1. Sri Gopal Chandra Padhi,

            129, Motilal Nehru Road, Kolkata-29.                                                      _________ Complainant

____Versus____

1. The Oriental Insurance Co. Ltd.

            A-25/27, Asaf Ali Road, New Delhi-110002.

2. MD India Health Service (TPA) Pvt. Ltd.

169, Sarat Bose Road, Kolkata-26.                                                         ________ Opposite Parties

Present :           Sri Sankar Nath Das, Hon’ble President

                          Dr. Subir Kumar Chaudhuri, Member.

                        Smt.  Samiksha Bhattacharya, Member

Order No.  19     Dated  27/04/2015 

          The case of the complainant in short is that complainant was an employee of Punjab National Bank being P.F. No.106703 and complainant was insured under o.p. no.1 under the scheme of Bhavishya Arogya Policy being no.211700/48/2007/451-Certificate No.55698 with effect from 1.6.06 for a sum insured of Rs.50,000/- only during the life time of the employee after retirement and the said benefit under the policy shall commence on and after the retirement date i.e. 60 years as per the relevant rules of the employers. It is evident from the record that this policy commenced from 31.8.08 which is the date of the retirement of the complainant. The 1^st annual installment premium including service tax was collected from the complainant through Punjab National Bank i.e. the employer of the complainant vide cheque no.648898 dt.30.5.06. The said insurance policy is valid subject to receipt of all the annual premium installment as per the policy terms and conditions.

            Complainant was admitted on 4.11.11 at Ramkrishna Seva Pratisthan, Kolkata since he had been suffering from breathing problem and complainant was discharged from the said hospital on 11.11.11 after getting treatment from them and he had to pay Rs.23,500/- to the said hospital. Photocopies of the documents had been annexed by complainant with the petition of complaint. Complainant further stated that he had to admit several times in the said hospital for various diseases and after the discharge from the hospital, as stated above, complainant submitted the claim to o.p. no.2 on several dates i.e. dt.10.11.11, 15.5.12 and 29.5.12 for reimbursement of the expenditure incurred by him. But after a great deal of persuasion complainant failed to reimburse the claims. Under such conditions complainant filed the instant case the prayers contained in the prayer portion of the petition of complaint.

            O.p. no.1 appeared before this Forum and contested the case by filing w/v. O.p. no.2 did not contest the case by filing w/v and as such, the matter was heard ex parte against o.p. no.2. In their w/v o.p. no.1 stated that it is specifically mentioned in the policy that maximum amount of benefit available for any hospitalization under such scheme shall exceed 40% of the insured available under the policy for illness i.e. 40% of Rs.50,000/- is Rs.20,000/-. Such condition has been stated in the certificate of insurance for employee of Punjab National Bank for sum assured of Rs.50,000/- and the same had been communicated to the complainant under their communication dt.,23.11.06 which  has been annexed by complainant himself with the petition of complaint. O.p. further stated that they could not dispose the claim due to the stipulation in the policy as stated above. So, the case has got no merit and the same is liable to be dismissed.

Decision with reasons:

            Upon considering the submissions of both the parties and on careful scrutiny of the entire materials on record, this Forum hold that it is the dispute between the employer and employee since annual installment premium and allied was collected from the complainant by his employer for the insurance in question. This Forum is not having any jurisdiction to adjudicate, if any dispute arises between the employer and employee. In this particular case, the premium was collected from complainant by employer for such insurance in question. as such, it goes without saying that any dispute if any arising at all though related with the insurance matter, but the instant case cannot be adjudicated by this Forum because basically it is the dispute between the employee and employer even if the insurance company is involved in the matter.

            In view of the above, the instant case is rejected since it is not tenable before this Forum to adjudicate as the reasons stated above.

            Hence, ordered,

            That the case is dismissed on contest without cost against the o.ps.

            Supply certified copy of this order to the parties free of cost.