Hon’ble Mr. Haradhan Mukhopadhyay, President.

The basic fact of the case in hand in a few wards is that the Complainant Sri Anup Kumar Saha is a consumer under the O.P. No.1, Office-in-charge, HDFC ERGO Health Insurance Company Limited and O.P. No.2 Branch Manager, Bandhan Bank. The Complainant opened the above account for group assurance health plan. The Complainant paid Rs.10,880/- as gross premium of health insurance of his family members of sum insured Rs.2 Lakh. The O.P. No.2 had tie up with O.P. No.1. The certificate of insurance was issued on 13.02.20 with full health coverage for the period of 11.02.20 to 12.02.21 vide application No. BB00500583, Policy No.150100/12587/2020/A017464/PE07038625 after full investigation and satisfaction. The Complainant fell seriously ill and was admitted on 20.05.20 and discharged on 24.05.20 with problem of CAD-Accute Coronary Syndrome( Interolateral Well MI) and doctor of Neotia Getwell, Siliguri treated the Complainant “Encoplastic” which was under the purview of the said health insurance coverage. The O.Ps handed over the health card with all ID to the Complainant. As per terms and conditions of health insurance policy, the Complainant sent claim through Neotia Getwel Care Centre, Matigar, Siliguri for payment of medical bill on 01.06.20. Due to treatment of the Complainant he paid Rs.2,13,254/- but the O.P. No.1 did not repay anything for the same. The Complainant went to the Office of the O.Ps several times to collect the insurance claim but both the O.Ps refused to repay it. The O.P. No.1 illegally repudiated health claim on 22.05.20 on the ground that “As per the available documents they observed that  there was incorrect good health declaration of FRACTURE PROXIMAL HOME RUS IN 2019”. The said misdeeds of the O.Ps amounts to deficiency in service for which the Complainant suffered mental pain and agony as well as financial loss. The cause of action for the present case arose on 13.02.20, 20.05.20 and on 22.05.20. The Complainant therefore prayed for an award for a sum of Rs. 2 Lakh for health insurance coverage alongwith interest, Rs.1 Lakh for deficiency in service and Rs.20,000/- for litigation cost and any other relief.

The notice was sent to the O.Ps. So far as the postal remark is concerned, it is found that the item was shown to have been delivered. After verifying all the documents regarding issue of notice this Court vide its order No.10 dated 23.05.2022 decided to hear the case ex-parte. Accordingly the case was heard ex-parte against O.P. No.1 & 2.

Complainant in order to establish his claim adduced evidence by filing evidence on affidavit and also proved some documents in course of evidence.

Annexure- A is the certificate of the insurance in the name of Complainant Anup Kumar Saha for sum assured Rs. 2 Lakh. The said document stands unchallenged and un-discarded.

Annexure- B is the health insurance card in the name of Complainant Anup Kumar Saha.

Annexure- C is the discharged summary of the Complainant against medical treatment for dated 20.05.20 and date of discharge dated 24.05.20.

Annexure- D is the health insurance card in the name of the Complainant.

Annexure- E is the bill of supply receipt ( Financial bill issued by the Neotia Getwel Care Centre) for a sum of Rs. 2,13,254/-. The entire evidence of the Complainant through evidence on affidavit as well as the documentary evidence being Annexure-A to E stand unchallenged and un-discarded in as much as the O.Ps did not cross-examine by filing any interrogatory due to the case being heard ex-parte.

The Complainant categorically stated in his evidence on affidavit about not refunding the mediclaim by the O.Ps. The entire deposition in the form of evidence on affidavit by the Complainant stands unchallenged and un-discarded.

The documents of affidavit clearly shows that the Complaint despite exercising best effort for realising his medical claim, did not succeed because the O.Ps did not repay the said mediclaim to the Complainant. Therefore the demeanour of the O.Ps in not allowing the medical claim of the Complainant tantamounts to deficiency in service.

So far as the relation between the Complainant and the O.Ps are concerned the Complainant is a consumer under the O.Ps and as such he is protected for realisation of the claim under the consumer protection Act.

Thus, having assessed the entire pleadings and evidence on record of the Complainant vis-à-vis the reluctance of the O.Ps in contesting the case, this Commission comes to the finding that the Complainant successfully proved the case against the O.Ps up to the hilt.

In the result the complaint case succeeds ex-parte.

Hence, it is

Ordered

That the complainant case CC/14/2021 be and the same is allowed ex-parte with cost.   

The Complainant do get an award for a sum of Rs. 2 Lakh towards health insurance coverage alongwith  up to date interest @ 6% per annum from the O.Ps, and Rs. 1 Lakh towards deficiency in service and Rs.20,000/- for litigation cost.

The O.Ps are directed to pay a sum of Rs.3,20,000/- to the Complainant within 30 days from the date of passing award failing which the O.Ps shall pay an interest @ 6 % per annum alongwith the principal amount from the date of passing the award till the date of realisation.

Let a plain copy of this Order be supplied to the concerned party by hand/by Registered Post with A/D forthwith, free of cost, for information & necessary action as per rule.

The copy of the Final Order is also available in the official website: Dictated and corrected by me.