West Bengal

Paschim Midnapore

CC/54/2015

Sri Debasis Dey - Complainant(s)

Versus

The Manager, National Insurance Co. Ltd. - Opp.Party(s)

Swapan Bhattarcharya

28 Jul 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

and

Mrs. Debi Sengupta, Member

   

Complaint Case No.54/2015

                                                       

Sri Debasis Dey, S/o-Madhsudan Dey

at Sangat Bazar, P.O.-Midnapore P.S.-Kowtali,   Dist-Paschim Medinipur…..….………Complainant

Versus

The Manager,The National Insurance Co. Ltd.,

at Inda, (OT Road),Kharagpur, Dist-Paschim Medinipur

and another ……………………….……Opposite. Parties.

 

 For the Complainant: Mr. Swapan Bhattacharya, Advocate.

 For the O.P.              : Mr., Mrinal Kanti Chowdhury,Advocate.        

 

 

Decided on: -28/07/2016

                               

ORDER

   Mrs. Debi Sengupta, Member - The case of the complainant in a nutshell is that the complainant is a bonafide policy holder of the Op. No.1-National Insurance Company. The policy of the complainant is a mediclaim policy bearing policy no.153802/48/12/500000972. The validity of the said policy is on 29/01/2013 to 28/01/2014. The complainant submits that on 14/01/2014 all on a sudden the complainant fall in chest put and he was taken to B.M. Birla Heart Research Centre  on the same day. The concerned Dr. after examination detected that the complainant was attacked by coronary artery disease. The complainant states that he has spend a

Contd……………….P/2

( 2 )     

sum of Rs.3,52,942.25/- from his own pocket for his treatment and there after submitted claim form with all relevant documents to the Op. No.1 through its T.P.A. the Op. No.3. As per the terms and conditions of the policy the complainant entitled to Rs.1,50,000/- as sum assured money plus amount of bonus. Considering the documents the Op. No.1 has paid a sum of Rs.1,15,000/- only  in the Bank a/c of the complainant through RTCS on 06/08/2014 but no documents has been  produced to the complainant regarding insufficient  settlement amount by the Op. No.1.  Thereafter the complainant met the Op. No.1 on several times and lastly on 11/02/2015 the complainant demanded to the Op. No.1 to pay actual sum assured and also bonus amount which the complainant  entitled to get. At first the Op. No.1 assured to the complainant but lastly on 11/02/2015 the Op. No.1 refused the complainant.

 Findly no other way the complainant has come before the Hon’ble Forum for proper redress. The  complainant states and submits that he is  entitled to get Rs.1,50,000/- only as sum assured and Rs.25,000/- only as bonus from the Op. No.1 but the Op. No.1 with some malafide intention refused to pay that amount to the complainant. So  there is deficiency of service on the part of Op. as contained by the complainant. The  complainant therefore prays before the Hon’ble Forum to pass necessary order  directing the Op. No.1 to pass rest sum assured money of Rs.45,000/- and bonus amount of Rs.25,000/- only with interest  to the complainant. The complainant also prays for compensation of Rs.20,000/- for deficiency in  service on the part of the Op. and also prays for a litigation cost of Rs.5,000/- and other relief or  reliefs.

The Op. contested the case by filing written objection challenging that the complainant case is barred by limitation estoppels, acquiescence and waives. The petition of complaint is not maintainable in law and also in the present form and prayer. The Op. denied and disputed that the allegation made in the petition of complaint. The  Op. denied all the facts in all the para(3) of the complaint petition. The Op. begs to state that as per the terms and condition of the policy the complainant is entitled to Rs.1,50,000/- as sum assured and Rs.25,000/- only as bonus and Op. also states that no documents has been produced by the Op. no.1 regarding insufficient settlement by the Op. No.1. Op. No.1 also states there is no malafide intention to pay the amount to the complainant. So there is no deficiency of service on the part of the Op. no.1 and the prayer of the complainant is improper, illegal and unjustified.  Op. submits that the complainant submitted claim form along

Contd……………….P/3

( 3 )    

with related papers and from the  said claim form the Op. party came to know that the complainant admitted in B.M. Birla Heart Research Centre. After submitting the claim form the Op. due process of law settled the claim of Rs.1,15,000/- which was sent to the account of Debasish Dey through R.T.O.S. on  06/08/2014  paid to the complainant against bill of Rs.3,20,000/- Op. states that there was deduction  of Rs.2,37,941/- from the claim amount of Rs.3,52,941/-. The Op.  states that such deduction was made for various investigation, Medicine O.T. and other miscellaneous charges as per package of Op’s TPA. Roth shield Health Care Service Limited. Such deduction has been clarified against each item in  details.

Therefore the Op. argued and states that it can not be said that there is any deficiency in service from the side of the Op. and the settlement of claim of Rs.1,15,000/- can not be said to be  unjust and improper and prays for dismissal  of the above instant case with cost.

Upon the case of both parties the following issues are framed.

Issues :-

1. Whether the case is maintainable;
2. Whether there is deficiency of service ?
3. Whether the complainant is entailed for getting relief as prayed for :-

 

                                Decision with reason

Issues nos. 1 to 3.

All issues are taken up together for discussion as those are inter linked with each other  for the purpose of arriving at a correct decision in the dispute.

Ld. Advocate for the complainant made his argument that the case is maintainable under the statutory provisions of Consumer Protection Act. It is to be member here that neither the complainant nor the Op. adduced any evidence either oral or documentary but they have relied upon some documents.

Ld. Lawyer for the complainant argued that  according to the plicy condition complainant is entitled of Rs.1,50,000/- only  as sum assured and Rs.25,000/- only as bonus but the Op. no.1 with some malafide intention did not pay the amount to the complainant as such Op. no.1 has caused deficiency in service. At first Op. No.1 assured the complainant but lastly on 11/02/2015 the Op. No.1 refused the complainant. Having no other alternative the complainant has filed the instant compliant before the Hon’ble Forum.

Ld. Advocate for the Op. argued and replied that the complaint made in the petition of complaint are not correct and the allegation made against the Op. is

Contd……………….P/4

(4 )    

disputed and denied. Ld. Advocate further argued that as per policy condition the complainant is entitled to Rs.1,50,000/- only as assured sum and Rs.25,000/- only as bonus. The claim submitted by the complainant to Op. settled the claim of Rs.1,15,000/- which was paid to the complainant against bill of Rs.3,20,000/- as Rs.2,37,941/- has  been deducted from the claim amount of Rs.3,52,941/- and such deduction was made  with the reason being  investigations, medicine and other miscellaneous charges. As per package the Op parities TPA Rothsheild Health Care Service Limited deducted the inadmissible expenses and they have clarified each items in details Ld. Advocate states that the settlement of claim of Rs.1,15,000/- is not unjust and improper.  So there is no deficiency of service on the part of the Op. as alleged by the complainant and the reliefs claimed by the complainant be dismissed with cost.

We have carefully considered the case of both parties including there documentary evidence.

In view of the facts and circumstances we find that there is scope to accept the plea of the complainant.

Thus the complainant should get relief in terms of the prayer made in the petition of complainant.     

Hence, it is

                 Ordered

                               that the complaint case and the same is allowed on contest against Op. No.1.

                                      Op. no.1 is directed to pay the rest sum of Rs.45,000/- and bonus amount of Rs.25,000/-  of mediclaim to the Complainant.  Op. no.1 also be directed to pay compensation of Rs.5,000/- and Rs.2,000/- for litigation cost. All such payment shall be made  within 30 days from the date of this order.

                                    Let plain copy of this order be given to the parties free of cost.                   

                  Dictated and Corrected by me

                                 Sd/- D. Sengupta.                                                                 Sd/-B. Pramanik. 

                                     Member                                                                                 President

                                                                                                                                District Forum

                                                                                                                            Paschim Medinipur