In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No.125 / 2012
1) Sri Sheo Pujan Gupta,
49/5/H/8, Karl Marx Sarani,
P.S. SPPS. Kolkata-23. ----------- Complainant
---Versus---
1) The Divisional Manager,
National Insurance Co. India, Division-IV,
2nd Floor, Royal INS Bldg., 5, N.S. Road, Kolkata-1 and
3, Middleton Street, Kolkata-71, P.S. Park Street.
2) Heritage Health TPA Pvt. Ltd.
“Nicco House”, 5th Floor, 2, Hare Street, Kolkata-1. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri ,Member
Order No. 16 Dated 12-02-2013.
The case of the complainant in short is that the complainant is a policy holder along with his family members under the “Hospital Benefit Policy” scheme which is deemed as a cashless policy for medical treatment vide no.100400/48/11/8500003724/100400 covering period from 15.9.11 to 14.9.12 and it was a continuing policy from the year 2010. Complainant paid the total premium to the tune of Rs.4295/- for himself and other four family members. The complainant was personally covered to the limit of Rs.75,000/- plus cumulative bonus of Rs.3750/- i.e. 78,750/-.
On 22.9.11 he was admitted in B.M. Birla Hospital and Research Institute having chest pain, but due to turmoil he could not apply for cashless benefit and thereafter complainant arranged Rs.2,78,532/- and paid the same to the hospital and was discharged therefrom on 26.9.11.
After discharge from the hospital the complainant requested the o.p. no.2 on 29.9.11 to reimburse the claim to the tune of Rs.78,750/- (sum insured) and submitted all the relevant documents for perusal and assistance. On 13.10.11 the complainant submitted the claim form with o.p. no.2.
O.ps. did not settle the claim of Rs.78,750/- of the complainant and ultimately, on 18.2.12 a demand notice was sent by complainant through his ld. advocate. O.p. no.1 sent a letter dt.5.3.12 thereby repudiating the claim of the complainant. The claim was repudiated as per clause 4.3. Hence the case was filed by complainant with the prayer contained in the petition of complaint.
O.p. no.1 had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case. O.p. no.2 did not contest this case by filing w/v and matter was heard ex parte against o.p. no.2.
Decision with reasons:
We have gone through the pleadings of the parties, evidence and documents in particular and we find that complainant is a policy holder along with the members of his family which is deemed as a cashless policy for medical treatment vide no.100400/48/11/8500003724/100400 covering period from 15.9.11 to 14.9.12 and it was a continuing policy from the year 2010 and the premium was Rs.4295/- for the complainant and other four members of his family and complainant himself was personally covered to the limit of Rs.75,000/- plus cumulative bonus of Rs.3750/- from the previous years policy for Rs.78750/-.
Further case of the complainant is that on 22.9.11 he was admitted in B.M. Birla Hospital and Research Institute having chest pain, but due to turmoil he could not apply for cashless benefit and thereafter complainant arranged Rs.2,78,532/- and paid the same to the hospital and was discharged therefrom on 26.9.11. Further we find from the record that complainant requested o.p. no.2 on 29.9.11 to reimburse his claim to the tune of Rs.78,750/- together with all the relevant documents and on 13.10.11 complainant submitted the claim form with o.p. no.2, but o.ps. did not settle the claim of Rs.78,750/- and complainant sent ld. lawyer’s notice on 18.2.12 demanding settlement of his claim. O.p. no.1 by sending a letter on 5.3.12 repudiated the claim of the complainant.
We have gone through the entire materials on record. It is nowhere disputed that complainant was not admitted in B.M. Birla Hospital and Research Institute and he had to incur huge amount his treatment in the said hospital.
Now o.p. no.1 repudiated the claim of the complainant vide letter dt.5.3.12 stating that the claim preferred by the complainant is contrary to clause no.4.3 of the policy. It is a settle principle of law that in case of purchase of policy conditions insured should suffer and this is the view of Hon’ble Supreme Court of India published in CTJ May 2010 Vol 18 No.5 page 66.
In view of the findings above and on perusal of the entire materials on record we find that complainant is not at all a defaulter in the matter of making payment of policy premium amount and we do not find any justification for such repudiation debarring complainant from having his legitimate claim and this act on the part of o.ps. amount to deficiency of service being service provider to its consumer / complainant and we are of the opinion that complainant is entitled to relief.
Hence, ordered,
That the case is allowed on contest against o.p. no.1 with cost of Rs.25,000/- (Rupees twenty five thousand) only and ex parte without cost against o.p. no.2. O.p. no.1 is directed to pay to the complainant a sum of Rs.78,750/- (Rupees seventy eight thousand seven hundred fifty) only towards the reimbursement of his claim amount and is further directed to pay compensation of Rs.30,000/- (Rupees thirty thousand) only for his harassment and mental agony and litigation cost of Rs.7000/- (Rupees seven thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 10% shall accrue over the entire sum due to the credit of the complainant till full realization.
Complainant is at liberty to file execution case before this Forum in case of non execution of the aforesaid order in its entirety within the stipulated period under the provision of the COPRA, 1986.
Supply certified copy of this order to the parties free of cost.
