DIST. CONSUMER  DISPUTES  REDRESAL  COMMISSION

NORTH 24 Pgs., BARASAT.

C. C.  No. 72/2018

Date of Filing:                      Date of Admission:              Date of Disposal:

12.02.2018                                 19.02.2018                              20.02.2023

P R E S E N T                        :- Smt. Monisha Shaw …………………. Member.

                                                :-  Sri Abhijit Basu……………………….Member.

JUDGMENT / FINAL ORDER

This complaint is filed by the Complainant u/s 12 of the Consumer Protection Act, 1986 (as amended up to date) alleging deficiency in service as well as unfair trade practice against the OPs.

The Complainant hired service of the opposite parties by taking a family health insurance plan upon payment. The O.P. No. 1 is a private insurance company and deals with in general insurance of various type taking into account of the interest of the public at large and the O.P. No. 2 and 3 is TPA. The insurance coverage under a policy name and style group mediclaim “insurance scheme” and policy no. 030400/48/09/41/00003108 issued by O.P. No. 1 and also issued a policy certificate. The policy was issued in the name of the Complainant as insured by fiving coverage to the Complainant and other insured family members of the petitioners in the event of any hospitalization benefit was during the period from 01/11/2009 to midnight of 01/03/2019 and to that effect the Complainant regularly paid the premium in favour of the Opposite Party No. 1 to 3 as such all formalities were settled.

The Complainant further stated that his son named Anik Roy Chowdhury was suffered injury after falling from two wheeler on 01/07/2012 resulting injury on left knee joint and then the Complainant visited to the hospital for the treatment of his son and the said doctor has prescribed some medicines and advised to be admitted urgently before the hospital for better treatment so the Complainant admitted his son at G D Hospital and Diabetic institute on 01/07/2012 for better medical and therein he was operated and discharges from the said hospital on 28/07/2012.

During the said treatment, the said hospital charges are arising out of accommodation charges, consultant charges, diagnostics charges, procedures charges and pharmacy charges and the total figure of this charges comes to Rs. 2,11,398.44/- only out of which the bank has paid their part of liability amounting to Rs. 1,07,904.79/- and till date the insurance has not paid their part of liabilities.

The Complainant further stated that he submitted his first claim in respect of his son Anik Roy Chowdhury before the Opposite Party No. 1 to realize the benefit of insurance hospitalization benefit and the Complainant spend for the treatment of Rs. 2,11,398.44/- against the policy no. 030400/48/09/41/00003108 vide claim PFM No. 27438 . As per version of the Complainant it was mentioned that the sanctioned amount was Rs.1,07,904.79/- but did not sanctioned is Rs.1,03,493.65/-.

Contd. To page No. 2 . . . ./

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     C. C.  CASE  NO. 72/2018

The Complainant submitted that the 2^nd claim in respect of his son Anik Roy Choudhury and his wife  Rama Roy Chowdhury which were amounting to Rs.94,294/- and out of which the opposite party no 5 has already disbursed a sum of Rs.26,129/- and the rest amount is due for payment by the opposite party no 1 to 3 but they did not release the claim till to date.

The Complainant further stated relying upon the medical documents the OP No. 1to 3 assured that they will disbursed the claim but till to date they are not perform their part. The O.P. No. 1 contested the case by filing w/v on 09.0402019 vide order no. 7. The O.P. No. 1 stated that the complaint is not maintainable and it should be liable to dismiss and rejected the complaint. The OP no1 also stated that the OP no 1 did not issued such type of policy in the name of the Complainant as insured by fiving coverage to the Complainant and other insured family members of the Complainant in the even of any Hospitalisation Benefit during the period from 01.11.2009 to midnight of 01.03.2019 and denying the allegations of the Complainant. The O.P. No. 1 contended that the Complainant filed this case concealing fact and the complaint was nothing but vexatious complaint and the Complainant in a clandestine manner have not submitted relevant documents.

The OP No.1 admitted that the Complainant has taken an insurance under Group Mediclaim policy covered of Rs 2 lac under policy no 030400481141000005230 issued by OP No 1 United India Insurance Co. Ltd. to the Employee of the U.CO Bank. As per agreement with the UCO Bank at the time of issuing policy all the claims first lodged with the concerned bank itself which would pay at certain percentage of the claim as per bank’s policy. After their payment remaining portion of the claim will be submitted by the United India Insurance Co. Ltd,. for payment of balance payable amount with the help of TPA.

The O.P. also admitted that on 01/07/2012 the son of the Complainant Sri Anik Roy Chowdhury met with a road accident as a result he was admitted the hospital for treatment on that day. The son of the Complainant admitted to G D Hospital and Diabetic Institute Kolkata and he was operated by the doctor Tilak Mal and discharged from there on 28/07/2012. Again on 16/08/2012, Sri Anik Roy Chowdhury was admitted the same hospital and discharged from there on 22/08/2012. During this period for treatment hospital bill was Rs. 2,11,398.44/- and the concerned bank has paid amounting to Rs. 1,07,904/- out of 2,11,398.44/- only.

On the other hand, Smt. Rama Roy Chowdhury who is the wife of the Complainant was admitted to G D Hospital and Diabetic Institute, Kolkata under treatment of Dr. Uday Shankar Chatterjee on 18/08/2013 and discharged from there on 21/08/2013 due to calculus cholecystitis with diabetes, melitous, hypertension and dyslitidaemia and hospital bill was 18,228/-. Again on 05/09/2013 said Rama Roy Chowdhury admitted to the said hospital for surgery for cholecystectomy, done by Surgeon Dr. Aniruddha Dasgupta and she was discharged from thereon 08/09/2013 and the nbill comes of Rs.32,411.00, so total bill was Rs.18,228.00+Rs.32,411.00=Rs.50,639.00 and U.Co Bank has paid of Rs.26,129.00/- out of Rs.50,639.00 to Asish Kumar Roy Chowdhury and rest portion should be realized by O.P no. 1United India Insurance Co. Ltd. through TPA O.P No. 3.

.

Hence, the O.P. No. 1 prayed for dismissal of the case. The O.P. No. 2,3,4&5 did not contest the case.

From the contention of the parties as per the Complainant the written version and evidence the points for consideration in this case are whether the case is maintainable or not and whether the Complainant is entitled to get any relief or not.      

Contd. To page No. 3 . . .

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     C. C.  CASE  NO. 72/2018

Prayer of the Complainants:-

1. The O.P No. 1 to 3 are directed jointly and / or severally to pay the amount of Rs. 1,03,493.65/- only (for 1^st claim) and Rs. 68,165/- only (for 2^nd claim).
2. The O.P No. 1 to 3 are directed jointly and / or severally to pay Rs. 2,00,00/- towards mental agony, pain and unnecessary harassment and litigation cost of Rs. 10,000/-.
3. Pass any other order / orders as the Ld. District Commission may deemed fit and proper in the fact and circumstances of the case.

Following issued were framed for the purpose of decision:-

1. Whether the complaint is maintainable or not?

2. Whether the Complainant is entitled to get relief / reliefs in this case.

Decision with Reasons

Considering the facts and circumstances as well as nature and character of this case all the points are interlinked to each other and as such all the points are taken up together for consideration for the sake of brevity and convenience.

On proper study of the complaint filed by Asish Kumar Roychowdhury (Complainant) is the consumer within the meaning of Consumer Protection Act, 1986.

On perusal of the materials along with the supporting affidavit related to documents available in the case record as well as hearing of argument by the Ld. Advocate for the Complainant, it is revealed that the Complainant received an amount of Rs. 1,07,904.79/- out of 2,11,398.44/- as part payment towards consideration from the Opposite Party No. 4 and 5 and the rest amount i.e. Rs. 1,03,493.65/- should be paid by the O.P No. 1, 2 and 3.

Here the status of the OPNo. 1 to 3 are service provider and the Complainant being a customer of the OPs so the Complainant becomes a consumer as per Consumer Protection Act, 1986 (as amended up to date).

The Complainant resides 33/5, School Road, Natunpukur, P.O. and P.S. Barasat, Kolkata-700124, Dist- North 24 Parganas, W.B. and the O.P. No. 1 situated at Division-IV, Branbourne Road,, 3^rd floor, Kol-700001, O.P. No. 2 situated at Flat No.10, Paul Mansions,, 6B Bishop Lefroy Road, Kolkata-700020 and the O.P. No. 3 situated at 33A, 6^th Floor, Chatterjee International Centre, Jaharlal Nehru Road, Kolkata-700071 and the claimed amount does not exceed the pecuniary limit of this Commission. Therefore, this Commission has ample power to try this case.

The discussed points bear positive results.

As such we are of the view that the Complainant is entitled to receive the claim amount and he is also entitled to other relief/reliefs and that will be reflected in the ordering portion.

Thus all the points are disposed of accordingly.

Contd. To page No. 4 . . .

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     C. C.  CASE  NO. 72/2018

Hence, for ends of justice:

It is

 Ordered

That the instant case being no.CC- 72/2018 be and the same is allowed ex-parte against the OP No. 2,3with cost & 4&5 without cost.

The O.P No. 1to3 are  directed to pay the claim amount to the Complainant, Asish Kumar Roychowdhury of Rs. Rs.1,03,493.65/- within 2 months from this day.

The Complainant also do get a decree ofn Rs.5,000/-as compensation towards mental agony and Rs. 2,000/- as litigation cost.

The O.Ps are hereby directed to pay the aforesaid decretal amount to the Complainant within 02 months from this day, failing which the Complainant will be at liberty to put this decree into execution according to law.

Let plain copy of this order be given to the parties free of cost as per CPR, 2005. 

Dictated & Corrected by

           Member         

           Member                                                                                            Member