Sri A.K. Bhattacharyya, President

The complainant’s case may be briefly stated as follows:

The complainant took a mediclaim policy being no. 0200179415 for Rs.200000/- for the period from 03.06.2013 to 02.06.2014 from the OP 1 through its agent OP 2. Rs.23900/- was spent by him for his mediclaim treatment under Astha PolyClinic & Nursing Home at Tamluk on account of his illness from 26.10.2013 to 31.10.2013 as an indoor patient and discharged on 31.10.2013.

The OP 1 by his letter dtd. 22.07.2014 informed the complainant with regard to closing of claim inspite of his demand for such claim in relation to his mediclaim policy to the OP, hence the instant case.

The OP1 appeared in this case but ultimately no W/V was filed on its behalf within specific fixed time as provided under the provision of Consumer Protection Act, 1986 and as such an order was passed on 09.10.2014 for exparte hearing of this case against the OP1. The OP2 contested the case by filing W/V and WNA. It is stated by the OP2 in his W/V that there is no privy of contract of insurance in between the complainant and OP2 in respect of the subject matter, that the OP2 was an agent/broker by holding Code no. 1891411 and Contract no. 02222189106 of the OP1 relating to the policy schedule of AIG Insurance. The contract of insurance was held on behalf of the complainant and OP1 and he (OP2) is not responsible for the instant claim case filed by the complainant. Accordingly, to him this case may be dismissed against him.

Point for determination:

Whether the complainant is entitled to any relief as sought for?

Decision with reason:

We have heard the ld. Advocate for the complainant as well as the ld. Advocate for the OP2at considerable length.

We have gone through the pleadings and WNA of the complainant and the W/V and WNA of the OP2 and documents filed on record by them. The OP1 did not contest this case by filing W/V for which this case was heard exparte against the OP1.

The photocopy of the computer generated letter dtd. 22.07.2014 of Tata AIG addressed to the complainant relates to the subject closure of complainant’s claim under the policy no. 0200179415, wherein it is mentioned that due to non-submission of all necessary documents, they are unable to proceed further and will be closing the case as “No claim”.

It is important to note that the OP1 did not contest the case to justify their grievance as alleged in the said letter dtd. 22.07.2014 filed by the complainant on record. The OP2 being an agent of the OP1 admitted that the policy in question was issued by the OP1 in favour of the complainant (in his W/V in paragraph no.3).

The photocopy of schedule policy (Mediprime) related to Tata AIG Insurance filed by the complainant on record squarely point out that the complainant had a Mediclaim policy for Rs.200000/- for the period from 03.06.2013 to 02.06.2014 under Tata AIG Insurance in respect of policy no. 0200179415 with Policy Type-Family Floter Plan. The photocopy of letter dtd. 09.07.2014 addressed to the OP2 indicates that the complainant submitted all documents to the OP1. The circumstance suggests that the complainant did not get his medical claim from the OP1 despite of demand.

So, we find that there was no cogent ground on the part of the OP1 to close the said insurance mediclaim of the complainant.

          It is also clearly mentioned in the said policy schedule of Tata AIG Insurance on record that Broker/Agent was the OP2 (Axis Bank Ltd.). So it (OP2) cannot avoid its duty to pursue the matter of claim with OP1, although the OP2 has no liability to make payment of the mediclaim as demanded by the complainant.

          Discharge Certificate (photocopy) dtd.31.10.2013 speaks that the complainant received medical treatment from the Astha PolyClinic & Nursing Home from 26.10.2013 to 31.10.2013 under Dr. A. Samanta, M.D. The photocopies of six money receipts/cash memos stood in the name of the complainant under reference of Dr. Arijit Samanta, M.D. for the period from 26.10.2013 to 31.10.2013 filed on record on behalf of the complainant by a list of documents in relation to his medical treatment disclose that Rs.16263/- (in total) was incurred by the complainant with regard to his medical expenses.

          On careful consideration of the discussions made above and the material on record, we are of the view that there is deficiency in service on the part of the OP1 for repudiating complainant’s mediclaim in respect of the said policy issued in favour of the complainant. That being the position, the complainant is entitled to get the sum of Rs.16263/- as mediclaim together with Rs.3000/- towards compensation and further sum of Rs.2000/- as to litigation cost from OP1.

          The above point, is thus, decided in favour of the complainant.

          Hence, it is,

Ordered

          that the instant consumer case be and the same is allowed exparte against the OP1 and this case is dismissed against the OP2 on contest. The OP1 is directed to pay the sum of Rs.16263/- as mediclaim together with Rs.3000/- as compensation and further sum of Rs.2000/- as litigation cost to the complainant within 30 days from the date of communication of this order, failing which the complainant shall have liberty to execute this order as per law, in which case the OP1 shall be liable to pay interest@ 9% p.a. over the aforesaid total amount of Rs.21263/- from the date of communication of this order till realization in toto.