Tapas Kumar Panchali,

son of late Ram Pada Panchali,

 residing at Anurag Apartment ( 2^nd floor ),

169, J.K. Paul Road, Kolkata – 700038 and

working at Bank of Baroda, Howrah M.G. Road Branch,

as senior Branch Manager.---------------------------------------------------- COMPLAINANT.

-          Versus   -

1.      The  Divisional Manager,

Howrah, National Insurance Company Limited,

Howrah Division, 22, G.T. Road ( South ),

Howrah – 711101.

2.      National Insurance Company Limited,

registered office at 3, Middleton Street,

Kolkata – 700071.

3.      M/S. Medsave Health  Care,

1/1, Camac Street ( 3rd floor ),

Kolkata – 700016.-------------------------------------------------OPPOSITE PARTIES.

                                                P    R    E     S    E    N     T

President     :     Shri T.K. Bhattacharya, M.A. LL.B. WBHJS.

Member      :      Shri P.K. Chatterjee.

Member       :     Smt. Jhumki Saha.

                                                 F  I   N   A    L       O   R   D    E     R

1.                  The instant case was filed by complainant U/S 12 of the C.P. Act, 1986

wherein the complainant has  prayed for direction upon the o.ps. to reimburse the hospitalization claim amount of Rs. 51,443/- vide the insurance policy being no. 153500/48/12/8500001549 together with  compensation to the tune of Rs. 1,00,000/- and litigation costs of Rs. 50,000/- as the O.Ps. in spite of repeated requests did not release the medi claim against hospitalization benefit policy claim covering Rs. 3 lacs valid on and from 18-05-2012 to 17-05-2013 incurred for medical treatment and tests of his wife who underwent treatment at Christian Medical College Vellore, Chennai.

2.                  The o.p., National Insurance Company Ltd.,  in the written version contended

interalia that the company shall not liable to make any payment under this policy in respect of any expenses whatsoever for diagnosis, x-ray or laboratory examination or other diagnostic studies. So the complaint should be dismissed.

3.         Upon pleadings of both parties two points arose for determination :

i)          Is there any deficiency in service on the part of the O.Ps.  ?

ii)                  Whether the complainant is  entitled to get any relief as prayed for ? 

DECISION  WITH   REASONS      :

4.      Both the points are  taken up together for consideration. Admittedly the

complainant has a family Floater Medi claim Scheme tie-up with Bank of Baroda under the style of Baroda Health Policy being no. 153500/48/12/8500001549 since 10-12-2011, with an yearly premium of Rs. 4,213/- covering Rs. 3,00,000/-. The current policy was valid from 18-05-2012 to 17-05-2013. For medical treatment of wife of the complainant suffering from Disseminated tuber Culorsis or Sarcoidosis disease, she had to be admitted at Christian Medical College, Vellore, Tamilnadu, on 20-10-2012 and underwent thorough medical check-up till 29-10-2012. The total medical bill the complainant had to bear was Rs. 88,113/-. But the complainant claimed only Rs. 51,443/- from the O.Ps. which was ultimately repudiated on the plea of exclusion clause that the complainant shall not bear any expenses for tests etc., ( vide cl. Nos. 4 and 10 ).

5.      Surprisingly  the  Annexure nos. A and B does not contain any such  exclusion

clause. Nor the O.Ps. filed any document in support of their claim. Arguably, if it is accepted that such clauses are embodied any where in their contract paper, such clauses cannot take the shape of religious scriptures as unassailable.

6.      We fail to understand if the wife of the complainant suffering from Disseminated

tuber culorsis had to undergo certain medical tests for her ongoing medical treatment and if the bill amount is within the coverage, how the O.Ps. could repudiate such claim on fragile ground ?

7.      In repudiating the claim amount, the O.Ps. not only committed deficiency in

service, but also caused tremendous mental pain to the complainant. We are, therefore, of the view that this a fit case where the prayer  of the complainant shall be allowed. Both the points are accordingly disposed of.         

      Hence,

O     R     D      E      R      E        D

      That the C. C. Case No. 95  of 2013 ( HDF 95 of 2013 )  be  and the same is allowed on contest with costs against O.P. nos. 1 & 2 and dismissed  ex parte without  costs against O.P. no. 3.

      The O.P. nos. 1 & 2 be directed to reimburse the hospitalization claim amount of  Rs. 51,443/- in favour of the complainant against insurance policy no. 153500/48/12/8500001549  within  30 days from the date of this order together with interest @ 10% p.a. since 06-12-2012 till full reimbursement.

      The complainant is entitled to a compensation of Rs 10,000/-  for causing mental pain and prolonged harassment from the O.P. nos. 1 & 2.

      The complainant is further  entitled to a compensation  of Rs. 10,000/- for their journey to Vellore and stay there for the purpose of treatment covering a distance of nearly 3500 km. to and fro.

      The complainant is entitled to a litigation costs of Rs. 5,000/- from the O.P. nos. 1 & 2.

      The O.P. nos. 1 & 2 are directed to pay the compensation amount as above within 30 days from the date of this order failing the amount  Rs. 25,000/- (  Rs. 10,000 + Rs. 10,000 + Rs. 5,000/- )  shall carry interest @ 10% p.a. till full satisfaction.

      The complainant is at liberty to put the decree into execution after expiry of the appeal period.

      Supply the copies of the order to the parties, as per rule.

DICTATED  &    CORRECTED

BY   ME.  

  (    T.K. Bhattacharya  )                                               (    T.K. Bhattacharya  )

  President,  C.D.R.F.,Howrah.                                   President, C.D.R.F.,Howrah.

 (  Jhumki Saha  )                                                              (  P. K. Chatterjee )

 Member, C.D.R.F.,Howrah.                                       Member,  C.D.R.F.,Howrah.