DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA :  AGARTALA

 

 

CASE   NO:   CC- 102 of 2020

 

1. Sri Mahapravu Saha,

C/O. M/S. Sri Rama Krishna Engg. Works,

C.R. Road, Agartala,

P.O.-Agartala, P.S.- East Agartala,

Pin-799001, Dist.- West Tripura …....…....................Complainant.

 

 

-VERSUS-

 

 

The Divisional Manager,

National Insurance Company Limited,

Divisional Office, 42, Akhaura Road,

P.O.- Agartala, Pin-799001, 

P.S.-West Agartala, Dist.-West Tripura,…...............Opposite party.

 

 

 

    __________PRESENT__________

 

 SRI RUHIDAS  PAL

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

DR (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

  WEST TRIPURA,  AGARTALA.

 

SRI SAMIR  GUPTA

MEMBER,

  DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA. 

 

 

C O U N S E L

 

For the Complainant : Sri Sankar Chandra Sen,

  Advocate. 

For the O.P. : Sri Sandip Datta Choudhuri,

  Advocate. 

 

 

JUDGMENT  DELIVERED  ON: 29/10/2021.

 

J U D G M E N T

The complainant Sri Mahapravu Saha  set the law in motion by presenting the petition U/S 35 of the Consumer Protection Act, 2019 complaining deficiency of service committed by the O.P.  

  The complainants' case, in brief, is that the Complainant has purchased Mediclaim Policy No.203000501710000041 from the O.P. National Insurance Company Ltd., Agartala. The Complainant gave Rs.22,337/- vide cheque No.360878 dated 01/12/2017 SBI, Agartala Branch. As per terms and condition of the said policy during 10 years continuation of a valid policy if any person admitted in the hospital then he will get benefit of the aforesaid claim. The Complainant was admitted as an indoor patient on 08/11/2018 in the Dr. Mohan's Diabetes Specialities Centre, at 6 Conran Smith Road, Gopalapuram, Chennai due fluctuating Blood sugars, backache, neck and hand tremors, muscle spasm on back and constipation. After admission the doctors attended to the Complainant and prescribed medicine and various pathological tests for his improvement. Thereafter, the Complainant was discharged from the said hospital on 10/11/2018.   After discharge from the Hospital the Complainant within due time submitted his all treatment papers along with report and cash memos i.e. the claim document to the concerned authority i.e. National Insurance Company Ltd. but the O.P. never gave any positive reply. Thereafter, the Complainant sent a letter to the O.P. But O.P. repudiate the claim on 01/03/2019.  

Before filing the complaint, legal notice was also served upon the O.P. from the Complainant side on 28/12/2020. As the Complainant did not get any response from the O.P., the complainant  has filed the present complaint before this Commission being the cost of treatment and the policy amount of Rs.4,00,000/- and compensation for mental agony and harassment, apart from the cost of litigation. 

Hence this case. 

 

The O.P. National Insurance Company Ltd. has contested the claim raised by the Complainant by filing written statement refuting the allegations of the Complainant. The O.P. has denied negligence and deficiency on his part in dealing with the claim of the Complainant. In the written objection is stated that the Complainant at Para-8 of his complaint has mentioned that he spent Rs.64,234/- for treatment purpose whereas at Para-10 he claimed the sum assured i.e. Rs.4 lakh. It is further stated that there was no deficiency of service or negligence by the O.P. in rejecting the claim as per Clause No.4.19 of National Mediclaim Policy. It is also stated that O.P. repudiated the claim as per Exclusion Clause Sl. No.4 of the policy. Hence, the claim is not tenable in law as such liable to be dismissed. 

 

3. EVIDENCE ADDUCED BY THE PARTIES:

The Complainant examined himself as PW-I and submitted his examination in chief by way of affidavit. He has produced 14 documents comprising 51 sheets under a Firisti dated 10/12/2020 & 14/07/2021 but documents are not exhibited.  

The O.P. did not adduce any evidence.  

 POINTS TO BE DETERMINED:- 

 

4.  Based on the contentions raised by both the parties the following issues were framed for determination:  

   (I). Whether  there was/is  any deficiency of service committed by the O.P. towards the Complainant?

     (ii). Whether the Complainant is entitled to get any  compensation/relief ?

 

5. ARGUMENTS OF BOTH SIDES:

      We have heard arguments from both sides. At the time of argument, Learned Counsel Mr. S. C. Sen on behalf of the Complainant submitted that the original documents are lying with the custody of the O.P. and as a result the photocopy of the documents are submitted by the Complainant. He further submitted that  Complainant Sri Mahapravu Saha in his examination-in-chief on affidavit deposed that he has a mediclaim policy and he was admitted as indoor patient as per advise of Specialist Doctor on 08/11/2018 in the Dr. Mohan's Diabetes Specialities Centre, at 6 Conran Smith Road, Gopalapuram, Chennai-600086 due to fluctuating Blood sugars, backache, neck and hand tremors, muscle spasm on back and constipation. For that purpose he spent Rs.64,234/- only. After discharged from the Hospital he submitted his all treatment paper in original along with report and cash memo to the O.P. in time. But the O.P. never gave any positive reply. Learned Counsel further argued that finding no alternative Complainant filed this instant complaint for compensation. Learned Counsel of the Complainant further submitted that O.P. did not adduce any evidence to rebut the oral evidence of the Complainant. So, the Complainant is entitled to get the mediclaim amount as well as compensation.   

On the other hand Learned Counsel Mr. S. Datta Choudhury submitted that Complainant has failed to exhibit any documents and that is why O.P. did not adduce any evidence. The Oral evidence is not enough to grant any relief to the Complainant as claim petition is based on documentary evidence. Mr. Datta Choudhury submits that since Complainant has failed to exhibit any documents, he is not entitled to get any relief and claim petition is liable to be dismissed. 

 

6. DECISION AND REASONS FOR DECISION:

Both points are taken-up together for convenience for decisions. 

We have considered the submission of both sides and we have perused the pleadings of both parties and also the oral evidence adduced by Complainant. Though, the Complainant failed to exhibit any documents but we have taken-up for consideration the un-exhibited documents submitted from the side of the Complainant. The Complainant submitted a photocopy of repudiation letter dated 01/03/2019 issued by Sr. Divisional Manager, National Insurance Company Limited, Agartala Division the said letter is reproduced here:- “the TPA M/s. Vipul Med Corp Insurance TPA Private Ltd. has repudiated the claim as per their opinion: Admission for blood sugar level monitoring and adjustment of Anti-diabetic medication. Admission for diagnostic and evaluation purpose. Hence recommended for rejection of claim under clause No.4.19 of National Mediclaim Policy. 

In view of the above, we are also agreeing with their opinion that the claim does not seem to fall within the purview of consideration for settlement under the clause No.4.19 of standard National Mediclaim Policy. Hence, this is to inform you that the subject claim is stand repudiated on the reason as stated above from our end.”

Apart from this repudiation letter we have also perused the treatment papers as well as Doctor's certificate and after careful consideration of the un-exhibited documents we found that O.P. has rightly repudiated the claim and there is no ground for interference. 

 

7. In the result, we are in the opinion that the Complainant has not been able to prove his claim U/S 35 of the Consumer Protection Act, 2019. 

                  Accordingly, the complaint is dismissed and no costs. Supply a certified copy of the judgment to both the parties free of cost.    

 Announced.

 

SRI  RUHIDAS  PAL

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA

 

 

 

DR (SMT)  BINDU  PAL

MEMBER, 

DISTRICT CONSUMER DISPUTES 

REDRESSAL COMMISSION, 

WEST TRIPURA,  AGARTALA

 

 

SRI SAMIR  GUPTA

MEMBER,

 DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA.