In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No.133/2011
1) Sri Mohit Minni,
10, Gurusaday Road, Flat No.2A,
2nd Floor, Kolkatga-19 ---------- Complainant
---Versus---
1) The Divisional manager,
The Oriental Insurance Co. Ltd.,
4, Lyons Range, Kolkata-1
2) The Oriental Insurance Co. Ltd.,
A-25/27, Asaf Ali Road, New Delhi-110002
3) Medicare TPA Services (I) Pvt. Ltd.,
Flat No.10, Paul Mansion, 65, Bishop Lefroy Road,
Kolkata-20, P.S. Bhowanipore ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member
Smt. Sharmi Basu, Member
Order No. 18 Dated 25/09/2012.
The petition of complaint has been filed by the complainant Sri Mohit Minni against the o.ps. The Oriental Insurance Co. Ltd. and others. The case of the complainant in short is that complainant purchased a Happy Family Floater Policy from the o.p. The o.p. no.3 is a TPA under o.p. nos.1 and 2. Complainant purchased the said policy vide no.311200/48/2011/1429 for coverage of the medical expenses of complainant and three others family members including his mother Madhubala Minni. Complainant during the continuation of the said policy suffered medical expenses for the treatment of his mother. The mother of complainant was admitted in the hospital for necessary management and subsequently she was discharged by the doctor. Complainant subsequently submitted the claim on 16.12.10 for reimbursement of the medical expenses of Rs.23,065.90 to o.p. Dr. Chittra Chakraborty issued the certificate on 16.12.10 certifying that Mrs. Madhubala Minni was operated on 30.11.10 for Dilation and cure Hage operation. O.p. nos.1 and 2 accepted the claim but finally on 3.3.11 repudiated the claim on the ground that surgery for which mother of complainant was hospitalized falls under 2 year waiting period. O.p. insurance company did not explain the clause under which they repudiated the claim. Hence the case.
O.ps. had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them. Ld. lawyer of o.ps. submitted in the course of argument that the claim in question has got no basis and case needs be dismissed.
Decision with reasons:
We have gone through the pleadings of the parties, evidence and documents in particular. It appears from the record that the complainant was not defaulter at the time of lodging claim for payment of the amount incurred by him for the operation of his mother and o.ps. did not cite this clause and such repudiation of claim is simply unjustified and unethical too and this action on the part of o.ps. amounts to gross deficiency of service to its consumer / complainant and complainant is entitled to relief.
Hence, ordered,
That the case is allowed on contest with cost against o.p. nos.1 and 2 and without cost against o.p. no.3. O.p. nos.1 and 2 are jointly and/or severally directed to pay Rs.30,065.90 (Rupees thirty thousand sixty five and paise ninety) only to the complainant for the medical expenses incurred by him for his mother together with interest @ 9% p.a. from the date of repudiation till the date of realization and are further directed to directed to pay to the complainants compensation of Rs.10,000/- (Rupees ten thousand) only for harassment and mental agony and litigation cost of Rs.3000/- (Rupees three thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 9% shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
