West Bengal

South 24 Parganas

CC/275/2014

ASHOKE BHATTACHARYA , S/O. Late Shadhan Chandra Bhattacharjee. - Complainant(s)

Versus

THE MANAGER, STAR HEALTH AND ALLIED INSURAANCE COMPANY LIMITED. - Opp.Party(s)

30 Jul 2015

ORDER

DISTRICT CONSUMER DISPLUTES REDRESSAL FORUM

SOUTH 24 – PARGANAS , JUDGES’ COURT, ALIPORE KOLKATA-700 027

 

         C.C. CASE NO. _275_ OF ___2014_

 

DATE OF FILING : 20.6.2014                                 DATE OF PASSING JUDGEMENT: _31.7.2015___

 

Present                                      President       :   Udayan Mukhopadhyay

 

                                                  Member(s)    :    Mrs. Sharmi Basu & Jinjir Bhattacharya

                                                                             

COMPLAINANT                 : Ashoke Bhattacharya,s/o late Shadhan Chandra Bhattacharjee of Chakmir(N),

 P.O Santoshpur(M), P.S. Maheshtala, Kolkata – 142.

 

-VERSUS  -

 

O.P/O.Ps                            :1.     The Manager, Star Health and Allied Insurance Company Limited, 738/2, Diamond Harbour Road, 2^nd Floor, Behala Branch, P.S. Behala, Kol-8.

                                            2.     The Manager,  Star Health and Allied Insurance Company Limited, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.

                                           3.  The Manager, Star Health and Allied Insurance Company Limited6th Floor, K.R.M. Centre, No.2, Harington Road Chetpet, Chennai-600031.

________________________________________________________________________

 

                                                            J  U  D  G  E  M  E  N  T

 

Sri Jinjir Bhattacharya, Member

 

 

            The present complaint under section 12 of the C.P Act ,1986 has been filed alleging deficiency in service on the part of the O.P Insurance Company.

            Facts of the case, in brief, is as under:-

            The complainant purchased Mediclaim Insurance Policy no.P/191117/01/2012/002940 of the O.P for sum assured Rs.1,00,000/- for the period of 1(one year i.e. since 30.01.2012 to 29.01.2013) and became an insured person under the said Mediclaim Policy. The complainant, Police Holder, was admitted in the Ramkrishna Mission Seva Pratisthan Hospital twice in the year on 27.07.2012 and 06.10.2012 and discharged on 02.08.2012 and 10.10.2012 respectively for treatment and operation of Pancreatitis and Gall Bladder stone. He submitted both times after discharge the Claim Form with all original documents for treatment on two occasions in the Behala Branch office of the O.P. He personally attended O.Ps office but got no response from the O.Ps. On 16.8.2013 the complainant sent advocate’s letter to the O.P in this matter . In reply to that letter, the O.P on 29.8.2013 sent a letter demanding original documents which had already been submitted to the O.P at the time of making claim for treatment. Correspondences were further made from the end of the complainant and also from the end of the O.P. But the complainant did not get the claimed amount of Rs.37,883/- from the O.P.

 

            The O.P contested the case by filing written version wherein all material allegations of the complainant have been challenged. It is alleged that due to non-cooperation of the complainant regarding submission of documents the claim had not been entertained. So far it can be gathered from the written version, the O.P decided to settle the claim at Rs.12,834/- relying on the documents submitted by the complainant. The O.P expressed its desire of settling the claim at Rs.12,834/- before this Forum by a letter dated 10.11.2014. In the written version, the O.P has stated that as per policy exclusion clause ‘service charge’ of Rs.150/- and post hospital expenses of Rs.6549/- wee deductable from Bill dated 10.10.2012 and 11.10.2012. The O.P had denied any deficiency of service on its part and prayed for dismissal of the present complaint case.

                                                                        Decision with reasons

            Both the parties filed evidence in affidavit and questionnaires and replied to questionnaires. We find that the complainant has not filed all the documents in respect of medical expenses for treatment in the hospital on two occasions. He has not filed the policy for the period from 30.01.2012 to 29.01.2013 which he claims to have been issued under no. P/191117/01/2012/002940 for sum assured Rs.1,00,000/-. He has not even filed any documents to proceed that he filed claim Form along with documents of treatment and expenditure incurred for the treatment to the O.P . But it is an admitted position that there was a medical insurance cover of Rs.50,000/- for the period 13.01.2012 to 12.01.2013 (vide evidence on affidavit of the O.P). It is also evident from records that the O.P offered for settlement of claim by paying Rs.12,834/- after making deduction from the bill amount Rs.150/- and Rs.6549/- for some reasons. The O.P was given opportunity to produce documents of policy wherein terms and conditions for entitlement of claim for medical treatment have been stipulated. But the O.P did not dare to file policy documents despite getting opportunity to justify the deduction made. It is clear that the fact of admission of the complainant in the hospital for medical treatment on two occasions have not been denied by the O.P. But we find that the O.P was reluctant to settle the claim of the complainant and there is a deficiency in service on the part of the O.P.

            We hold that the complainant is entitled to get compensation for the mental agony and harassment caused to him by the negligent acts of the O.P and some litigation cost in addition to the cost of his medical trea5tment being insured with the O.P at the material point of time.

            Hence, we hold that the petition of complaint should be allowed in part.

 

 

 

 

            Hence, it is

                                                                                    Ordered

That the petition of complaint is allowed in part on  contest against the O.P.

The O.P is directed to pay to the complainant within 30 days from the date of this order by issuing account payee cheque in favour of the complainant as under:-

1.  Rs.19, 533/- towards medial expenses.
2. Rs.10,000/- as compensation.
3. Rs.7000/- as litigation cost

Failing which, interest @10% p.a will be payable from the due date for payment till realization.

Let a copy of this order be served upon the parties free of cost.

 

 

Member                                                           Member                                                                       President                    

Dictated and corrected by me

 

                        Member

 

                

                                                                                                                                                                                                                                                                                                                                                                       

The judgement in separate sheet is ready and is delivered in open Forum. As it is ,

 

                                                            Ordered

That the petition of complaint is allowed in part on  contest against the O.P.

The O.P is directed to pay to the complainant within 30 days from the date of this order by issuing account payee cheque in favour of the complainant as under:-

1.  Rs.19, 533/- towards medial expenses.
2. Rs.10,000/- as compensation.
3. Rs.7000/- as litigation cost

Failing which, interest @10% p.a will be payable from the due date for payment till realization.

Let a copy of this order be served upon the parties free of cost.

 

 

Member                                                           Member                                                                       President