Tripura

West Tripura

CC/14/44

Sri Nirmal Kumar Pal. - Complainant(s)

Versus

The Divisional Manager, Oriental Insurance Company Limited - Opp.Party(s)

Mr. D.D. Choudhury, Mr. F.Mia.

04 Dec 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSSAL FORUM
WEST TRIPURA : AGARTALA

    CASE NO:  CC-  44 of 2014

Sri Nirmal Kumar Pal,
S/O- Late Upendra Ch. Pal,
Town Pratapgarh,
Central Road Extension,
Agartala, West Tripura.    .............Complainant.
    
         ______VERSUS______

The Divisional Manager, 
The Oriental Insurance Company Limited,
Divisional Office, Central Road,
Agartala, West Tripura,

M/S Rakhsha TPA Pvt. Ltd. 
C/O- Escort Corporation Centre,
15/5, Mathura Road, Faridabad, 
Haryana-121003.            ...........Opposite Parties.
            

                    __________PRESENT__________

 SRI S. C. SAHA
PRESIDENT,
  DISTRICT CONSUMER  DISPUTES REDRESSAL FORUM,
      WEST TRIPURA, AGARTALA. 

SMT. Dr. G. DEBNATH
MEMBER,
  DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

SHR. B. BHATTACHARYA,
MEMBER,
  DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

 

C O U N S E L

For the Complainant    : Sri Dip Dutta Choudhury,
                  Sri Biplab Debnath and
                  Faruk Miah,
                  Advocates.
                                               
For the O.P. No.1        : Sri Basudev Chakraborty,
                  Advocate.

For the O.P. No.2        :  None appeared.

JUDGMENT  DELIVERED  ON:  04.12.15

J U D G M E N T
  
            This is a complaint U/S 12 of the Consumer Protection Act, 1986 (herein after referred to as 'the Act') filed by the complainant, Sri Nirmal Kumar Pal of Town Pratapgarh, Central Road Extension, Agartala, West Tripura against the O.Ps, namely The Divisional Manager, The Oriental Insurance Co. Ltd., Divisional Office, Central Road, Agartala, West Tripura and M/S Raksha TPA Pvt. Ltd., 15/5, Mathura Road, Faridabad, Haryana over a consumer dispute alleging negligence and deficiency in rendering service on the part of the O.Ps.
2.        The fact of the case as gathered from the record is that the complainant had taken a Mediclaim Policy No- 322700/ 48/ 2014/ 591 under the product name 'Individual Mediclaim Policy' for a sum assured Rs.1 lakh with one time premium of Rs.7,189/-. The date of commencement of the policy was 19.08.2013 covering the period for one year till 18.08.2014. The policy was purchased from the O.P. No.1, The Oriental Insurance Co. Ltd. through the 3rd party corporate agent, O.P. No.2, Raksha TPA Pvt. Ltd. As per terms of the policy, during continuance of the valid policy if any person admitted in the network hospital, it has to be reported to the Insurance company within 48 hours and the claim documents are to be submitted to the company within 7 days of discharge from the hospital. The complainant got admitted to Peerless Hospital and Research Centre Ltd., Kolkata as inpatient on 28.10.13 with the complaint of left lower quadrant pain and alternating loss motion or constipation. On being admitted to the said hospital he gave due information to the O.P. No.2. The fact of his discharge from the hospital on 01.11.13 also intimated to the O.P. No.2 within the stipulated time. He  spent a sum of Rs.27,948/- for his treatment in the said hospital. On being discharged from the hospital he made claim to the O.P. No.2  supported by necessary documents. But he did not get any positive reply from the O.P. No.2 as to the settlement of the claim. Finding no other alternative, on 13.11.13 he sent a letter to the O.P. No.1 for early settlement of the claim, but the O.P. No.1 did not respond to his letter. According to the complainant, the conduct of the O.Ps constituted negligence and deficiency in rendering service on the part of the O.Ps. Hence, this complaint.

3.        The complaint was contested by the O.P. No.1, The Oriental Insurance Co. Ltd. by filing written objection stating, interalia, that the O.P. No.2 was approached a cashless request  by Peerless Hospital & B,K. Roy Research Centre, Kolkata for the complainant. On getting such request, the O.P. No.2 had raised query to the hospital regarding treatment of the complainant but the hospital authority did not give any reply to their query. Further that, the complainant never preferred any claim before the O.Ps. In absence of notice of claim from the end of the complainant the case could not be settled. For that matter, the O.Ps can not be held responsible in any manner whatsoever. It is denied that the O.Ps were negligent and deficient in rendering service to the complainant.
4.            The O.P. No. 2 did not contest the case despite receipt of notice. Hence, the case has been proceeded exparte against him.
5.        In support of the case, the complainant has examined himself as P.W.1 and has proved and exhibited the documents filed by him with firisti on 20.03.15 as Exhibit- 1 Series.
6.        On the other hand, one Sri Goutam Banik, the Administrative officer of the O.P. Insurance company, has examined himself as O.P.W.1 and has proved and exhibited the following documents: 
        Exhibit A - E-mail dated 11th August, 2014,. 
           Exhibit B- The terms and conditions of Mediclaim Insurance Policy (Individuals) ,
        Exhibit C Series- Copies of Mediclaim Policies dated 04.08.12, 04.08.13 and 18.08.14. 
        Findings:
7.            The point that would arise for consideration in this proceeding is whether the O.Ps were negligent and deficient in rendering service to the complainant.
8.        We have already heard argument advanced by the learned counsel for the O.P. Also perused the pleadings, documents on record and the evidence adduced by the parties meticulously.
9.        It is the assertion of the complainant that during continuation of the valid Mediclaim Insurance Policy suddenly he had fallen ill and got admitted to peerless Hospital and Research Centre Ltd., Kolkata for his treatment. After receiving due treatment he was discharged from the hospital on 01.12.13. It is alleged by the complainant that though he preferred claim to the O.P. No.2, the 3rd party corporate agent of the O.P. No.1, within the specified time as laid down in the terms and conditions of the Mediclaim Policy of Insurance(Individual). But the O.Ps neither settled the claim nor responded to his letter dated 13.11.13 sent by him to the O.P. No.1.
10.            The O.P. No.1, the Insurer of the Mediclaim Policy, controverted the claim of the complainant stating that he  never  approached them for settlement of the claim. As per terms and conditions of contract of the Mediclaim Insurance Policy (Individuals), he did not give any notice to them within 7 days of discharge from the hospital. Since they did not receive any claim petition supported by the documents from the complainant, they were not in a position to settle the claim.
11.            It is the settled position of law that the party to the proceeding, who asserts something, the burden of proving lies on him to prove such assertion. In the present case, it is the plea of the complainant that on being discharged from the hospital he made his  claim to the O.P. No.2 as per procedure laid down in the contract. The complainant has failed to show any document to the effect that he preferred claim either to O.P. No.1 or to O.P. No.2 as per terms of Mediclaim Insurance Policy(Individuals). There is absolutely no document on record to suggest that he sent notice to the O.Ps for settlement of the claim as per provision laid down in the contract.  From the E-mail dated 11th August, 2014 (Exhibit A ) it appears that the O.P. No.2 received only a cashless request on 29.10.13 from the Peerless Hospital and B.K. Roy Research Centre, Kolkata for the complainant. Having received the said letter the O.P. No.2 raised query to the hospital, but the hospital authority did not respond to it. Since there is nothing on record to show that the complainant preferred claim along with supporting documents to the O.Ps as per terms of contract of the Insurance Policy, the O.Ps  can not be said to be guilty of negligence.
12.            For the reasons aforementioned,  it is ordered that the complainant may prefer claim along with supporting documents as envisages in clause 5.5 of the terms and conditions of the 'Mediclaim Insurance Policy (Individuals)' to the O.P. No.1, The Oriental Insurance Co. Ltd within 2 weeks from today, if so desired, who on receipt of such claim petition shall dispose of the same in accordance with law within 30 days. The complainant will have the liberty to approach the Forum if he is dissatisfied with the decision of the O.P. No.1 within 15 days of receipt of communication from him. 
        In view of what is stated above, the case is disposed of accordingly.  

        
13.                  A N N O U N C E D

SRI S. C. SAHA
PRESIDENT,
DISTRICT CONSUMER  DISPUTES 
REDRESSAL FORUM,
WEST TRIPURA,  AGARTALA.

 

 

 
SMT. DR. G. DEBNATH,
MEMBER,
  DISTRICT CONSUMER DISPUTES 
REDRESSAL FORUM, 
  AGARTALA, WEST TRIPURA.    SHRI. B. BHATTACHARYA,
MEMBER,
  DISTRICT CONSUMER DISPUTES 
REDRESSAL FORUM, 
  AGARTALA, WEST TRIPURA.