DATE OF FILING : 17.11.2015.
DATE OF S/R : 06.01.2016.
DATE OF FINAL ORDER : 08.03.2016.
Amit Kumar Jaiswal,
son of Prem Chand Jaiswal,
338, G.T. Road ( North ), Salkia,
Howrah 711106.………………………………………………….. COMPLAINANT.
1. The Manager,
United India Insurance Company Ltd.,
B 1, 8, N.S. Road,
Kolkata 700001.
2. The Manager,
United India Insurance Company Ltd.,
4/12, G.T. Road ( South ),
District Howrah,
PIN 711101……………..…………………………………OPPOSITE PARTIES.
P R E S E N T
Hon’ble President : Shri B. D. Nanda, M.A. ( double ), L.L.M., WBHJS.
Hon’ble Member : Smt. Jhumki Saha.
Hon’ble Member : Shri A.K. Pathak.
F I N A L O R D E R
- Complainant, Amit Kumar Jaiswal, by filing a petition U/S 12 of the C .P. Act, 1986 ( as amended up to date ) has prayed for a direction to be given upon the o.ps. to clear the amount of Rs. 47,493/- towards insurance claim, to pay Rs. 50,000/- as compensation for harassment physical and mental agony, cost along with other relief or reliefs as the Forum may deem fit and proper.
- Brief fact of the case is that complainant took one medi claim policy issued by o.ps. on payment of requisite premium for a period of 29.12.2013 to 28.12.2014 having policy no. 030600/48/13/97/00004940. The policy also covers his wife and infant son, Swyam Jaiswal. In this policy period, complainant’s infant son was required to be hospitalized for surgery of tonsil for which he incurred an amount of Rs. 63,200/- vide Annexures. Complainant subsequently filed claim with o.p. nos. 1 & 2 for imbursement of the said amount vide Annexure. But o.ps. released amount of Rs. 15,707/- only with respect to the said claim and repudiated the reimbursement of the rest amount of Rs. 47,493/-. Being dissatisfied and alleging deficiency in service against o.ps., complainant filed this instant petitioner with the aforesaid prayers.
- Notices were served. O.Ps. appeared and filed written version. So, the case heard on contest.
- Upon pleadings of both parties two points arose for determination :
i) Is there any deficiency in service on the part of the O.Ps. ?
- Whether the complainant is entitled to get any relief as prayed for ?
DECISION WITH REASONS :
- Both the points are taken up together for consideration. We have carefully gone through the written version and documents filed by o.ps, as well as the complainant and noted their contents. O.ps. have given in para nos. 3 & 4 of written version the details of the deductions made by them with respect to the medi claim amount submitted by the complainant. On going through the details, we find that o.ps. made all deductions under the heading ‘investigation, medicine, professional charges for surgeon / physician, bed charges and others.’ We think they have forgotten that hospitalization always involves the occupation of a bed by the patient. The patient had to undergo certain investigations without which the surgery could not have been performed perfectly by the surgeons or physicians. We are to keep in my mind that the patient is a baby. By deducting the amount incurred on major and important things, o.ps. are not only deficient in service, they have adopted unfair trade practice, too. They acted on their own sweet will which is utterly whimsical in nature. And by that, complainant was debarred from getting his legitimate claim. O.ps. should have remembered that foreseeing all unforeseen medical expenditure, people purchase the medi claim policy and for that, they pay the fees in the form of premium decided by the companies, like o.ps., herein. For getting his legitimate claim, complainant has been compelled to run from pillar to post which should not be allowed to be perpetuated any more. O.ps. have neglected to perform their duty towards the complainant for which o.ps. have been found to be deficient in providing service towards the complainant. When they have received the premium amount from the complainant, they ought to have been more careful about their duties. By not paying the rest amount of Rs. 47,493/- till date, o.ps. have showed gross negligence to the complainant. O.ps. in para 8 of their written version have also stated that “if insurer as repudiates a claim in good faith after due application of mind to all the matters concerning the claim, the act of the insurer cannot be challenged or questioned as an act of deficiency in service, so there is no deficiency in service on their part.” So according to such statement, we are to accept that the insurer, herein, o.ps. have applied their mind in the best possible manner in repudiating the claim of the complainant, which is not only unthinkable, unacceptable, too. Points under consideration are accordingly decided.
Hence,
O R D E R E D
That the C. C. Case No. 367 of 2015 ( HDF 367 of 2016 ) be allowed on contest with costs against the O.Ps.
That the O.Ps. are jointly and severally directed to pay Rs. 47,493/- to the complainant within one month from the date of this order. .
That they are further directed to pay to the complainant an amount of Rs. 3,000/- as compensation and Rs. 2,000/- as litigation costs.
That the o.ps. are further directed to pay the entire amount of Rs. 52,493/- to the complainant within one month from the date of this order i.d., the aforesaid amount shall carry an interest @ 8% per annum till full realization.
The complainant is at liberty to put the order into execution after expiry of the appeal period.
Supply the copies of the order to the parties, free of costs.
DICTATED & CORRECTED
BY ME.
( Jhumki Saha)
Member, C.D.R.F., Howrah.
