his wife, after complying necessary formalities, to the office of the O.Ps. All original papers annexed with the claim at the submission of the reimbursement of claim form. The O.P. instructed the complainant to submit computer printed bill of the doctor as the original bill which the doctor was issued and the same has been submitted, was prepared by the doctor by his own handwriting. The complainant approached to the doctor and requested him to issue a fresh computerized bill. The doctor finally issued printed bill as per request of the complainant and he submitted the same to the O.Ps. Thereafter O.P. came to learn from the website of the O.P. that the claim of the complainant has partly been allowed and the O.P. turned down the reimbursement of bill of the doctor for an amount of Rs.11,000/- and also deducted Rs.6183/- without assigning any reason. The complainant raised objection against such unjustified act of the O.Ps and lodged written complaint to their office but O.Ps flatly denied to pay the same to the complainant. In this way the O.Ps committed deficiency in service and perpetuated unfair trade practice upon the complainant.
The cause of action arose on 04.01.2018 and subsequently when the insurance company made part payment of the claim amount.
Upon this background, the complainant prayed for directing the O.Ps to pay the claim amount of Rs.11,000/- and Rs.6,183/- totaling Rs.17,183/- (Seventeen Thousand One Hundred Eighty Three) only along with interest thereon till date of payment from the date of filing of the case along with compensation of Rs.20,000/- for mental agony & harassment and litigation cost of Rs.10,000/-.
The O.P. Nos.1 & 2 have contested the case by filing written versions denying all the material allegations contending, inter alia, that the complainant has no bonafide cause of action to file the case and that the complaint is not maintainable in law and that the complaint is misconceived one and that no deficiency or negligence in service has been caused by the O.Ps and that the complaint case is not maintainable for defect of parties and that the complainant did not come to the Ld. Forum with clean hands and as such he is not entitled to get any relief.
The specific case of the O.Ps is that in column No.4 of the application complainant as per instruction of the O.P., the complainant submitted computerized money receipt of the doctor namely Dr. Kanchan Mukherjee but the money receipt (Annexure -4 with the plaint) and the computerized money receipt (Annexure-6) are not identical and bearing no serial number of the receipt and both the alleged money receipts not signed by the doctor after affixing the revenue stamp which is mandatory in which cases where the receipted amount is more than five thousand so this O.Ps denied to pay the amount as claimed by the complainant. According to BOI National Swasthya Bima Policy, the O.P. is bound to pay/settle any claims as per the guideline of the said policy that as per 2.7(v) of the guideline pre-natal and post natal expenses are not covered unless admitted in hospital and treatment is taken there. As some bills are related to the said period those bill amounts are to be deducted. Upon this background, the O.Ps claimed for dismissal of the case.
Decision with Reasons
In order to prove the case, the complainant has filed the evidence-on- affidavit and Xerox copies of the document.
The O.Ps filed questionnaires against the said evidence. The complainant has filed reply on 08.03.2019. On 22.04.2019 as per prayer of the O.Ps, the written version has been treated as evidence-on-affidavit.
On 14.08.2019, the complainant filed questionnaire against the said evidence and on 19.11.2019, the O.P. submitted a reply. O.P. also filed the Xerox copies of the guideline of BOI National Sasthya Bima Policy.
Perused the oral and documentary evidence of both sides including the written notes of argument filed by the O.Ps.
Admittedly, the complainant subscribed into the Mediclaim Policy Number 154100/48/17/850000274 which was covered up to Rs.1, 00,000/-(One Lakh) only & valid from 05.04.2017 to 04.04.2018 and his wife Mrs. Sudeshna Koner was admitted into Eveland Nursing Home at Nababhat More, G.T. Road, Burdwan on 25.12.2017 under the treatment of Dr. Kanchan Mukherjee and LUCs were done by the said Doctor and she was discharged on 29.12.2017. The complainant paid an amount of Rs.28,777/- towards the treatment of his wife and claim was lodged before the O.Ps which was partly allowed and the bill of the doctor for an amount of Rs.11,000/- was refused and they also deducted Rs.6183/-.
The O.Ps in their written version stated that the computerized money receipt of Dr. Kanchan Mukherjee was disputed one as the content of the handwriting money receipt and the computerized money receipt are not identical and bearing no serial number and also the money receipts were not signed by the doctor after affixing the revenue stamp which is mandatory where the receipted amount is more than Rs.5,000/-. This is the ground for refusal of reimbursement of Rs.11,000/- and doctor fees and according to BOI National Sasthya Bima Policy the O.Ps are bound to pay or settle the claim but according to 2.7(V) of the guideline pre-natal and post-natal expenses are not covered unless admitted in hospital and treatment is taken there and this is the reason for deduction Rs.6183/- but from the document issued by Eveland Nursing Home at Nababhat More, G.T. Road, Burdwan as discharge certificate disclosed that the patient Mrs. Sudeshna Konar was admitted in the said Nursing Home on 25.12.2017 and date of discharge was 29.12.2017 and the treatment synopsis was LUCs done Sp.A on 25.12.2017 and male baby delivered and according to the request for submitting of the computerized money receipt as submitted by the complainant and the computerized money receipt shows that it bears the signature of the doctor mentioning received amount of Rs.11,000/- for the patient Mrs. Sudeshna Konar. But the O.Ps in spite of his plea stated above could not file any documents to show that computerized money receipt and the manuscript money receipt submitted by the complainant is in dispute regarding the bearing of the signature of the doctors etc. It is the O.P. who has the bounden duty to prove their case but the O.P. could not prove their fact by way producing document but the complainant has proved that computerized money receipt bears the signature of the doctor. Therefore, the submissions of the O.Ps cannot be relied on. The computer money receipt do not bears the revenue stamp but it is not the outlook of the O.Ps whether the money receipt bears any revenue stamp or not. The competent authority in this regard has right to look into the matter.
Therefore, the O.Ps are bound to pay the said claim of the complainant as doctors’ fees. The O.Ps has refused to pay Rs.6183 on the ground that pre-natal and post natal expenses are not covered unless admitted in hospital and treatment is taken there as per guideline No.2.7 (v) of the BOI National Sasthya Bima Policy but what expenses was claimed for what period, whether it was pre natal or post natal expenses has not been mentioned either in the W/V or in the evidence-on-affidavit. Therefore, the O.P. has also failed to prove his pleas as taken by him rather the complainant has proved that he has a claim of total expenses of Rs.28, 777/- for treatment of his wife who was admitted in the Eveland Nursing Home on 25.12.2017 and discharged on 29.12.2017.
Under the above facts and circumstances of the case, we are of opinion that the O.Ps committed deficiency in service and the complainant is entitled to get his relief. The O.Ps are also liable to pay compensation to the complainant as they committed harassment and mental agony to the complainant without disbursing his claim according to law and the complainant also entitled to get a litigation cost as he has to file this case for his claim. As a result the case succeeds.
Hence, it is
O R D E R E D
that this case be and the same is allowed on contest against the O.P. Nos.1 & 2 but without any cost.
The O.P. Nos.1 & 2 is jointly and severally liable to pay the relief of the complainant. The O.P. Nos.1 & 2 are directed to pay Rs.11, 000/- plus Rs. 6183/-totalling amount Rs.17, 183/-(Seventeen Thousand One Hundred Eighty Three) only to the complainant jointly and severally. They also directed to pay compensation of Rs.15,000/- and litigation cost of Rs.10,000/- to the complainant jointly or severally within 45 days from the date of receipt of the final order failing which the said amount of Rs.17,183/-plus 15,000/- plus 10,000/- totalling amount of Rs.42,183/-(Forty Two Thousand One Hundred Eighty Three) only shall carry interest @ 10 per annum till the date of realization.
Let a copy of this order be given to the parties on free of cost.
Dictated & corrected by me.
President
D.C.D.R.C., Purba Bardhaman.
Member Member President
D.C.D.R.C., Purba Bardhaman. D.C.D.R.C., Purba Bardhaman. D.C.D.R.C., Purba Bardhaman.
