Present : Biswanath De …. President
The complainant approached this Forum claiming due amount from the oP/Insurance company which was not paid by the oP/company regarding total cost of treatment in the hospital/nursing home.
The complainant’s case embodied in the petition in a precise form is that the wife of the complainant suffered fractured and was admitted Life Line Diagnostic Centre cum Nursing home for making surgery. The patient was admitted on 8.7.2014 in Life Line Diagnostic Centre, Kolkata -16 and released on 13.7.2014. Complainant submitted claim of Rs,.88,152/- for reimbursement . Op no.1 made payment of Rs.25,841/- for the first time and second time Op no.2 made further payment Rs.18,900/- on 24.6.2015. Thus total amount stand. 44,741/-. The balance amount of Rs.43,411/- is still unpaid inspite of correspondence , the complainant got no relief . Hence, this complaint.
The Op no.1 and 2 appeared by filing Written version denying inter alia all material allegations. Ops case is that as laid down in para 18 the claimant is not entitled to pay the amount of Rs.43,444/- as claimed, as per conditions of the Insurance policy contract to which both the parties and bound and this Op submits that as per condition of the policy and sum assured the oPs had already paid the amount to the petitioner . Further claim is not payable as per policy condition. Therefore, no deficiency of service does not arise. Hence, the case is deserved for dismissal. It appears that the OP did not state the policy condition.
Complainant filed photocopy of Insurance Policy, letter dated 9.9.2014 , photocopies of some payment receipts and other document. Complainant also filed Evidence in chief and W.N.A. Op on the other hand filed Written version, Evidence in chief and Written Notes of Argument.
POINTS FOR DECISION :
- Whether the complainant is a consumer ?
- Whether there is any deficiency in service on the part of the oP ?
- Whether the complainant/petitioner is entitled to get relief as prayed for ?
DECISION WITH REASONS :
All the points are taken together for the sake of convenience and brevity of discussion.
It is admitted position that the complainant lodged the claim regarding cost of expenditure of treatment of his wife being Rs.88,152/- . Op paid Rs.44,741/- and Rs.43,411/- is yet to be paid. So, complainant’s case is totally admitted by the oP. But OP does not state the reason why the complainant is not entitled to get the amount of Rs.43,444/-. Complainant has filed the Policy condition. Op advanced argument that some amount of money has been deducted based on the policy condition. But Op did not show before us what was the policy condition and reason for not payment . Even the op did not state anything in reply to the letter of the complainant requesting to pay the total amount. The Op did not file cogent documents or rules to substantiate their cause of deduction as laid down in the argument. But not mentioned in the Written version filed by the oP. Such conduct of the ops itself is negligence even the conduct of the OP before the Forum is full of negligence and non cooperation. Accordingly, as per material on records we have not hesitation to hold that complainant’s case which has been admitted by the oP Insurance company, Op must pay the full amount as per treatment cost given by the Nursing Home. It appears from the record that complainant spent Rs.88,152/- for the treatment of his wife and he also submitted the bill to the OP for payment. But the Op paid Rs.44,741/-. So the due amount is Rs.43,411/- to be paid by the Ops to the complainant.
So after deliberation of all the documents filed by both the parties and argument advanced by both parties , we are of opinion that the complainant has been able to substantiate his case and the complainant is entitled to get relief as per policy all expenditure. Hence it is –
Ordered
That the CC no.28 of 2016 be and the same is allowed on contest. The Ops are jointly and severally liable to pay Rs.43,411/- to the complainant being the due cost of treatment of the wife of the complainant. The Ops are also jointly and severally liable to pay Rs.10,000/- towards compensation to the complainant. The Ops are further jointly and severally liable to pay Rs.10,000/- to the complainant towards litigation cost. The Ops are directed to comply the above order within 45 days by issuing A/c payee cheque in favour of the complainant in case of failing to comply the above order within 45 days Rs.300/- per day shall be imposed upon the Ops till recoveries of all amount and that amount would be deposited in the Consumer Legal Aid Fund.
Let a copy of this order be made over to the parties free of cost.
