In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, 4th Floor, Kolkata-700087.
CDF/Unit-I/Case No.32/2012
1) Sankar Kumar Roy,
13, Bakul Bagan Row,
Kolkata-25, P.S. Bhowanipore. ---------- Complainant
---Versus---
1) The Divisional Manager,
The Oriental Insurance Co. Ltd.
P-41, Dobson Lane, 4th Floor, Howrah-711 101.
2) Woodlands Multispeciality Hospital Ltd.
8/5, Alipore Road, Kolkata-27, P.S. Alipore. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member.
Smt. Sharmi Basu, Member
Order No. 14 Dated 17-04-2013.
The case of the complainant in short is that complainant made his individual mediclaim policy with o.p. no.1 herein with coverage for the period from 25.8.11 to 24.8.12 (midnight) by making payment of premium for Rs.3842/-.
O.p. no.1 issued individual mediclaim policy having its policy no.311700/48/2012/2266 with coverage for the period from 25.8.11 to midnight 24.8.12 on payment of premium as aforesaid in favour of the complainant and the total sum assured of the said policy is Rs.1 lakh and the limit of domiciliary hospitalization was Rs.20,000/-.
Complainant took his first individual mediclaim policy for his own from o.p. no.1 in the year, 2010 and the said mediclaim policy number was 311700/48/2011/1541 with coverage for the period from 25.8.10 to 24.8.11 and the same has been renewed by the complainant on payment of premium as fixed by o.p. no.1 and they issued fresh individual mediclaim policy as aforesaid in favour of the complainant with the coverage for the period from 25.8.l11 to 24.8.12.
On 25.8.11, complainant felt serious chest pain at his residence and immediately he was removed to o.p. no.2 hospital for treatment and Dr. S.B. Roy of o.p. no.2 hospital attended and examined the complainant and advised for admission in cardiology ward of the said hospital. Complainant was admitted in o.p. no.2 hospital in Bed No.118A, on the same date i.e. 25.8.11 as advised by Dr. S.B. Roy and discharged from there on 27.8.11.
O.p. no.2 issued In-patient Discharge bill for Rs.17,348/- on 27.8.11 in favour of complainant for payment, but complainant could not pay the said amount of Rs.17,348/- to o.p. no.2 on the date of discharge as the said amount was not available to him. However, one Bijoyesh Dubey somehow attached with the said hospital and took charge for payment of the said amount on behalf of complainant and upon such undertaking of Bijoyesh Dubey, the complainant was discharged from the said hospital on 27.8.11.
The complainant submitted insurance claim form for Rs.17,348/- to o.p. no.1 on 29.8.11 in connection with the said individual mediclaim policy vide no.311700/48/2012/2266 covered for the period from 25.8.11 to 24.8.12. Complainant submitted claim form along with all relevant documents to o.p. no.1 for disbursement of the said amount of Rs.17,348/-.
O.p. no.1 by their letter dt.17.11.11 intimated to complainant that his insurance claim has been denied as per policy exclusion 4.10 and 4.23. In the said letter dt.17.11.11 they have stated that complainant was admitted in the hospital only for observation purposes and there was no active line of treatment.
Complainant submitted his claim form with all relevant documents in support of his claim but unfortunately o.p. no.1 repudiated the claim of the complainant without any just cause. Hence the case was filed by the 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 the case by filing w/v and matter was heard ex parte against o.p. no.2. Ld. lawyer of o.p. no.1 in the course of argument submitted that the case has got no merit and the same is liable to be dismissed.
Decision with reasons:
