IN THE COURT OF THE LD. DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT S I L I G U R I.
CONSUMER CASE NO. : 38/S/2015. DATED : 16.12.2015.
BEFORE PRESIDENT : SRI BISWANATH DE,
President, D.C.D.R.F., Siliguri.
MEMBER : SRI PABITRA MAJUMDAR.
COMPLAINANT : SMT. RITA THAKUR (DUTTA),
W/O Sri Tanmoy Dutta ,
10, Milan Mandir Road, Subash Pally,
P.O. & P.S.- Siliguri,
Ph. No. – 94343 28035.
O.Ps. 1. : THE NEW INDIA ASSURANCE CO. LTD.,
87, Mahatma Gandhi Road,
Mumbai – 700 001.
Represented by The Divisional Manager,
The New India Assurance Co. Ltd.,
having its office at Malhotra Tower,
H.C. Road, P.O. & P.S.- Siliguri,
Dist.- Darjeeling.
2. : THE DIVISIONAL MANAGER,
The New India Assurance Co. Ltd.,
having its office at Malhotra Tower,
H.C. Road, P.O. & P.S.- Siliguri,
Dist.- Darjeeling.
FOR THE COMPLAINANT : Self.
FOR THE OP Nos. 1 & 2 : Sri J. P. Pawa, advocate.
J U D G E M E N T
Sri Biswanath De, Ld. President.
The complainant’s case is succinctly summarized as follows :-
On 4th September, 2014, the husband of the complainant suffered a motor bike accident near Siliguri court. Mr. Tanmoy Dutta was injured. He was brought to the Dr. B. G. Das for treatment. After X-ray
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it was diagnosed patellar fracture. He was admitted Nursing Home for necessary operation on the next day. Operation was done in New Ramkrishna Seva Sadan by Dr. B.G. Das on 6th September, 2014, and implanted patella of left knee and her husband was released from the Nursing Home on 8th September, 2014. The matter was informed to the New India Assurance Company Ltd. on 5th September, 2014. The complainant then applied for reimbursement of her husband’s medical expenses with all necessary documents in original to the Divisional Manager. The complainant was informed that settlement would be done by 45 days. After 45 days the complainant got two letters from Medicare TPA. The complainant was requested to file pre and post operative reports, X-ray reports, original money receipt of hospital and Self declaration of the patient. On 20th November, 2014 those documents were sent to TPA by Speed Post. The complainant again got one letter from TPA on 28.11.2014 in which the complainant was asked to supply same documents. After some days, the complainant was told that the file was handed by a person who did not take proper action. After a sometime, Deputy Divisional Manager demanded self declaration from the complainant. The complainant being frustrated lodged a complaint for the settlement of the complainant to the Consumer Affairs & Fair Business Practices for pre-litigation mediation on 26.12.2014. Suddenly the complainant came to know that on 18.01.2015 has been fixed for hearing and hearing had been going inside a room. The Assistant Divisional Manager of the New India Assurance Company Ltd. came there, but the complainant was not informed in writing. In the said meeting, the complainant was present and Assistant Divisional Manager told the complainant for settlement within 20 days. Later on, after 2nd February, 2015, the complainant had been informed that the matter had been settled. The complainant came to know that settlement has been done for Rs.26,625/- against claim of Rs.43,725/-. The Insurance Company did not consider the claim of Rs.17,099/- for reason known to
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them. It is also complainant’s case that by accepting the amount in absence of the complainant the office of the Consumer Affairs & Fair Business Practices, violated the spirit of the provision and the activities of the Consumer Affairs & Fair Business Practices are questionable and suspicious. In such circumstances, the grievances of the complainant took the form of a case before the District Consumer Disputes Redressal Forum, Siliguri and the complainant has approached before this Forum with prayer as laid in the schedule to get the expenses of treatment and other compensation for harassment and cost of litigation.
The New India Assurance Company Ltd. has filed written version denying inter-alia all the material allegations as raised by the complainant. They admitted that the complainant is a holder of a mediclaim policy with the OPs and same is always subject to reimbursement, coverage, exclusion etc. After receiving the complaint from the complainant on 25.09.2014 and the same was immediately processed and thereafter in terms of general rules and provisions made under Section 54 of Insurance Act, 1938, received the confirmation and compliance report regarding the policy in question and subsequently forwarded the claim file to the concerned TPA Services Pvt. Ltd. for settlement of claim. TAP received the claim file on 18.10.2014 and TPA issued a letter to the complainant on 01.11.2014 asking the complainant to file the original money receipt against payment of hospital bill for Rs.38,108/- and self declaration from the patient regarding circumstances of injury along with pre-operative and post operative x-ray report in its original form. Thereafter, the TPA vide letter no.22.11.2014 informed the complainant that owing to non-receipt of the above said documents they were unable to process the claim further and therefore the claim stands closed. Thereafter, the complainant lodged a complaint against the said OPs before the Consumer Affairs & Fair Business Practices for pre-litigation mediation, Siliguri Regional Office. The OPs thereafter appeared before the concerned authority on 08.01.2015 and
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thereafter settled the claim on 05.02.2015 as per commitment of the said OPs. It has been also stated by the OPs that the TPA has settled the mediclaim as per policy terms, conditions, definition, coverage etc. It is further case of the OPs that in terms of the policy terms and conditions since the complainant had already received the payment towards the instant claim as settled by the TPA and as such the complainant is not entitled to raise any such further more amount from the OPs with respect to the said policy which is beyond limitation coverage of the policy in question. As OPs had paid the already settled the claim and made the payment thereof and as such the complainant is not entitled to raise any such further more amount from the OPs with respect to the said policy. So, there is no deficiency in service and the case should be dismissed.
Points for determination
1. Is there any deficiency in service on the part of the OPs ?
2. Is the complainant entitled to get any relief as prayed for ?
Decision with reason
Both issues are taken up together for the brevity and convenience of discussion.
Complainant has filed the following documents :-
1. Mediclaim Policy papers from 2005 to 2015 (Annexure-I).
2. Prescription of Dr. B.G. Das (M.S. Ortho) (Annexure-II).
3. Discharge Record.
4. Final Bill of New Ramkrishna Seva Sadan.
5. Pre-operative X-ray receipt.
6. Receipt of Medicine.
7. X-ray Report.
8. Hematology Report.
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Complainant has filed some documents showing expenditure of treatment. Medicine cost and original payment for hospital bill.
From the documents filed the complainant, Rs.38,108/- is hospital bill and Rs.4,787/- is cost of medicine. Total cost of medicine and hospital bill thus stands Rs.(38,108.00 + 4,787.00)= Rs.42,895/-.
The complainant filed claim on 25.09.2014. OPs received confirmation from the concerned policy issuing office on 13.10.2014. OPs sent the claim file to TPA on 18.10.2014. TPA issued letter to complainant on 01.11.2014 for some documents :- i) Original Money receipt and ii) Self Declaration. On 22.11.2014, TPA informed the complainant noting “the claim stands closed”. OPs appeared before the Consumer Affairs & Fair Business Practices on 08.11.2015. The claim was settled on 05.02.2015 and made payment of Rs.26,226/-. The details of settlement claim amount has been elaborately briefed in the settlement sheet.
From the analysis of claim settlement sheet of the OP, it appears from the claim settlement sheet prepared by OP that claim amount of Rs.43,280/-. Inadmissible amount is Rs.16,654/-, admissible amount is Rs.26,626/-, but there is no shown reason of such calculation appended in the claim settlement sheet. But result is that claim was Rs.43,280/- and admissible amount was Rs.26,626/-. There is no iota of evidence to show that complainant has supported or complainant has accepted this amount before the OP or before the Consumer Affairs & Fair Business Practices, and it has been done as per OP’s version by the OP’s men and agents and there had been no chance of representing this complainant before the OPs or before the Consumer Affairs & Fair Business Practices for raising any objection or acceptance of that settled amount, which is less than the actual cost shown and admitted in the claim amount column at Rs.43,280/-.
The complainant has filed application and other averments (as per her evidence-in-chief), but the OPs and TPA department has invited the
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explanation from the complainant who is holding a respectable position in society regarding veracity of her application. The TPA vide a letter dated 24.11.2014 informed the complainant that owing to non-receipt of above mentioned document, they were unable to process the claim further, and therefore the claim stands closed. In such circumstances, such letter may create any adverse in her mind regarding the claim. This anxiety instigated the complainant to approach before the Consumer Affairs & Fair Business Practices for getting justice.
The complainant was not presented at the pre litigation mediation because she was not informed by the Consumer Affairs & Fair Business Practices. In spite of that the matter was settled on 05.02.2015 and payment was made in her SBI account without the consent and knowledge of the complainant, and after that alleged ex-parte settlement, the complainant has presented her bunch of grievances before this Forum praying justice as well as compensation for creating mental agony, and harming social reputation by calling explanation again and again.
It is also admitted that she was policy holder of Mediclaim Insurance Policy being No. 51230034142500000040, Claim No.T1210142134 sum assured of Rs.1,25,000/-.
A common man goes to the insurance company for protecting her interest and interest other members of her family in case of any injury to her family member, or disease of her family member with expectation that she will be reimbursed by expenditure to cure the injury or disease. It is the duty of the Insurance Company to extend their hand for the protection of the members of the society. Insurance Companies are living by the people who are insuring their lives by depositing money. So, Insurance Company exists for the people, works for the people.
As per declaration of the “Family Mediclaim 2012 Policy” as per Section 2.22 sum insured is the maximum amount of coverage opted for each insured person and shown in the schedule.
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In Section 3 “WHO MUCH WE WILL REIMBURSE” ?
3.1 Our liability for all claims admitted during the Period of Insurance will be only up to Sum Insured in respect of You and all Insured Persons covered under this Policy as mentioned in the Schedule.
So, the claim amount regarding treatment, cost of medicine etc. shall borne by the Insurance Company up to the maximum amount of sum insured.
In this case in our hand, assured sum amount is Rs.1,25,000/-. Claim amount on voucher is Rs.43,280/- and this amount should have been given to the complainant. But as per record OP has given Rs.26,626/-. This is not tenable in law.
By allotting this amount and that too without the knowledge of the complainant, the OP has done another wrong to the complainant i.e., mental wrong. OP has mental injury to the complainant. Moreover, OPs have done late in sanctioning this amount only when the complainant informed the Consumer Affairs & Fair Business Practices. On then OP Nos.1 & 2 come forward with this paultry amount instead of sanctioning total amount claimed by complainant. The order of the OP by giving Rs.26,626/- is an act except which shows utter negligency to the complainant’s claim. It act itself shows that it is wrong to the complainant “Res Ipsa Loquitor” i.e., the act itself shows wrong with injury to others. In such case, the complainant is entitled to get damages for the act of the OPs.
The OP Company ought to have settled the case on earlier occasion without wasting time on different grounds. Such conduct of the OPs is itself negligence causing deficiency of service to the insured person. Accordingly, the poor insured person should be given sufficient compensation by the OPs.
The complainant has prayed for Rs.43,755/- for treatment of her husband and Rs.50,000/- for mental pain, agony, and harassment by the negligence act and deficiency of service on the part of the OPs. The complainant has also prayed for Rs.3,000/- for litigation cost.
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But the documents supplied by the complainant regarding the hospital bill and medicine bills show that the total expenditure is Rs.42,895/- as per voucher. Therefore, the complainant is entitled to get the sum of Rs.42,895/- of incurring expenditure regarding treatment of her husband. But the OPs have already paid Rs.26,626/- to the complainant. So, the complainant is entitled to get the balance amount of Rs.(42,895.00 – 26,626.00) = Rs.16,279/- from the OPs.
The complainant is further entitled to get Rs.50,000/- towards compensation for her mental pain, agony, harassment, disturbance of official duties and family life by the act of the OPs.
The complainant is further entitled to get Rs.3,000/- towards litigation cost.
In the result, the case succeeds.
Hence, it is
O R D E R E D
that the Consumer Case No.38/S/2015 is allowed on contest against the OPs.
The complainant is entitled to get the balance amount of Rs.(42,895.00 – 26,626.00)=Rs.16,269/- from the OPs for incurring expenditure regarding treatment of her husband.
The complainant is further entitled to get Rs.50,000/- towards compensation for her mental pain, agony, harassment, disturbance of official duties and family life by the act of the OPs.
The complainant is further entitled to get Rs.3,000/- towards litigation cost.
The OP Nos.1 & 2, who are jointly and severally liable, are directed to pay Rs.16,269/- by issuing an account payee cheque in the name of the complainant for incurring expenditure regarding treatment of her husband within 45 days of this order.
OP Nos.1 & 2, who are jointly and severally liable, are directed to
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pay Rs.50,000/- by issuing an account payee cheque in the name of the complainant towards compensation for her mental pain, agony, harassment, disturbance of official duties and family life by the act of the OPs within 45 days of this order.
The OP Nos.1 & 2, who are jointly and severally liable, are further directed to pay Rs.3,000/- by issuing an account payee cheque in the name of the complainant towards litigation cost within 45 days of this order.
In case of default of payment, the complainant is entitled to get interest @ 9% per annum on the awarded sum of Rs.66,269/- from the date of this order till full realization.
In case of default, the complainant is at liberty to execute this order through this Forum as per law.
Copies of this judgment be supplied to the parties free of cost.
