BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION.
KAMRUP
C.C.No. 67/2019
Present: I) Shri A.F.A.Bora, M.Sc.,L.L.B.,A.J.S(Rtd.) -President
II) Smti Archana Deka Lahkar,B.Sc.,L.L.B. -Member
III) Shri Tutumoni Deva Goswami, B.A.L.L.B. - Member
Sri Mahendra Kumar Jain - Complainant
-vs-
1) The Oriental Insurance Company Ltd. -Opposite parties
C.D.O.-III, M.R.D. Road,Chandmari
P.O.Guwahati-3,Dist.Kamrup(Metro)
2) M/S Raksha Health Insurance Pvt.Ltd,
Prag Plaza, 2nd Floor, Bhangagorh,
G.S.Road, P.O.Guwahati-5
Dist.Kamrup,(Metro) Assam
3) M/S North East Medical Care & Research Centre
(P) Ltd. a private limited company,
owner of Nemcare Hospital, G.S.Road, Bhangagorh
Guwahati-781005, Dist.Kamrup,(Metro) Assam
Appearance :
For the complainant Sri Mahandra Kr.Jain in person .
Date of filing written argument :- 21.12.21
Date of oral argument :- 3.3.22
Date of judgment: - 4.4.22
JUDGMENT (Exparte)
Case of the complainant
1) The case of the complainant is that complainant had a mediclaim policy (Happy Family Floater) bearing policy No. 321300/48/2018/2473 with the opp.party No. 1 jointly with his wife Mrs.Urmila Devi Jain for a sum of Rs.4,00,000/- (four lakhs) which continued since 2009 without break . The complainant suffered from abdominal pain and accordingly he was examined by the surgeon who diagnosed B/I indirect inguinal hernia and was advised for operation immediately . Complainant was admitted in the Nemcare Hospital i.e. the opp.party No. 3 at Guwahati on 31.1.2018 and after operation on 1.2.2018 he was discharged on 3.2.2018 . The complainant obtained pre-authorization from the opp.party No. 2 for cash-less operation, but he was asked to make the payment of Rs.35,840/- at the time of discharge on the ground that opp.party No. 2 had deducted a sum of Rs. Rs.35,840/- from the bill of Rs.1,29,386/- submitted by the opp.party no.3. The opp.parties No. 1 & 2 has been sanctioned Rs.93,546/- only and deduction of amount Rs.35,840/- is against the terms and condition of the said policy.
2) The opp.party No.2 had deducted the sum of Rs. 35,840/- from the bill of Rs.1,29,386/- on the allegation that there were 2 operations . It is alleged by the op.party that there were two operation of the complainant without any basis and hypothetical in as much as the operation was done in single sitting . The complainant as alleged in the petition submitted letters on 9.4.2019 which has been submitted as annexure 6 & 7 for payment of the aforesaid Rs.35,840/-. But opp.party did not respond which has caused harassment and deficiency in service for which complainant pray for compensation amounting to Rs. 1,00,000/- along with cost of the operation and interest @ 12% per annum.
3) We have gone through the record and found that opp.party had not appeared nor contested the proceeding for which the matter proceeded exparte. Accordingly complainant submitted evidence on affidavit along with documents to substantiate his claim. Seen the policy documents submitted by the complainant. We have gone through the written argument available on record and found that there is deficiency of service on the part of the opp.party No. 1 & 2.
4) On perusal of record it is found that the o.party has deducted Rs.35,840/- from the final bill submitted by the hospital concerned and op.party have not turned up to establish any cogent ground for refusal of aforesaid amount. Mere alleging that there were two operations of the complainant is hypothetical as the operation was done in single sitting. Without establishing any fact of dispute by the party in our opinion the complainant is entitled for the entire payment of operation submitted by opp.party No. 3 and hence the dispute is decided in favour of the complainant and decreed accordingly.
5) In the result it is directed that opp.parties No. 1 & 2 are jointly and severally liable for payment of Rs.35,840/- along with interest @5% from the date of filing this complaint till realization along with compensation of Rs.30,000/- for harassment and mental agony. The decretal amount is to be paid within 45 days from the date of judgment failing which an interest of 12% per annum be paid till realization.
Given under our hand and seal of the District Commission, Kamrup, this the 4th day of April ,2022.
( Shri A.F.A.Bora )
President
DCDRC,Kamrup
( Smti Archana Deka Lahkar )
Member
DCDRC,Kamrup
( Shri Tutumoni Deva Goswami )
Member
DCDRC,Kamrup
Dictated and corrected by me
( Shri A.F.A.Bora )
President,
District Consumer Commission, Kamrup.
Typed by me
( Smt Juna Borah )
Stenographer, District Consumer Commission, Kamrup.
