In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No. 265/2012
1) Saroj Kumar Mukherjee,
42G, Babu Bagan Lane, Kolkata-31. ---------- Complainant
---Versus---
1) The Divisional Manager,
United India Insurance Co. Ltd.
Divisional Office–VIII, 2, Gariahat Road (South),
Kolkata-68, P.S.Lake. ---------- Opposite Party
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri ,Member
Smt. Sharmi Basu ,Member
Order No. 9 Dated 18-02-2013.
The case of the complainant in short is that a deduction of Rs.1820/- was made by the TPA of th e first party from his wife’s medical claim. On enquiry, the first party’s dealing officer sent an e-mail on 21.1.11 giving explanation on the deductions made from the claim amount. The explanation gives details of the items and corresponding exclusion clause nos. of the policy.
A complaint was lodged on 15.3.11 with the second party with facts and figures for redressal of grievance against the first party. Hearing was fixed on 15.3.12 by the second party and then an award was issued by the Insurance Ombudsman on 20.3.12 allowing reimbursement of the cost of Volini Gel. The award was not accepted by the complainant.
The first party rejected payment against MRD charges under Exclusion clause no.4.16. Keeping Medical Record Data is an essential and integral service like providing the hospital bed, the nursing staff etc. and hence the same cannot be excluded under clause no.4.16. As such, the amount withheld against MRD charges is due and payable.
The first party refused to reimburse OT consumable and pharmacy charges on the pretext that these are medical / non-medical equipment. Hence the case was filed by complainant with the prayer contained in the petition of complaint.
Sole o.p. i.e. 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. Ld. lawyer of o.p. in the course of argument submitted that the case has got no merit and the same is liable to be dismissed.
Decision with reasons:-
We have gone through the pleadings of the parties, evidence and documents in particular and we find that complainant had a mediclaim policy for his wife’s medical claim and the policy number was being 030800/48/10/97/00004713 and o.p. did not allow Rs.1820/- of complainant on flimsy ground and the reimbursement of the cost of Volini Gel was awarded by Ombudsman and the same was not accepted by complainant.
In view of the above position and on perusal of the entire materials on record we find that o.p. no.1 had sufficient deficiency being service provider to its consumer / complainant and complainant is entitled to relief.
Hence, ordered,
That the case is allowed on contest with cost against the sole o.p. i.e. o.p. no.1. O.p. no.1 is directed to pay to the complainant a sum of Rs.1645/- (Rupees one thousand six hundred forty five) only and is further directed to pay a sum of Rs.2500/- (Rupees two thousand five hundred) only towards miscellaneous cost incurred by the complainant for various charges and is further directed to pay compensation of Rs.5,000/- (Rupees five 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 @ 10% shall accrue over the entire sum due to the credit of the complainant till full realization.
Complainant is at liberty to file execution case before this Forum in case of non execution of the aforesaid order in its entirety within the stipulated period under the provision of the COPRA, 1986.
Supply certified copy of this order to the parties free of cost.
