FINAL ORDER / JUDGEMENT
Shri Swapan Kumar Mahanty, President.
This is an application u/s.12 of the C.P. Act, 1986.
The instant case emanates from repudiation of insurance claim.
The case of the complainant, in short; is that he obtained aHealth Insurance Policy being No.P/190000/02/2017/000950 with the OPs and the said policy was valid for the period from 27/10/2016 to mid-night of 26/10/2017. Complainant sustained major injury on his right leg due to accident and undergone operation to Bhattacharya Orthopedics and Related Research CentrePvt. Ltd., Rajarhat. He incurred Rs. 1,58,762/- toward his medical treatment and lodged claim being No. CLI/2017/190000/02/0002997 to the OP-2 with all relevant documents but the OPs rejected his claim. The complainant alleged that rejection of the claim is arbitrarily and illegal. There is deficiency in service on the part of the OPs. Hence, the complainant filed the instant consumer complaint against the OPs with a direction to settle the claim amount of Rs. 1,58,762/- along with other reliefs.
The OP-2 has contested the case by filing Written Version contending inter-alia, that the complaint is not maintainable in its present form and in law. The specific case of the answering OP is that out of total claim of Rs. 1,58,762/- they have already settled Rs. 96,527/- as medical reimbursement. The percentage of disability is too much higher than actual disability and the disability certificate is procured otherwise. The settled amount of Rs. 96,527/- is justified. Accordingly, the answering OP has prayed for dismissal of the complaint.
Despite of service of notice, the OP-1 did not turn up to contest the case. As such, the case has proceeded ex parte against the OP-1.
In the light of above pleadings of the parties, the following points necessarily came up for determination.
- Whether the complainant had any mediclaim policy with the OPs?
- Whether the OPs have been deficient in rendering services to the complainant?
- Whether the OPs have rejected the claim arbitrarilyor illegally?
- Whether the complainant is entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos.-1 to 4.
All the three points are taken up together for the sake of convenience and brevity in discussion.
Both parties have filed their evidence by way of affidavit. Complainant relied upon the documents annexed with the complaint petition
We have perused the complaint petition coupled with its written version including the evidence of the parties and documents relied by them in support of their respective cases.
On perusal of the photocopy of medical policy, it appears that complainant obtained MediclaimPolicy being No. P/190000/01/2017/002978 for a total floater sum of Rs.3,00,000/- issued by the OP-1 and the said policy was valid from 15/06/2016 to mid-night of 14/06/2017. Undisputedly, complainant sustained major injury on his right leg due to an accident during subsisting of the Medical Policy and was admitted to Bhattacharya Orthopedics and Related Research Centre Pvt. Ltd., Rajarhat on 13.02.2017. He was undergone operation and discharged from the said Research Centre on 24.02.2017 at 12.02 P.M. Complainant submitted claim of Rs.1,58,762/- and the OP-2 settled the claim to the extend for Rs. 96,527/-. Remaining amount of reimbursement claim was rejected on the ground that physical disability of the complainant to the extend of 25 percent formonoparesis of right leg has been repudiated by the medical team of answering OPs as the right leg post fracture is not a permanent disability and the said disability is not a scheduled injury as per EC Act, 1923. There is no clarification how the percentage of disability has been assessed and their medical team disbelieve the veracity of the disability certificate. The contesting OP has failed to produce the copy of report of their medical team to establish that fracture of the complainant is not a permanent disability.On the contrary, the report of the District Hospital, Barasat, North 24 Pgs goes to show that the complainant sustained permanent disability to the extend of 25 percent on his right leg.Disability Certificate issued by the competent authority of Government Hospital.Thus, the rejection of the claim of the complainant is not justified. Complainant submitted his claim to the OP-2 for reimbursement along with original document but OP-2 rejected the claim of the complainant which was capricious illogical and unethical. We think that the OP-2 has rejected such claim arbitrarily in capricious way and settled the amount according to their own will. Therefore, the complainant is entitled to get reimbursement of remaining portion of claim. Accordingly, all the points under determination answered in the affirmative.
In the result, the case succeeds in part.
Hence,
Ordered
That the complaint case be and the same is allowed on contest in part against the OP-2. OP-2 is directed to pay Rs. 1,58,762/- to the complainant with litigation cost of Rs.5,000/- within 30 days from the date of this order.
OP-2 is directed to reimburse remaining claim amount of Rs. 62,235/- with a liberty to deduct Rs. 96,527/-,if already paid to the complainant.
OP-2 is further directed to pay an amount of Rs.15,000/- as compensation to the complainant for causing harassment and mental agony within the stipulated period.
We make no order against OP-1.
Failure to comply with the order, the complainant may put the order in execution under appropriate provision of the C.P. Act, 1986.
