Judgment  dt.3.5.2016

            This is a complaint made by one Diptendra Mohan De against the Divisional Manager, The New India Assurance Co. Ltd., Medicare TPA Services (I) Pvt. Ltd., praying for depriving the Complainant of claim of Rs. 2,762/- less paid with interest from 28.8.2014, for mental worries, anxieties and physical harassment and for litigation cost.

            Facts in brief are that Complainant and his wife Krishna De took a Mediclaim Policy bearing No.51060034132500001783.

            Complainant informed the Divisional Manager that the cataract surgery of the left eye of Krishna De was scheduled on 24.7.2014. The cataract operation was performed on the scheduled date at Suryodaya and the cost for that was Rs.28,880/-. On 5.8.2014 Complainant submitted a Claim Form being Claim No.T 1208141347 for Doctor Fees Rs.150/- ,Medicines Rs.238/- and Hospitalization Rs.28,880/- .

            On 28.8.2014 an amount of Rs.21,238/- was transferred to the bank account of Complainant by OP No.3 towards settlement of his claim. Since the payment for cataract operation was limited to Rs.24,000/-  Complainant requested OP No.1 to let him know the reason for less amount reimbursed than Rs.24,000/-.

            Complainant did not receive any reply. Thereafter, Complainant visited Divisional Manager on several occasions but of no use. He made representation to the Grievance Cell and informed the Deputy Manager there that he will be compelled to take legal measures. After that Mr. Pintu Saha, authorized signatory of OP No.3 by a letter dt.16.5.2015 informed that as per PPN Package only Rs.21,000/- is payable for cataract operation. Complainant failed to find any reference of PPN Package in the policy and so he approached the Kreta Sureksha Bhavan, Kolkata -700 087 where a tripartite meeting was held on 21.7.2015 but OPs remain absent.

            So, the Complainant files this complaint for realization of Rs.2,762/- , compensation and litigation cost.

            On the basis of above facts this case was admitted and notices were served upon the OPs but OPs did not appear. So the case is heard ex-parte.

Decisions with reasons

            Complainant files affidavit-in-chief and certain copies of the documents to be proved the allegation made in the complaint. Complainant has also filed written argument.

            The main point for determination is whether the Complainant is entitled to get the reliefs as prayed in the complaint.

            On perusal of the affidavit-in-chief it appears that Complainant has averred the facts of the complaint in the affidavit-in-chief.

            Further, on perusal of Annexure “A” it appears that the Mediclaim Policy has been issued in favour of the Complainants. Also it appears that for cataract operation for one eye there is a limit of Rs.24,000/- which Complainant has claimed since OPs did not contest the allegation of the Complainant it can be presumed that Complainant proved the allegation and is entitled to relief as prayed for.

Hence,

O R D E R E D

            CC/47/2016 is considered and allowed ex-parte.

            OP are directed to pay Rs.2,762/- to the Complainant within 2 months of this order failing which it shall carry the interest of 10% p.a. from the date of this order till realization. In addition OPs are directed to pay Rs.2,000/- as compensation for mental pain and harassment and Rs.1,000/- as litigation cost within this period. In default this amount also shall carry interest @ 10% p.a. till realization.

            CC/47/2016 stands disposed off.