MRS. MANJUSRI SARKAR CHOWDHURY MEMBER FACTS This is a complaint u/s 35 of the CP Act, 2019 made by Nandita Saha alleging deficiency in service against the OPs i.e. OP No.1 & 2 and accordingly prays for a direction upon them for payment of Rs.14,055/-, to pay cost of Rs.50,000/- for mental agony and Rs.24,000/- towards cost of litigation. The Complainant had a health insurance policy namely, “Happy Family Floater – 2015 Policy Schedule” being No.311303/48/2021/8 which was issued by the Oriental Insurance Company Limited, 22, B.T. Road, Fourth Floor, Kolkata – 700002. The proposer for the said policy was Complainant’s son Partha Saha, Rupa Saha, Nandita Saha and Atmadip Saha which was renewed and valid from 26.04.2020 to 25.04.2021. The Complainant had some uterus as well as vaginal problem on 24.03.2021 for which she had to meet Dr. Jayanta Kumar Gupta of Apollo Gleneagles Hospital, Kolkata, West Bengal, 58, Canal Circular Road, P.S. – Phoolbagan, Kolkata. The said doctor advised her for urgent transfer vaginal USG with certain blood test, ECG etc and also to undergo operation for “Vaginal Hysterectomy” for which the date of admission was fixed on 11.04.2021 and the operation date was fixed on 12.04.2021. As stated in the petition of complaint, the Complainant applied for cashless facility as per protocol to OP No.1 on 10.04.2021 to which OP No.1 had sent one “Authorization Approval Letter” for Rs.48,600/- in respect of the above-said procedure. After being discharged from the hospital on 16.04.2021, the Complainant sent a letter along with relevant documents and bank details through her son on 28.06.2021 to the OPs who is the proposer to the OPs claiming an amount of Rs.22,312/- related to Pre and Post Hospitalization expenses. Thereafter, on 27.07.2021, the Complainant was credited with an amount of Rs.8,257/- to the savings bank account of her son, since the full amount was not paid as per her claim. The Complainant again sent a notice on 22.01.2022 claiming the balance of Rs.14,055/- and subsequently several notices were sent to the OPs claiming the balance amount. But the OPs failed to pay the legitimate claim of the Complainant as alleged. Thus, being old aged lady, having no source of income filed this instant case before this Commission along with certain relief(s) as discussed above. The OPs did not contest this case by filing written version despite notices were served upon them and finally the case was heard ex parte against them. Complainant adduced evidence and produced all relevant documents during the course of final hearing in support of her contention. POINT FOR CONSIDERATION Whether the Complainant is entitled to the relief(s) as claimed in this instant case? FINDINGS We have carefully perused the evidences and documents available with the record and also noted the submissions of the Ld. Advocate for the Complainant during the course of final hearing. On perusal of the record, it is noticed that the Complainant had one Mediclaim policy, namely, “Happy Family Floater – 2015” being no.311303/48/2021/8 which was issued by OP No.2 against the premium paid for Rs.22,468/- and the said policy had a validity period from 26.04.2020 to mid-night of 25.04.2021. What we find from the copy of the prescription of Dr. Jayanta Kumar Gupta of Apollo Gleneagles Hospital, Kolkata, West Bengal is that the Complainant had some uterus and as well as vaginal problem on 24.03.2021 and she was advised by the said doctor for urgent vaginal USG and was also advised for “Vaginal Hysterectomy” with certain blood tests, ECG etc. On further scrutiny of the documents available with the record it is found that the Complainant was admitted on 11.04.2021 and discharged on 16.04.2021 for the said surgery as discussed above against which a bill amount of Rs.57,800/- was raised by the Apollo Hospital and Rs.48,600/- as per the approval of the OPs were adjusted from the said bill. A copy of money receipt is also filed by the Complainant which reveals that the remaining balance of Rs.8,637/- was paid on behalf of the Complainant during the discharge from the Hospital. Now, the main contention of the Complainant is that after having submitted her claims on 28.06.2021 with the OPs in respect of pre and post hospitalization expenses amounting to Rs.22,312/-, wherein the OPs had only paid Rs.8,257/- against her claimed amount of Rs.22,312/-. Now, we need to discuss why and how the OPs ascertained and paid the amount of Rs.8,257/- out of Rs.22,312/- and whether the same was justified or not. Complainant had also filed a copy of passbook of her son wherein it is found that there was a transfer of Rs.8,257/- through NEFT on 27.07.2021. Therefore, it is clearly understood that the OPs have received the claims of the Complainant with regards to pre and post hospitalization expenses and so they have credited a part of the claim which is approximately nearest to pre-hospitalization expenses i.e. Rs.8,269.50/-. The copy of the policy reveals that the policy holder is also entitled for the post-hospitalization expenses if the same is claimed within 60 days. We also found one legal / demand notice claiming the said amount which is already with the record other than this, no such documents related to communications exchanged between the Complainant and the OPs are available with the record. Apart from these, Complainant filed certain copies of bills of medicines and diagnosis. Therefore, ongoing through the materials on record, we opined that the Complainant should get the said amount of Rs.14,055/- along with interest @9% p.a. from 27.07.2021 when the last payment was made by the OPs. This apart, Complainant is also entitled to Rs.3,000/- towards cost of litigation. Hence it is, ORDERED That the instant case be and the same is allowed ex parte against the OPs. OPs are directed to make the said amount of Rs.14,055/- (Rupees Fourteen Thousand Fifty-Five Only) and also to pay Rs.3,000/- (Rupees Three Thousand Only) towards cost of litigation to the Complainant. If the above-said order is not complied with by the OPs within 30 days from the date of this order, the Complainant shall be at liberty to proceed in accordance with law. Dictated and corrected by me Member | 
