West Bengal

Paschim Midnapore

CC/151/2014

Sri Subrata Basu - Complainant(s)

Versus

The New India Assurance Co. Ltd. - Opp.Party(s)

06 Jan 2016

ORDER

 

                                                              DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

&

Mrs. Debi Sengupta, Member

 

Complaint Case No.151/2014

                                                       

                                      Sri Subrata Basu……..………………Complainant.

Versus

 

1. The New India Assurance Com. Ltd.;

2. The New India Assurance Com. Ltd.;

3. Family Health Plan (TPA) Ltd.;

4. Glaxosmithkline Pharmaceuticals Ltd.;

5) Glaxosmithkline Pharmaceuticals Ltd.…...........…..Opp. Parties.

 

              For the Complainant: Mr.  Suvojit Dutta, Advocate.

              For the O.P.               : Mr. Mrinal Kanti Chowdhury, Advocate.

 

Decided on: - 06/01/2016

                               

ORDER

                          Bibekananda Pramanik, President – Facts of the case, in brief, is that the complainant is a bona fide permanent employee of opposite party nos.5 & 6 and he is working as a Medical Business Associate in the said opposite party nos.5 & 6 and by virtue of his employment in the said company, he had a mediclaim policy with opposite party no.1 since on 01/12/1986.  The complainant had underwent treatment for a “Branch Retinal Vein Occlusion with Macular Oedema” and had spent a sum of  Rs.27,580/- for his such treatment at Disha Eye Hospitals Pvt. Ltd. After such operation, he submitted all documents pertaining to his said treatment along with all documents of expenses incurred by him for his treatment to the opposite party no.1 and his claim was registered with I.D.

Contd………………P/2

 

 

 

( 2 )

no.609759 being third party of opposite party nos. 1& 2 in the matter of processing the claim against Mediclaim Policies in the prescribed forms provided by the opposite party no.1.  The complainant was surprised to be receive a communication by mail informing him that the complainant is not entitled to get reimbursement of the money spent by him for the medical expenses incurred by the complainant to the tune of Rs.27,580/- under policy no.130300/34/13/400000002 with card no.9194038.  The complainant sent letters addressed to all the opposite parties and in particular, the opposite party nos1&2 requesting them to pay the said claim.  It is stated that rejection of the bona fide claim of the complainant tantamounts to deficiency in service on the part of the opposite party nos.1 & 2 and the complainant is entitled to reimbursement of medical expenses incurred for the treatment of “Branch Retinal Vein Occlusion with Macular Oedema”.  Hence the complaint, praying for directing opposite party nos.1 & 2 to pay the sum of Rs.27,580/- to the complainant along with interest @ 18% p.a. and for compensation and litigation cost. 

             Opposite party nos. 1 & 2 has contested this case by filling a joint written objection. Opposite party nos.3, 4 & 5 received notice of this case but they did not appear to contest this case for which the case was ordered to be heard ex parte against them.

                   Denying and disputing the case of the complainant, it is the specific case of the opposite party nos.1 & 2 as disclosed in their written objection that the complainant submitted claim along with related papers on 02/09/2014 and from the same claim form along with related papers, opposite party nos.1 & 2 came to know that the complainant Subrata Basu was admitted in Disha Eye Hospitals Pvt. Ltd. on 29/09/2014 with “Branch Retinal Vein Occlusion with Macular Oedema” and was discharged on 29/08/2014.  Process of claim, submitted by the complainant, was started by the opposite parties and after process of claim on the basis of documents submitted by the complainant and on examination, it was found that the complainant was treated with Intravit Inj. Lucentis which is not covered according to policy terms and conditions and for which the claim being not payable was repudiated by the opposite party and such repudiation was duly intimated to the complainant by letter dated 18/09/2014.  It is stated that in the above facts and circumstances it cannot be said that there is any deficiency in service from the side of the opposite parties.  The opposite parties therefore claim dismissal of the complaint case.

                                                  Point for decision

                        Is the complainant entitled to get the reliefs, as sought for ?                        

Decision with reasons

                To prove his case, the complainant has examined himself as PW-1 and during his evidence, few documents were marked as ‘X’-series for identification.  On the other hand, opposite party-Insurance Company adduced no evidence. 

Contd………………P/3

 

 

( 3 )

                    Now let us considered as to whether the complainant has been able to prove his case or not.  It is not denied and disputed that the complainant had a Mediclaim Policy with the opposite party nos.1 & 2.  It is not also denied and disputed that the complainant was admitted in Disha Eye hospitals Pvt. Ltd. on 29/08/2014 for “Branch Retinal Vein Occlusion with Macular Oedema” and he was discharged on 29/08/2014.  It is also not denied and disputed that after discharge, the complainant submitted claim form for medical reimbursement before the opposite party Nos.1&2 under the said Mediclaim Policy.  Admittedly, the claim of the complainant was rejected by the opposite party- Insurance Company.  According to the complainant such rejection of bona fide claim of the complainant tantamounts to deficiency in service on the part of the opposite party nos.1&2.  Now the question remains for consideration as to whether such rejection of the claim of the complainant tantamounts to deficiency in service on the part of the opposite party nos.1 & 2.  In their written objection in paragraph no.9, opposite party nos.1 & 2 have specifically stated that after processing the claim on basis of documents submitted by the complainant and on examination it was found by them that the complainant was treated with Intravit  Inj. Lucentis  which is not covered according to policy terms and conditions  for which the claim being not payable was repudiated.  It thus appears that the claim of the complainant was duly processed by the opposite party nos.1 & 2 and after examining all documents they found that the claim was not payable as per policy terms and conditions for which they repudiated the claim of the complainant.  It thus appears that the claim of the complainant was duly processed and the same was considered and rejected as the claim was not payable under the policy terms and conditions. It is the settled law that insurance policy between the insurer and the insured represents a contract between the parties and the insured has to act strictly in  accordance with the statutory limitations or terms of the policy expressly set out therein. In this case, the claim of the complainant was duly processed and the same was rejected as the claim was not payable under the policy terms and conditions.  Therefore, it cannot be held that there was any deficiency of service on the part of the opposite party nos.1 & 2.    We are therefore of the view that the petition of complaint is liable to be rejected.

                                                Hence, it is,

                                                     Ordered,

                                                         that the complaint case no.151/2014  is hereby dismissed on contest but in the circumstances without cost.     

                 Dictated & Corrected by me

             

                           President                                    Member                                 President

                                                                                                                          District Forum

                                                                                                                      Paschim Medinipur