Hon’ble Mr. Haradhan Mukhopadhyay, President.

The basic fact of the case of the Complainants Manindra Sarkar and Mayukh Sarkar in brief is that Complainant No.1 Manindra Sarkar is an Ex-employee of O.P. No.2 the Branch Manager, Oriental Insurance Company Limited and Complainant No.2 Mayukh Sarkar is the son of Complainant No.1. As per proposal of O.P. No.2 the Complainant No.1 done staff group medication policy since 2018 and still now he is paying yearly renewal premium to the O.P. No.2. The mediclaim policy is also continuing. O.P. No.1 the Office- In-Charge of the Health Insurance TPA of India Limited, P.S. Kolkata issued three staff group mediclaim policy card bearing employee No.332372/R, UHID No.13180000058155101 for Manindra Sarkar, employee No.332372/R, UHID No.1318000005815503 in the name of Laxmi Sarkar and employee No.332372/R, UHID No.1318000005815502 in the name o Mayukh Sarkar Complainant No.2 for which the Complainant No.1 paid Rs.11,971/- through cheque No.137952 dated 24.04.20 in favour of O.P. No.2 but the O.Ps did not supply any policy to the Complainants. Due serious illness the Complainant No.2 Mayukh Sarkar was admitted in KPC Medical College & Hospital due to Covid-19 positive on 23.03.21 to 31.03.21. During treatment the Complainant No.2 incurred hospital expenditure of Rs.32,175/- for which the Complainant raised claim to the OP but the OP did not disburse the claim. As per demand of O.P. No.2 the Complainant No.1 submitted all the documents to the O.P. No.2 on 06.04.21 but still today the OP did not disburse the claim. On 25.08.21 and 24.06.21 the Complainant No.1 submitted written complaint to the O.P. No.2 but they did not settle the claim. After long time the O.P. No.2 forwarded the claim of the Complainant to the O.P. No.1 on 01.09.20222. The Complainant contacted with the O.P. No.1 through email but the OP did not settle it nor did they reject it. Lastly on 21.12.2022 the Complainant No.1 sent written complaint to the O.Ps which they received on 26.12.2022 but they did not settle the complaint. Therefore the O.Ps acted negligently which amounts to deficiency in service. The Complainants are entitled to get the medical bills and vouchers from the O.Ps. The cause of action arose on for this case 23.03.21 and on subsequent dates till 21.12.2022 and it is continuing. The Complainant therefore prayed for an award for a sum of Rs.32,175/- towards actual medical cost with up to date interest, Rs. 2 Lakhs for deficiency in service and Rs.20,000/- towards litigation cost.

The notice upon the O.Ps were sent on 13.02.23. The OP received the notice but did not prefer to contest the case. The Complainant in order to establish the service of notice filed the track report of postal department wherefrom it transpires that the item No. RW594843298IN was delivered on 17.02.23. Since the OP did not contest the case so the case is decided to be heard ex-parte against O.P. No.2. As regards O.P. No.1 it appears that as per Order No.03 dated 10.04.23 the notice was served upon O.P. No.1 on 27.02.23. Thus both the O.Ps preferred not to contest the case despite service of notice upon them. Accordingly the case was decided to be heard ex-parte against both the O.P. No.1 & 2.

The Complainant in order to substantiate the case adduced oral evidence in the form of evidence on affidavit dated 10.07.23 wherein they categorically proved the entire facts stated in the written complaint by means of written evidence.

The Complainant also proved the pass book of the Complainant No.1 Manindra Sarkar wherefrom it is revealed that the Complainant paid money for said insurance policy to the Oriental Insurance Company on 24.04.20 for a sum of Rs.11,971/-. The O.P. No.2 insurance company also issued health insurance card valid from 01.04.18 in the name of Manindra Sarkar, Mayukh Sarkar and Laxmi Sarkar. The Complainant also proved the documents relating to the medical treatment of O.P. No.2 of KPC Medical College & Hospital. Annexure-4 also discloses that the Complainant raised claim to the O.P. No.2 on 06.04.21 which the OP received on 06.04.21. Annexure-5 also proved the claim form filed by the Complainant. Annexure-6 further discloses that a reminder was also given on 25.08.21 to the O.P. No.2 regarding non settlement of mediclaim.

Annexure-7 further discloses that the O.P. No.1 received the complaint and acknowledged it and replied thereto. Annexure-8 further discloses that an email was sent to the Oriental Insurance Company on 17.12.2022. Correspondence also took place through Annexure-9 in between the O.P. No.1 & 2 regarding non relies of claim of the Complainants.

Thus the Complainant proved the facts and allegation stated in the complaint through both oral evidence in the form of evidence on affidavit and documentary evidence being Annexure-1 to 9.

The entire oral and documentary evidence of the Complainant stands un-challenged and un-discarded since the case was heard ex-parte against the O.Ps.

The O.Ps also could not adduce any evidence on their behalf since they preferred not to contest the case leading to ex-parte hearing of the case.

Thus, having assessed the entire pleadings of the Complainant as well as the evidence adduced by them and in the backdrop of the observation made herein above the Commission comes to the findings that the Complainant proved the case up to the hilt against the O.Ps ex-parte.

Accordingly it stands well proved that the O.Ps acted in a manner with the Complainants which amounts to deficiency in service.

In the result the complaint case succeeds ex-parte.

Hence, it is

Ordered

That the complaint case No.CC/9/2023 be and the same is allowed ex-parte against the O.P. No.1 & 2 with cost Rs.10,000/-.

The Complainants do get an award against both the O.P. No.1 & 2 for a sum of Rs.21,175/- towards actual medical cost with up to date interest, Rs.50,000/- towards deficiency in service and Rs.10,000/- towards litigation cost for which both the O.P. No.1 & 2 are jointly and/or severally liable.

The O.P. No.1 & 2 are directed to pay a sum of Rs.81,175/- @ 50% each to the Complainant No.1 & 2 within 30 days from the date of passing the award failing which the entire award money shall carry an interest @ 8% per annum from the date of Final Order till the date of its realisation.

D.A. to note in the trial Register.

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 be also available in the official website: www.confonet.nic.in.

Dictated and corrected by me.