DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA :  AGARTALA

 

 

CASE   NO:   CC- 79 of 2020

 

 

Shri Amitava Das Gupta,

Military Road, Krishnanagar,

P.O.-Agartala, P.S.- West Agartala,

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

 

 

 

-VERSUS-

 

 

 

The Divisional Manager,

The Oriental Insurance Company Limited,

H.G. Basak 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 : Shri Bhupal Ch. Biswas,

  Advocate. 

For the O.P. : Shri Prahlad Kr. Debnath,

  Advocate. 

 

 

JUDGMENT  DELIVERED  ON: 18/10/2021.

J U D G M E N T

The complainant Shri Amitava Das Gupta  set the law in motion by presenting the petition U/S 12 of the Consumer Protection Act, 1986 complaining deficiency of service committed by the O.P.  

  The complainants' case, in brief, is that on 25/06/2019 the Complainant all on a sudden became unconscious in the Toilet/ Wash Room of his house. His wife initially tried her level best to bring him to their bed room. But her efforts had gone in vain. She thereafter intimated the same to her / his relatives seeking their help. The Complainant's relatives, well wishers on getting the information of his physical conditions rushed to the Complainant's house and with their help, his wife shifted him to the ILS Hospital, Agartala and the doctors of the Hospital had admitted him as an indoor patient. Initially he was kept in segregation, he had to stay in the Hospital as an in-door patient with effect from 25/06/2019 to 01/07/2019. That the near relatives, friends and well-wishers of the Complainant did not allow the Complainant to stay at Agartala without further treatment. They sent him to the Institute of Liver and Biliary Sciences, Delhi for further check up. He had to stay there for treatment. However he did not tag the expenditure of treatment of Delhi Hospital with the instant claim though he was entitled to have it. He only tagged the Prescription of the Hospital as a proof of continuation of his illness. Thereafter, the Complainant filed to the O.P. his claim petition along with necessary certificates, cash memos for the re-imbursement of the amount which he had to incur for his treatment. He submitted the medical bill amounting to Rs.1,56,038/-(Rupees one lakh fifty six thousand thirty eight) only along with the all original documents for their kind perusal and for releasing the amount which he had to incur for his treatment. The O.P. and TPA on getting the claim petition of the Complainant asked him to explain some matters related to the treatment. The Complainant on receipt of the letters from the O.P. and its TPA intimated them that he was under the direct control of Dr. Dimbeshwar Das from the date of his admission till the date of release from the Hospital. All matters, reports related to his treatment were / are in the Computer of the Hospital. Dr. Das was / is the competent authority to satisfy the queries, if any, of the Insurance Company. The Complainant had received two letters from Raksha, Guwahati dated 09/01/2020 and 24/01/2020. Raksha by sending a message intimated the Complainant that the ILS Hospital Authority was / is not cooperating with them by providing information as per their queries. On getting the said mail, the Complainant intimated the matter to the Hospital Authority on 03/01/2020 with a copy to the Divisional Manager, Oriental Insurance Company Limited and the Raksha TPA Private Limited.  

Ultimately, the claim of the Complainant was repudiated by the O.P. on the ground that Complainant did not submit the necessary documents in respect of treatment and being aggrieved the claimant filed this complaint.   

Hence this case. 

 

On the other hand O.P. Oriental Insurance Company Ltd. has contested the claim by way of filing written objection and in their written objection it is stated that there is no cause of action for filing the complaint and complaint is bad for non-joinder of necessary party. It is further stated that the O.P. on 18/01/2019 issued a registered letter to the M/S. Raksha TPA, Guwahati and sent the original claim filed against the instant policy and the same yet to be received by the O.P. It is further stated that claim was endorsed in the name of TPA and privileges of the assigned policy had been vested to the TPA to settle the claim as per the rights and liabilities of the Complainant. So there is no question of harassment and negligence or any deficiency of service on the part of the O.P. It is further stated that the claim has been repudiated due to non submission of relevant papers / documents as asked by the TPA. It is also mentioned that the necessary documents for settlement are :-

 

I).   Treating Doctors certificate mentioning history of CLD, UTI, T2DM, BPH clearly specifying duration. 

ii). Original Investigation Reports, Bactec culture Anaerobic & Aerobic dated 25/06/2019, SPLANTI liver kidney Microsomal,  Spl Smooth Muscle Antibody dated 29/06/2019, Gastroscopy/Endoscopy dated 28/06/2019. These are the basic documents which the Complainant did not provide. More-over, the Complainant have submitted the claim form and other claim documents after delay of 154 days which violets policy terms & conditions and the complainant was requested to provide copy of complete set of Indoor case papers and vital charting with treatment chart but the Complainant did not provide the required documents and thus the O.P. Insurance Company could not settle the claim due to non submission of requisite papers/documents for which the claim is repudiated and repudiation letter is delivered to the Complainant on 11/11/2020.  

 

3. EVIDENCE ADDUCED BY THE PARTIES:

In support of the Complaint, the Complainant Shri Amitava Das Gupta has been Examined as PW-1 and produced 23 documents comprising 27 sheets. The documents are marked  Exhibit-I series. 

On behalf of the O.P. one witness namely Sri Gopal Krishan, Divisional Manager, the Oriental Insurance Company Limited has been Examined. The said witness has adduced 03 document comprising 27 sheets which have been marked Exhibit-A series. 

 POINTS TO BE DETERMINED:- 

 

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

   (i). Whether the proceedings are bad for non-joinder of necessary party and maintainable in law ?

    ii). Whether  there was  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:

Both sides submitted their written argument. In the written argument submitted by the Complainant side, it is argued that the Complainant filed his claim petition before the O.P. along with all original documents which are lying with them. It is further argued that the TPA got false statement in respect of furnishing documents. Ultimately, it is submitted that the Complainant is entitled to get the claimed amount Rs.6,66,038/- along with interest of 12% P.A. 

On the other hand Learned Counsel Mr. P. K. Debnath submitted that M/S. Raksha TPA Private Ltd. is a necessary party. The Complainant failed to make them as a party and in absence of TPA claim petition is not maintainable. Mr. Debnath further submitted that the ILS Authority is also proper party and the Complainant ought to make them party in this proceeding as because Complainant made a baseless  allegation against TPA as well as O.P., Insurance Company. Mr. Debnath submitted that it is admitted fact that Complainant did not submit the necessary documents which is mentioned in the letter addressed to the Complainant(Exhibit-I series). Mr. Debnath submitted that the Oriental Insurance Company Ltd. vide letter dated 18/03/2020 informed to the Complainant to provide requisite paper / documents as required by TPA, so that the O.P. may proceed for further development. It is also informed to the Complainant that he may visit their Office but Complainant did not provide the requisite papers as required by TPA. At last Mr. Debnath submitted that the complaint petition is not maintainable in law as well as facts.    

 

6. DECISION AND REASONS FOR DECISION:

Issue No. i). Whether the proceedings are bad for non-joinder of necessary party and maintainable in law:-

We have minutely gone through the complaint, written statement as well as the Exhibited documents. 

From the pleadings and documents we found that it is admitted fact that Raksha TPA Private Ltd. made correspondence with the Complainant for furnishing necessary documents in respect of treatment of the Complainant. Insurance Policy also speaks that the name of TPA is M/S. Raksha Health Insurance TPA Private Ltd. In the instant proceedings Complainant did not make TPA as a party. In our opinion Raksha TPA Private Ltd. is a necessary party. In the instant proceedings in absence of them this Commission can not decide the issues. So, we are in the opinion that the Complaint is bad for non-joinder of necessary party. 

Moreover, we found that ILS Hospital Authority is also a necessary party as the Complainant got his treatment from ILS Hospital and the treatment papers are lying with the ILS Hospital and Complainant failed to produce the necessary document to TPA. Accordingly this issue is answered in the negative.  

 

Issue Nos. - ii) & III) are taken up together for convenience:-

We have perused the complaint as well as the examination-in-chief on affidavit submitted by the Complainant. In examination-in-chief on affidavit the Complainant reproduced the entire facts of illness as well as the treatment and also mentioned details of documents which are filed by the claimant along with claim petition but it is not found in the list of documents that the Complainant has submitted the necessary documents which are asked by TPA. The Complainant stated that he was under the treatment of Dr. Dimbeshwar Das from the date of admission to till date of release from the Hospital. All maters, report relating to treatment were / are in the Computer of the Hospital. Dr. Das was / is the Competent Authority to answer the query if any of the Insurance Company. The Complainant further stated that he received two letters from Raksha, Guwahati dated 09/01/2020 and 24/01/2020. In his evidence he further stated that ILS Hospital Authority intimated the Petitioner over telephone that none approached them for having any information relating to the Medical Report as asked by the TPA. 

 

From the evidence of the Complainant it is very much clear that the Complainant did not submit the necessary medical report / documents as asked by TPA. From the evidence it is also found that documents are lying in the computer of the Hospital Authority.  

It is the duty of the claimant to submit the necessary medical report / documents which are required for the settlement of the medical reimbursement to the Insurance Company / TPA. In the instant case, we find that the Complainant did not cooperate with the O.Ps. and due to non-cooperation from the side of the Complainant his claim was repudiated and it is justifiable.      

         On over all appreciation of entire facts and circumstances as well as the evidence adduced by the parties we are in the opinion that the Complainant has failed to prove his complaint U/S 12 of the C.P. Act, 1986. 

      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.