Judgment dt.01-07-2016

            This is a complaint made by Rajat Kanti Sikder against New India Assurances Co. Ltd. having its branches at 4, Donson Lane,Howrah, Howrah-71101 and 39, Diamond Harbour Road, Kolkata- 700008 and also Medicare TPA Services, 6, Bishop Lefroy Road, Kolkata-700020 praying for disbursement of mediclaim amount of Rs.61,184/-towards medical expenses of the petitioner, Rs.10,000/- as damages for mental agony, Rs.50,000/- for compensation and Rs.50,000/- for litigation cost.

              Facts in brief are that Complainant Rajat Kanti Sikdar subscribed a family floater mediclaim policy for his whole family members from the OP No.1. First of such policy was subscribed on 5/1/2005 and thereafter it got renewed and the claim is made for policy for a period from 5/1/2013 to 4/1/2014.

                    In the year 2013, Complainant suffered blood from nose which was diagnosed as DNS which may occur due to dislocation of any cartilage bone in the nose. Complainant went to Appollo Gleneagles Hospital in Kolkata where he underwent operation and remained in the said hospital for the period from 21/11/2013 from 24/11/2013 under supervision of Dr. Ajay Kumar Arya. After his discharge he raised the claim for Rs.61,184/- in a claim form where he paid Rs.60,900/- .

              After submission of that claim he received letters from OP No.3 where it was stated that some documents are required. He submitted documents but his claim was not settled. Thereafter he received a letter that his claim was closed. So he filed this complaint.

               OP No.1 & 2 filed written version and denied the allegation of the complaint. Their further allegation is that he paid Rs.60,900/- and made claim Rs.61,184/- . OP have also stated that X-ray of skull is required for settling the claim but since X-ray of skull was not made Complainant’s claim was not settled. Finally the OPs submitted that since Complainant could not furnish the required document, the claim was closed and it can be opened as and when documents are submitted. So OP prayed for dismissal of the case.

Decision with reasons

            Complainant filed affidavit-in-chief wherein he has reiterated the facts mentioned in the complaint. Complainant also replied to the questionnaire of OP No.1 where he has stated the facts which he has asserted in the complaint. OP also filed evidence wherein they have stated the facts which they brought in the written version. Complainant filed questionnaire to which OP replied.

            Main point for determination is whether Complainant is entitled to the reliefs as prayed for.

            On perusal of the affidavit-in-chief, questionnaire and affidavit-in-reply submitted by the parties it appears that the main dispute relates to non supply of X-ray of skull which as per the doctor of OP is essential in any nose operation even if the operation was due to dislocation of cartilage. Since Complainant failed to furnish the X-ray report of skull, his whole claim was denied by the OP.

            It is unfortunate that an Insurance Company doing business does not take care of the customers who undergo treatment as a indoor patient. Even after the Complainant’s insurance, they do not get reimbursement of the amount spent by them and Insurance Company on flimsy grounds rejects the claim of the consumers.            

            Argument has been filed by the OP wherein it is stated that if the operation was due to result of congenital disease Complainant was not entitled to reimbursement. Surprisingly allegation being made by the Insurance Company OPs. But they are shifting burden of proof on Complainant to establish that operation was not the result of congenital disease. If such be the situation insured at large will lose their claim by the Insurance Company.

            The document clearly reveals that Complainant has mediclaim policy at the relevant point of time and he remained hospitalized for the period from 21/11/2013 to 24/11/2013 and he spent Rs.60,900/-. As such we do not find any ground not to allow prayer of Complainant of re-imbursement of the amount which he spent.

        So far as the compensation of Rs.50,000/- and mental agony separately of Rs.10,000/- are concerned, it is clear that some harassment was faced by the Complainant for which if Rs.20,000/- is awarded justice would be served. Similarly, litigation cost of Rs.10,000/- would be if sanctioned in the situation purpose would be served.

       Hence,

            O R D E R E D

RBT/CC/134/2016 and the same is allowed on contest against OP No. 1 & 2 and ex-parte against OP No.3. OPs are directed to pay Rs.60,900/- to the Complainant on production of original documents if not produced within two months of this order. OPs are also directed to pay Rs.30,000/- within the same period. If the above amounts are not paid within two months it shall carry interest of 12% p.a. after two months till realization.