Brief fact of this case:-  This case has been filed U/s.12 of the Consumer Protection Act, 1986 by the complainant stating that on June, 2014 the husband of the complainant (herein after referred as deceased) attacked by Brain Tumor and the deceased was referred for Calcutta Ruby Hospital for further query regarding the gravity of the disease.  In the C.T. Scan report it was revealed that the Tumor carries malignancy (Cancerous). The Doctor of Ruby Hospital, Calcutta referred the deceased in Mumbai Tata Memorial Hospital.  The condition of the deceased became severe time to time and subsequently the deceased was attacked by Cerebral Thrombosis and thereafter for the purpose of saving the life of the deceased, the Tata Memorial Hospital caused operation of the Brain of the deceased and thereafter the deceased underwent coma.

            The complainant also states that after 15 days from the date of operation the deceased was referred by the doctor of Mumbai Tata Memorial to Apollo Hospital, Calcutta and the condition of the patient was precarious.  Another 15 days were elapsed in Apollo Hospital Calcutta.  The complainant also states that the expenditure of Apollo Hospital was extreme and thus the deceased was admitted at B.B. Plodder Hospital and thereafter he was taken returned at his residence and on 15^th September, 2015 the husband of the petitioner died at Imambara Sadar Hospital, Chinsurah, Hooghly.

        The complainant also states that the deceased was an employee under the authority of LICI as Assistant Administrative Officer and the employees of LICI are covered by the medi-claim policy, i.e. Health Insurance Scheme under the opposite party no. 1 to 3.  The opposite party no. 1 - The New India Assurance Co. Ltd is the well known named of Central Government Insurance for different insurance policies including the Medi-claim Policy of the Individual.  The opposite party no. 1 is the General Insurance Company carries its insurance business as Insurer throughout of our country and the opposite party nos. 2 and 3 carried its business under the authority of opposite party no. 1 and the opposite party no. 4 is the authorized agent company looking after the mediclaim business under the authority of opposite party nos. 1 to 3 and the deceased was an employee under the authority of L.I.C.I and the present claim application is very much related with the opposite party no. 5 and the deceased was covered by the mediclaim policy being no. 510000/48/14/85000001, 510000/48/14/85000001 because the amount of the policy was deducted from the salary of the deceased and the same was realized by the opposite party no. 1 and the deceased was duly insured by the above referred policy amounting to Rs, 6,00,000/- and after demise of the husband of the present complainant she lost the entire economic fund for the purpose of treatment of her husband and then she submitted the claim to the insurer and at the same time submitted the available medical papers to substantiate her claim of Rs. 6,00,000/- covering the mediclaim policy and although about Rs. 25,00,000/- was expensed for the purpose of saving the life of the deceased and all the documents were submitted on 21.3.2016 to the office of opposite party no. 1 and the office of opposite party no. 1 released the claim amount of Rs. 5,90,617/- and Rs. 9683/- only is lying due and on 5.1.2016 the complainant submitted one application at the office of opposite party no. 2 and it was communicated that some original documents and reports were found missing which were issued from Tata Memorial Hospital, Mumbai and without availing the missing documents in original, the opposite party – Insurer will not be able to release the residual amount of Rs. 9683/- and after her long effort the Hospital Authority was kind enough to spear substitute copies of the treatment of the deceased and all the documents were submitted to the insurer, the opposite party no. 4 issued letter dt. 2.2.2015 that all the original documents against queries from the insured for all four hospitalization was received by the office of the opposite party no. 4 but inspite of receiving all relevant documents of their queries the office of the opposite party no. 1 did not take any effort for releasing the due amount of the claim covered by the mediclaim policy in favour of the complainant and on 21.3.2016 the complainant submitted written application to the opposite party- Insurer explaining all details but the insurer did not take any action for payment of the remaining amount of Rs. 9683/- and thereafter ld. Advocate of the complainant sent one legal notice to the opposite party- Insurer and its agent on 12.12.2016 and inspite of several communications on behalf of the complainant personally and by the ld. Advocate the Insurer did not take any positive effort to release the real claim in favour of the complainant.

            Complainant filed the complaint petition praying direction upon the opposite party to pay sum of Rs. 9683/- for compensation and to pay a sum of Rs. 1,00,000/- for harassment and to pay a sum of Rs. 1,00,000/- for mental pain and agony and to pay the costs of this proceeding and to give any other relief or reliefs as deem fit and proper.

Defense Case:-       The opposite party Nos. 1 to 3 contested the case by filing written version denying inter-alia all the material allegation as leveled against him. These opposite parties submit that said amount so demanded were not admissible and it is not supported by documents under the said policy and  as such the complainant is not entitled to get any claim furthermore as alleged therein and there was no  deficiency of service from the end of either opposite party nos. 1 to 3 or from the opposite party no. 4 and no cause of action at all arose as against any of the opposite party as such the complainant is not entitled to get any relief as prayed in para 20 of the claim application and the said case should be dismissed with cost payable to opposite party nos. 1 to 3.

            The opposite party no. 5 has also contested this case by filing written version where it has been stated that this case is barred by limitation as this case has not been filed within the stipulated period of time of two years. As per case of the opposite party no. 5 LICI of India this Commission/ Forum has no territorial jurisdiction to try this case. It has also been alleged that the employee had not applied to the appropriate authority claiming the reimbursement under the scheme. For all these reasons the opposite party no. 5 has also prayed for dismissing this case with cost.

Issues/points for consideration

On the basis of the pleading of the parties, the District Commission for the interest of proper and complete adjudication of this case is going to adopt the following points for consideration:-

1. Whether the complainant is the consumer of the opposite parties or not?
2. Whether this Forum/ Commission has territorial/pecuniary jurisdiction to entertain and try the case?
3. Is there any cause of action for filing this case by the complainant?
4. Whether there is any deficiency of service on the part of the opposite parties?
5. Whether the complainant is entitled to get relief which has been prayed by the complainant in this case or not?

Evidence on record

The complainant filed evidence on affidavit which is nothing but replica of complaint petition and supports the averments of the complainant in the complaint petition and denial of the written version of the opposite parties.

            The answering opposite party nos. 2 and 5 filed evidence on affidavit which transpires the averments of the written version and so it is needless to discuss.

Argument highlighted by the ld. Lawyers of the parties

Complainant and opposite party nos. 2 and 5 filed written notes of argument. As per BNA the evidence on affidavit and written notes of argument of both sides are to be taken into consideration for passing final order.

            Argument as advanced by the agents of the complainant and the opposite party nos. 2 and 5heard in full. In course of argument ld. Lawyers of both sides have been emphasis on evidence and document produced by parties.

DECISIONS WITH REASONS

The first three issues/ points of consideration which have been framed on the ground of maintainability and/ or jurisdiction, cause of action and whether complainant is a consumer in the eye of law, are very vital issues and so these three points of consideration  are  clubbed together and taken up for discussion jointly at first.

            Over this issue it is important to note that the contesting opposite parties have not filed any separate petition challenging the maintainability point, jurisdiction point and cause of action issue in this case and the opposite parties have only pleaded the fact of non maintainability, jurisdiction point and cause of action issue. In this regard, it is important to note that according to the pleadings of the parties’ complainant of this case is a resident of Chinsurah, Hooghly and the husband of complainant expired on 15^th September, 2015 at Imambara Sadar Hospital, Chinsurah, Hooghly. On the background of this position according to the Section 34 of the Consumer Protection Act, 2019 this District forum/ Commission has jurisdiction to try this case. So, the above noted plea of the opposite parties that this District Forum/ Commission has no territorial jurisdiction is not admissible in the eye of law. The opposite parties also have raised the point of limitation in this case and it has been pointed out that according to the case of the complainant the cause of action arose in the year 2014 but this case has been filed in the year 2017 after lapse of 3 years and so this case is barred by limitation. In this connection the provision of Section 69(2) of the Consumer Protection Act, 2019 is very important and according to this said provisions of law complaint can be entertained by District Commission or State Commission or National Commission even after 2 years if the complainant satisfied the Commission that he/ she has sufficient cause for not filing the complaint within such period. In this instant case according to the case of the complainant cause of action arose in the year 2014 but the cause of action continued as the claim of the complainant has not been disbursed/ released by the opposite parties. This factor is clearly indicating that this case is not barred by limitation and as the claim of the complainant has not been released prior to the year 2015-16 by the opposite parties nos. 1 to 3 the cause of action continued and all these factors are clearly depicting that the complainant has cause of action for filing this case. Thus, the above noted plea of the contesting opposite parties is not acceptable. Moreover after going through the provisions of Section 2(1)(e) of the Consumer Protection Act, 2019 this case is maintainable and as per provisions of Section 2(7) the Consumer Protection Act, 2019 the complainant is a consumer in the eye of law. After going through the pleadings of the parties and also after scanning the evidence on record it appears that the claim of the complainant was under the coverage of insurance policy of opposite party nos. 1 to 4 and so there was/ is contractual obligation on the part of the opposite party nos. 1 to 4 to release the claim amount and thus it is crystal clear that this case is maintainable in the eye of law and over this issue the decision of the Delhi State Consumer Disputes Redressal Commission which is reported in 2022 (2) CPR 13(Delhi) is very important.

            Thus the above noted discussion and the point of law goes to show that this case is maintainable, there is cause of action for filing this case by the complainant and this District Commission has territorial jurisdiction to try this case and the complainant is a consumer in the eye of law and for these reasons the above noted three points of consideration are decided and/or disposed of in favour of the complainant.

            The point no. 4 is related with the question as to whether there is any deficiency in the service on the part of the opposite parties or not? The point no. 5 is connected with the question as to whether the complainant is entitled to get any relief in this case or not? These two pints of consideration are interlinked and/ or interconnected with each other and for that reason these two points of consideration are clubbed together and taken up for discussion jointly.

            For the purpose of deciding the fate of these two points of consideration and for the interest of getting answers of the above noted question there is necessity of scanning the evidence on affidavit filed by the parties and also there is necessity of making scrutiny of the documents filed by the parties of this case. Regarding this matter after going through the evidence on affidavit on record and documents filed in this case it appears that on the following points, the parties of this case have not raised any objection;-

1. It is admitted fact that husband of the complainant who died on 15^th September, 2015 was an employee of LICI of India who is the opposite party no. 5 of this case.
2. There is no dispute over the issue that the husband of the complainant was under the insurance coverage of opposite party nos. 1 to 3 and the premium of the said insurance mediclaim policy was deducted from the salary of the husband of the complainant by opposite party no. 5.
3. There is no controversy over the issue that the amount of the policy was Rs. 6,00,000/-.
4. It is admitted fact that the husband of the complainant in the month of June 2014 was attacked by brain tumor and he was medically treated at Ruby Hospital, Calcutta and thereafter at TATA Memorial Hospital, Mumbai and then shifted to Apollo Hospital and then he was admitted to B.B. Poddar Hospital and finally the husband of the complainant died at Imambara Sadar Hospital, Chinsurah, Hooghly on 15^th September, 2015.
5. The parties of this case also have not denied the fact that the opposite party no. 4 Heritage Health T.P.A. PVT. LTD. is the authorized agent of opposite party nos. 1 to 3 and has been looking after the mediclaim business of opposite party nos. 1 to 3.
6. There is no dispute on the point that opposite party no. 5 i.e. LICI of India used to deduct the premium of the mediclaim policy from the salary of the husband of the complainant.
7. There also not any controversy regarding the matter that even at the time of the death of the husband of the complainant on 15.9.2015 the husband of the complainant was in service under opposite party no. 5 and he was posted as assistant administrative officer of LICI of India at Krishnanagar branch 2.
8. After going through the pleadings of the parties of this case and evidence on affidavit filed by the parties of this case it transpires that there is no dispute over the issue that the office of the opposite party no. 1 released claim of Rs. 5,90,617/-.

On the background of above noted series of admitted facts the point and/ or apple of discord amongst the parties is that an amount of Rs. 9683/- has not been released by opposite party nos. 1 to 3 and this amount is lying due. Regarding this matter the point of contention and argument of the opposite parties is that this claim of Rs. 9683/- is not admissible under the terms and conditions of the mediclaim policy and for that reason the said claim has not been released but on the other hand the complainant in this connection pointed out that the opposite party no. 1 has declined to pay the said amount and so the complainant has filed an application on 5.1.2016 along with documents and reports but the said claim of the complainant has not been honored by the opposite party insurance company.

For the purpose of deciding the above noted point of dispute the District Commission after going through the pleadings of the parties and evidence on record finds that the opposite party Insurance Company in one hand denied the contends of the claim application but on the other hand in their written argument averred that the claim of Rs. 5,90,617/- was paid and settled the dispute as the same was admissible under the said mediclaim policy. It further appears that the opposite party nos. 1 to 3 in their second written argument filed on 11.2.2020 submitted that the claim of Rs. 9683/- has also been settled and released on 6.6.2016 but surprisingly this fact has not been incorporated in the evidence on affidavit filed by the opposite party nos. 1 to 3 in this case and it has also not been stated in W/V. Thus, it is crystal clear that the point of contention of the opposite party nos. 1 to 3, Insurance Company that the claim of Rs. 9683/- has been paid/ released on 6.6.2016 is not supported by any evidence and for that reason the above noted point of argument of the opposite party nos. 1 to 3 that the claim of Rs. 9683/- has been released in favour of the complainant cannot be accepted. All these factors are clearly depicting that the complainant of this case is entitled to get Rs. 9683/- from the opposite party Insurance Company as there was deficiency in service on the point of opposite party nos. 1 to 3.

A cumulative consideration of the above noted discussion and evidence on record goes to show that the complainant of this case is not only entitled to get the compensation of Rs. 9683/- but also entitled to get compensation/ monetary benefit on the ground of harassment of Rs. 1,00,000 and the complainant is also entitled to get compensation for sufferings of mental pain and agony of Rs. 1,00,000/- along with cost of litigation of this case of Rs. 10,000/-.

Hence,

it is

ordered

that the complaint case being no. 84 of 2017 be and the same is allowed on contest against opposite party nos. 1 to 3 and opposite party no. 5 and it is allowed ex parte against opposite party no. 4.

            It is held that complaisant is entitled to get the claim of Rs. 9683/- and she is further entitled to get compensation/ monetary benefit for harassment of Rs. 1,00,000/- and compensation for sufferings mental pain and agony of Rs. 1,00,000/- and litigation cost of Rs. 10,000/-.

            The opposite party nos. 1 to 3 are directed to pay the said amount of Rs. 2,19,683/- (in total) to the complainant within 2 months from the date of this final order. Otherwise complainant is given liberty to execute this order as per law.

In the event of failure to comply with the order the opposite party shall pay cost @ Rs. 50/- for each day’s delay, if caused, on expiry of the aforesaid 60 days by depositing the accrued amount, if any, in the Consumer Legal Aid Account.

Let a plain copy of this order be supplied free of cost to the parties/their ld. Advocates/Agents on record by hand under proper acknowledgement/ sent by ordinary post for information and necessary action.

            The Final Order will be available in the following website www.confonet.nic.in.