West Bengal

Paschim Midnapore

CC/22/2015

Netai Chattopadhyay - Complainant(s)

Versus

The Manager, Cholamandalam MS General Insurance Co. Ltd. - Opp.Party(s)

21 Dec 2015

ORDER

                                                              DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

and  

Mrs. Debi Sengupta, Member.

   

Complaint Case No.22/2015

                                                       

Sri Netai Chattopadhyay………….………Complainant

Versus

          The Manager, Cholamandalam MS General Insurance Co. Ltd...Opp. Party.                               

 

 For the Complainant: Mr. Gabinda Prasad Jana, Advocate.

 For the O.P.               : Mr. Pinaki  Sengupta Advocate.

 

Decided on: - 21/12 /2015

                               

ORDER

                    Bibekananda Pramanik, President - Case of the complainant, in brief, is that the complainant is a resident within the jurisdiction of this Forum and the Op-Cholamandalam MS General Insurance Co. Ltd. is carrying on their insurance business through it’s branch office at Kharagpur which is also within the jurisdiction of this Forum.  Complainant is under Group Health Master Policy of the opposite party having policy no.2842/00101431/0001/000/00 with validity period from 06/09/2013 to 05/09/2014.  Within the time of coverage of that Insurance Policy, the complainant had to undergo for management of mental stenoisis/urethral stricture for surgical management and for that purpose he was admitted in the Seva Nursing Home, Padumbasan, Tamluk, Purba Medinipur, West Bengal. Such surgical management was done on 26/07/2014 by Dr. J.Khan and the complainant was discharged on 08/08/2014 from the said nursing home.  He had to spend Rs.38,483/- for his such medical treatment including bed charge,

Contd…………………P/2

 

( 2 )

surgeon fees, nursing expenses, etc. After operation, the complainant was under  medical treatment and bed rest and as such he could not intimate and make claim earlier. After recovery, the complainant  submitted claim form for insurance benefit of such medical treatment alongwith documents before the opposite party but the opposite party repudiated the claim on 09/10/2014 on the ground “ On perusal of the claim documents and hospital visit report, it is observed that the submitted documents are manipulated and fabricated.  This claim is inadmissible under general condition D-9”.  The opposite party intentionally repudiated the claim of the complainant with oblique motive.  The cause of action arose on 09/10/2014 when the opposite party repudiated the said claim.  Hence, the complaint, praying for directing the opposite party to pay Rs.38,483/- towards medical treatment under that policy with interest @ 15% p.a. from the date of filing of this complaint and also  for litigation cost of Rs.20,000/-.

                     Opposite party contested this case by filing a written objection.                    Denying and disputing the case of the complainant, it is the specific case of the opposite party that as per claim condition as well as documents of complainant, it is found that the complainant was admitted on 12/07/2014 of treatment of Post Operative Hernia and the said disease was not covered under the policy of Group Health Care Master Insurance Policy.  It is further contended that on verification of documents, submitted by the complainant, it was found that the submitted  documents were not in existence as per register of Seva Nursing Home  of Padmabasan and on investigation, it was established that the complainant was never treated in Seva Nursing Home for treatment post Operative Hernia.  The documents filed by the complainant were not genuine and those were manipulated for getting the benefit of the Insurance Policy by fraud practice and for that reason the complainant is not entitled to get any benefit according to policy terms and conditions no.D-9.  In such circumstances, the opposite party was compelled to repudiate the claim of the complainant and the said decision was conveyed to the complainant by the opposite party vide their letter dated 09/10/2014.  In the above circumstances, the opposite party claims dismissal of the complaint.    

Point for decision

                     Is the complainant entitled to the reliefs, as prayed for ?

 

Decision with reasons

                        In this case, the complainant has examined himself as PW-1 by

Contd…………………P/3

 

( 3 )

tendering a written affidavit-in-chief, duly supported by an affidavit.  During his evidence, few documents were marked as 1-series for identification.  Another witness namely Samarendra Nath Samanta has been examined in this case by the complainant as PW-2 and during his evidence, few documents were marked as exhibit-2 series.  On the other hand, opposite party adduced no evidence. 

                        Now let us consider as to whether the complainant has been able to establish his case or not. 

                       It is not denied and disputed that the complainant obtained a Group Health Care Master Policy from the Op-Insurance Company and the same was valid from 06/09/2013 to 5/09/2014.  It is also not denied and disputed that the complainant submitted claim form along with documents before the opposite party for reimbursement of his expenses of medical treatment from the opposite party by virtue of that policy. Admittedly, the opposite party repudiated the claim of the complainant by sending a letter dated 09/10/2014 on the ground that the documents, submitted by the complainant were manipulated and fabricated.  During the cross-examination PW-1, the complainant, it was suggested to him by the opposite party that there is no existence of any such nursing home and that he was not at all treated in the said nursing home, which PW-1 strongly denied.   Opposite party adduced no evidence to show and to prove that there is no existence of any such nursing home named Seva Nursing Home and that the documents filed by the complainant are manipulated and false.  On the other hand, the complainant has produced series of documents regarding his treatment in the said nursing home and he has also filed the Government license issued under the West Bengal Clinical Establishment Act, 1950 which shows that there is existence of Seva Nursing Home at Padumbasan, at Mecheda-Haldia Road.  So the said case of the opposite party that there is no existence of Seva Nursing Home and that the documents of medical treatment issued by that nursing home are fabricated and false, is baseless and imaginary.  Therefore repudiation of the claim for medical reimbursement of the complainant under that insurance policy by the opposite party was not at all justified.  It is, therefore, held that the opposite party is liable for deficiency in service and the complainant is therefore entitled to get favourable order against the opposite party.

                                         Hence, it is,

                                                           ORDERED,

 

                                                               that the complaint case no.22/2015 is

Contd…………………P/4

 

 

( 4 )

allowed  on contest.  Opposite party-Insurance Company is directed to settle the claim of medical reimbursement under Group Health Muster Policy of the complainant and to pay litigation cost of Rs.10,000/- to the complainant within two months from this date of order. 

             Dictated & Corrected by me

                               

                        President                                  Member                               President

                                                                                                                 District Forum

                                                                                                              Paschim Medinipur