DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

WEST TRIPURA :  AGARTALA

 

 

CASE   NO:   CC- 02 of 2019

 

1. Shri Amitava Das Gupta,

S/O- Late Amiya Bandhu Das Gupta

Residing at Military Road, Krishnanagar,

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

Pin-799001, Dist.- West Tripura.

 

2. Shrimati Iva Das Gupta,

W/O.-Shri Amitava Das Gupta,

Residing at Military Road, Krishnanagar,

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

Pin-799001, 

Dist.-West Tripura,.…..................…...........................Complainants.

 

 

     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 BAMDEB MAJUMDER

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL FORUM,

      WEST TRIPURA, AGARTALA. 

 

SMT. Dr. G. DEBNATH

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

SRI U. DAS

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

 

C O U N S E L

 

For the Complainants : Sri Bhopal Chandra Biswas,

  Advocate. 

For the O.P. : Sri P. K. Debnath,

  Advocate. 

 

 

JUDGMENT  DELIVERED  ON: 24/07/2019

J U D G M E N T

The complainant Shri Amitava Das Gupta having been authorized by  his wife Smt. Iva Das Gupta, the Complainant No.2  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 the Complainant No.1 Sri Amitava Das Gupta and his wife Smt. Iva Das Gupta, the Complainant No.2 have jointly purchased Mediclaim Policy No.322700/48/2017/836 from the O.P. Oriental Insurance Company Ltd., Agartala on payment of due premium. The Policy was valid for one year commencing from 30/12/2016. During the valid period of the policy the wife of the Complainant namely Smt. Iva Das Gupta had suddenly fallen ill on 04/12/2017. She was first taken to Devlok Nursing Home & Hospital and on the same night she was shifted to ILS Hospitals, Agartala as her conditions had deteriorated. She had to be shifted to the ICU of the said Hospital on the same night and was placed under ventilation. She was treated in the ILS Hospitals as an indoor patient and was under medication. She was discharged from the Hospital on 07/12/2017. The Complainant on 07/02/2018 filed medical bill of her wife Smt. Iva Das Gupta before the O.P. the Divisional Manager, Oriental Insurance Company Ltd, Agartala with all original documents like certificates, cash memos & Pathological test reports etc. in connection with the cost of medical treatment which had been undertaken at the Devlok Nursing Home & Hospital and the ILS Hospitals, for getting the amount reimbursed. According to the Complainant an amount of Rs.64,011/- had been incurred towards the medical treatment of his wife.

Before filing the complaint, legal notice was also served upon the O.P. from the Complainants' side on 14/08/2018. As the Complainants did not get any response from the O.P., the complainant No.1 has filed the present complaint before the Forum on behalf of his wife Smt. Iva Das Gupta claiming Rs.64,011/- being the cost of treatment with 12% interest P.A. over the said amount, Rs.15,000/- as compensation for mental agony and harassment, apart from the cost of litigation. 

Hence this case. 

The O.P. Oriental Insurance Company Ltd. has contested the claim raised by the Complainant by filing written statement refuting the allegations of the Complainant. The O.P. has denied negligence and deficiency on his part in dealing with the claim of the Complainant. The O.P. asserted that the O.P. Company was not aware of any claim report having been filed from the side of the Complainants within 48 hours of admission of the Complainant No.2 in the Hospital. The O.P. has stated in his written objection that the policy of the complainants' was endorsed in the name of Raksha Health Insurance TPA Pvt. Ltd. and as such all the rights and privileges of the assigned policy had been vested to the TPA Pvt. Ltd. who is to recommend settlement of the claim of the Complainants as per the terms and conditions of the policy.  The O.P. has further stated in his W.O. that on 08/01/2019 a letter was issued by registered post to the M/S Raksha TPA Pvt. Ltd, Guwahati, Assam requesting for sending back the original claim file of the Complainant to him and that the O.P. is yet to receive the same from the TPA Pvt. Ltd. The O.P. has prayed for leave of the Forum to file additional / amended W.O. if found necessary at a letter stage of the proceedings after receipt of the relevant documents / report from the TPA Pvt. Ltd.

    Denying any sort of deficiency of service on his part towards the Complainants', the O.P. has prayed for dismissal of the complaint with costs.          

 

 3. EVIDENCE ADDUCED BY THE PARTIES:

In support of the Complaint, the Complainant Sri Amitava Das Gupta has been Examined as PW-1 and produced 39 documents comprising 60 sheets. The documents are marked  Exhibit-I series. 

On behalf of the O.P. one witness namely Sri Gautam Banik, Assistant Manager, Oriental Insurance Company Limited has been Examined. The said witness has adduced 03 document comprising 11 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  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. DECISION AND REASONS FOR DECISION:

We have heard arguments from both sides' Advocates. 

  It is evident from the pleadings of the parties that the Complainants had purchased Mediclaim Insurance Policy from the O.P. and that during the valid period of the Policy the Complainant No.2 Smt. Iva Das Gupta became seriously ill on 04/12/2017 for which she was first taken to Devlok Nursing Home and Hospital and on the same date she had to be shifted to ILS Hospitals Agartala as her conditions found to have been deteriorating. She was treated in the ICU of the ILS Hospitals and was placed under ventilation. On completion of her treatment she was discharged on 07/12/2017. From the case record we find that on 07/02/2018 the complainant No.1 for the first time submitted medical bill along with all original documents like certificates, cash memos & Pathological test reports etc to the O.P. for an amount of Rs.64,011/- being the cost of treatment of his wife Smt. Iva Das Gupta for reimbursement. But till filing of the complaint on 07/01/2019, the O.P. did not settle the claim though legal notice was also served upon the O.P. on 14/08/2018.

  After thorough checking of the claim papers including money receipts etc. we find that the Complainant had incurred Rs.60,901/- for the medical treatment of his wife. It is evident from the evidence-in-chief on Affidavit of the OPW and assessment report dated 04/06/2019 of the Raksha Health Insurance TPA Pvt. Ltd. under Exhibit-A series that an amount of Rs.47,172/- has been assessed and recommended to be payable to the Complainant instead of Rs.64,011/- as claimed by the complainant.  We have thoroughly checked the assessment report submitted by the TPA Pvt. Ltd. and also the Mediclaim Insurance Policy of the Complainants. 

  We find that the TPA as per clause 1.2..b of the Insurance Policy has deducted Rs.1,000/- as ICU stay expanses for two days out of the claim raised by the Complainants in this respect of Rs.9,000/-. We noticed that as per the Insurance Policy the sum insured in respect of the Complainant Smt. Iva Das Gupta was Rs.2 lac.   Hence, as per the terms of the policy under clause 1.2.b, the ICU stay expanses per day should not exceed 2% of the sum insured or Rs.10,000/- per day which ever is less. So, according to us the TPA did not commit any wrong in deducting Rs.1,000/- from the claim amount of Rs.9,000/- as ICU stay expanses.                   

    We also find that other deductions which had been made by the TPA and the grounds for which these were made does not appear to us in conformity with the terms and conditions of the Insurance Policy. The TPA also did not mention in the assessment report as to the violation of which terms and conditions of the Insurance Policy, the deductions were made by them.  We noticed that the expanses were incurred for the purpose of medical treatment of the Complainant No.2 and the expenses have been supported by the documents issued by the Appropriate Authorities. Hence, we have relied upon those documents produced by the complainant No.1.

      As discussed above, we find  that the Complainant is entitled to get Rs.59,901/-(Rs.60,901 – Rs.1,000/-) being the cost of medical treatment of the Complainant No.2. 

    In view of the discussion made above we find and hold that the complainants have succeeded in establishing their case U/S 12 of the Consumer Protection Act, 1986 against the O.P. 

6. In the result, the Complainant U/S 12 of the Consumer Protection Act, 1986 filed by the Complainant is allowed on contest. It is hereby directed that the O.P. shall pay Rs.59,901/- being the cost of medical treatment of the complainant No.2.  It is also directed that the O.P. will pay Rs.8,000/- as compensation to the Complainants for causing mental agony and harassment together with Rs.4,000/- as costs of litigation. The O.P. is to pay the aforesaid compensation of Rs.71,901/-(Rs.59,901/- + Rs.8,000/- + Rs.4,000/-) in total to the Complainants(the insured) within a period of 2 months from the date of judgment failing which the amount of compensation shall carry interest @ 9% P.A. till the payment is made. 

ANNOUNCED

 

 SRI BAMDEB MAJUMDER

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL FORUM,

WEST TRIPURA,  AGARTALA

 

 

 

 

 SMT. DR. G. DEBNATH,

 MEMBER, 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, 

WEST TRIPURA, AGARTALA

 

 

SRI U. DAS

MEMBER,

DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

 WEST TRIPURA,  AGARTALA.