C.F. CASE No.          : CC/08/54                                                                                                         

 

COMPLAINANT             :  Sri Sabyasachi Saha,

S/o Suklal Saha,

28 No. Kurchipote Lane,

P.O. Krishnagar, P.S. Kotwali,

Dist. Nadia.

 

       –  Vs  – 

 

OPPOSITE PARTIES/OPs   : 1. The Divisional Manager,

United India Insurance Co. Ltd.

Divisional Office No. XI, 2nd Floor,

Sudarsan Building, Old No. 14,

New No. 27, Whites Rd.

Chennai – 600014 ,

 

             : 2. The Manager, 

Indian Overseas Bank,

Krishnagar Branch, 16/1, D.L. Road,

Hugnitala, Bow Bazar,

Krishnagar, Dist. Nadia.

 

             : 3. The Authority 

TTK Health Care Services Pvt. Ltd.

2nd Floor, Anmol Palani,

G.N. Chetty Road, T. Nagar,

Chennai – 600017.

 

             : 4 Branch Manager,

United India Insurance Co. Ltd.,

Krishnagar Branch, D.L. Roy Road,

P.O. Krishnager, Nadia 

 

 

 

PRESENT              :  KANAILAL CHAKRABORTY             PRESIDENT

        :  KUMAR MUKHOPADHYAY          MEMBER

        :  SMT SHIBANI BHATTACHARYA       MEMBER Page 2 of 6

DATE OF DELIVERY             

OF  JUDGMENT               :    26th November, 2009.

 

 

:    J U D G M E N T    :

 

In brief, the case of the complainant is that on 04.02.07 he purchased a Group Mediclaim Insurance Policy under the name and style IOB – Health Care Plus from the OP, United India Insurance Co. Ltd. with endowment of Rs. 1,00,000/- and the annual premium of Rs. 3,038/- including accident cover of Rs. 47.00.   The petitioner applied for TPA but no TPA Card of policy paper was sent to him by the OP.  The policy covered the petitioner himself along with his wife, son and mother.   It is further case of the complainant that in March, 08 the petitioner became ill and he was initially treated by Dr. Brojeswar Mukherjee on 27.03.08 to 30.03.08.  Thereafter, on 31.03.08 he was admitted to Belle Vue Clinic, Kolkata under Dr. Subrata Moitra and was treated there up to 03.04.08.  The petitioner thereafter submitted claim application before the OP along with the relevant documents claiming Rs. 31,498.48 as the cost of his treatment.  From the reply of TTK Health Care Services Pvt. Ltd. the petitioner came to learn about the TTK identification No. and also the said TTK asked him to produce all the original documents.   Accordingly, on 17.06.08 he sent all the original documents by Courier Service to TTK Health Care Service Pvt. Ltd., but on 28.06.08 the said  TTK Health Care Service Pvt. Ltd. again sent a letter to this complainant which he replied on 10.07.08 stating everything with copy to the Manager, IOB Krishnagar Branch, IOB Regional Office, Kolkata  & IOB Central Office, Chennai.  Again he sent a letter to TTK Health Care Service Pvt. Ltd., Chennai, dtd. 18.08.08 requesting to disburse the claimed amount, but no step was taken on behalf of the OPs.  Rather the OPs illegally repudiated the claim of the of the policy by closing the file on false ground.   So having no other alternative, he has filed this case claiming for reliefs as stated in 

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the petition of complaint. 

The OP No. 1, United India Insurance Co. Ltd. has contested this case by filing a written version, inter alia, stating that the case is not maintainable in its present form and nature.  He has denied all the allegations made by the complainant against him.  His specific contention is that TTK Health Care Service Pvt. Ltd., Chennai was the TPA for the settlement of mediclaim policy to IOB account holders of the petitioner was a policy holder mediclaim for the period of 07.12.07 to 06.12.08.   This petitioner submitted claim along with xerox copy of documents on 09.04.08 and on receiving the same the TPA wrote a letter on 04.06.08 to the petitioner requesting him to submit all the original documents.  The TPA also sent reminder on 28.06.08, 14.07.08 and 18.08.08 asking him to submit no objection certificate from the hospital authority, but the complainant did not comply it.   So the TPA closed the case as per terms & conditions of the policy as all the supporting documents relating to the claim must be filed to the TPA within 7 days from the discharge from Hospital / Nursing Home, but the petitioner did not follow the conditions of the policy.   So there is no deficiency in service on the part of this OP and this complainant has no cause of action to file this case.  Hence, the case is liable to be dismissed against him.

The OP No. 2 has also filed a separate written version in this case, inter alia, stating that the complainant is the holder of one Bank Account with the OP Bank who has one insurance policy with the OP No. 1 & 2.  He has learnt from the petition of complaint that the complainant has not received the claim amount from the OP No. 1.  This amount is to be paid by the OP No. 1 who is the insurer and this OP No. 2 has no role to play in making payment of the claimed amount.  So the complainant has no cause of action to file this case against him and the same is liable to be dismissed.  

 

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POINTS  FOR  DECISION

 

Point No.1: Has the complainant any cause of action to file the case?

Point No.2:         Has the complainant become able to prove his case?

Point No.3:      Is the complainant entitled to get the reliefs as prayed for?

 

DECISION  WITH  REASONS

 

All the points are taken up together for discussion as they are interrelated and for the sake of convenience. 

On a careful perusal of the petition of complaint along with the annexed documents and the written versions filed by the OPs and also after hearing the arguments advanced by the ld. lawyers for both the parties, it is available on record

that the complainant purchased one Group Mediclaim Insurance Policy under the name and style IOB – Health Care Plus from the OP No. 1, United India Insurance Co. Ltd. with endowment of Rs. 1,00,000/- and the annual premium of Rs. 3,038/-.  The policy was valid for the period from 07.12.07 to 06.12.08.  During the valid period of the policy the complainant fell ill who was treated at Belle Vue Nursing Home, Kolkata from 31.03.08 to 03.04.08 and for this ailment, he spent Rs.31,498.48.  Thereafter, he submitted the claim application along with relevant papers before the OP.   Several correspondences were done between the parties, but ultimately the claim was not settled rather the OP repudiated the claim of the complainant on the ground that original papers were not duly submitted before him for settlement of his claim.  On this point, the complainant has categorically submitted that he sent all the original documents to the OPs by Courier Services to its Chennai Office in June, 08.   The receipt of the Courier Service is marked as Annexure – 3 which also supports the case of the complainant.  Perhaps in course of transit those 

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documents were lost.  So at the request of the OP the complainant thereafter submitted xerox copies of those documents for settlement of his claim but the OP did not settle the claim rather repudiated it.  It is submitted by the ld. lawyer for the complainant in course of his argument that during trial of this case the OP sent a cheque amounting to Rs. 28161/- on 06.04.09 which he received with objection to the OP No. 3 vide objection letter dtd. 23.04.09 and the said letter was sent through registered post.  In the said letter, he claimed to pay him Rs. 31,498.48 as per prayer of his complaint.  This is also stated by the complainant by filing an application on 25.05.09 and the said petition is supported by affidavit also.  Ld. lawyer for the OP has not denied this payment also.  So on a careful perusal of this petition and after hearing submissions of the ld. lawyers for the parties, we find that the OPs have accepted the claim of the complainant and in course of settlement paid him Rs. 28,161/-.   The complainant claimed Rs. 31,498.48 as cost of his treatment.   He has filed all the medical papers regarding his treatment at Belle Vue Nursing Home.  There is no denial on the side of the OP regarding his treatment as it is established through his payment of Rs. 28,161/- to this complainant.   Now the question is whether the complainant is entitled to get any further amount as compensation as per his claim.  The original claim application was filed before the OPs on 09.04.08 by the complainant.   Due to repudiation of the claim the complainant was compelled to file this case on 21.11.08 and the partial payment of Rs. 28,161/- was made by the OP on 06.04.09.   So we find that without having any cogent ground the OP harassed the complainant by non-settling his claim.   Rather he repudiated the claim of the complainant on flimsy ground.  So we hold that the complainant is entitled to get the compensation also in this case for the harassment caused to him and deficiency in service on the part of the OP.

In view of above discussions our considered view is that the complainant   is   entitled   to   get   the   entire   cost   amount   of   his   treatment + 

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compensation of Rs. 10,000/- + Rs. 5,000/- as litigation cost.   As the OP has already paid him Rs. 28,161/-, so the complainant is entitled to get cost of treatment of (Rs.31,498.48 – Rs. 28,161/-) =  Rs. 3337.48.    In result the case succeeds. 

Hence,

Ordered,

That the case, CC/08/54 be and the same is decreed on contest against the OPs.   The complainant is entitled to get Rs. 10,000/- + Rs. 5,000/- + Rs. 3,337.48/- = Rs. 18,337.48/-.   The OP No. 1 is directed to make payment of the decretal dues of Rs. 18,337.48/- to this complainant within a period of one month since this date in default the complainant is entitled to get interest upon the decretal dues @ 10% per annum since this date till the date of realization of the full amount.

Let a copy of this judgment be delivered to the parties free of cost.