In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No. 17 / 2010.
1) Mr. Anand Rajgarhia,
230A, A.J.C. Bose Road, Kolkata-700020. ---------- Complainant
---Versus---
1) The Oriental Insurance Co. Ltd.,
Divisional Office VI, 2F, Everest House,
46/C, Chourangee Road, Kolkata-700071.
2) The Oriental Insurance Co. Ltd.,
496, Diamond Harbour Road, Kolkata-700034.
3) M/s. Vipul Mad. Corporation TPA Pvt. Ltd.,
16/2, Lord Sinha Road, Kolkata-700071. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri ,Member
Smt. Sharmi Basu ,Member
Order No. 22 Dated 11/05/2012.
The instant case has been filed by the complainant against the o.ps. with allegation of deficiency in rendering service within the ambit of the C.P. Act, 1986.
In a nutshell the case of the complainant is that complainant’s Mediclaim Insurance Policy (Individual) vide Policy no.311603/2009/3 for the year 2009 issued by the o.p. no.2, the Branch Office of o.p. no.1 viz. The Oriental Insurance Co. Ltd. and under the said policy complainant was entitled to get compensation for medical expenses incurred by him in course of treatment. The complainant was treated in Beramji’s Hospital in the month of Sept. 2008 and he incurred medical expenses of Rs.80,000/- and the complainant was in aforesaid hospital from 1.9.08 to 12.9.08. Thereafter complainant placed his claim before the o.ps. vide claim file no.09 RB/00IG0124 and authorization no.04/RG11003, who were responsible for making payment of the claim made by the complainant. The o.ps. did not pay any heed to the aforesaid claim and lastly on 10.8.09 the complainant wrote a letter to the o.ps. stating that the grievances are not being investigated and requested them to pay Rs.79,990/- within 15 days from the date of receipt of this notice. on 24.8.09 the o.ps. intimated the complainant that steps are be taken for settlement of the claim, but till today no action has been taken by the o.ps. Hence, the complainant has no alternative but to file the instant case before this Forum with the prayer contained in the prayer portion of the petition of complaint.
Decision with reasons:
After scrutinizing vividly every nook and corner of each and every documents which are brought before this Forum by the parties and hearing minutely from the ld. advocate for the o.p. nos.1 and 2 it is observed by us that it is an admitted fact that the complainant had a mediclaim policy issued by o.p. nos.1 and 2 where o.p. no.3 is the TPA. It is also admitted fact the complainant was admitted in a hospital viz. Beramji’s Hospital from 1.9.08 to 12.9.09 and he placed his claim before the o.ps. for reimbursement of his medical treatment and the claim in question was repudiated by intimating it through a letter dt.27.11.08 on the ground stated in clause no.4.10 of the medicalim policy which was issued by the insurance company.
From the documents it is observed that in clause of 4.1 it is stated that the claim would be refused only when the expenses incurred at hospital or nursing home primarily for evaluation / diagnostic purpose which will not be followed by active treatment for he ailment during the period of hospitalization. But in the instant case it is observed from the Discharge Summary of the complainant given by the hospital that the insured person / complainant was admitted to hospital for his treatment of post traumatic effusion of left knee and right elbow following strain while exercising in the gym and after investigation, active treatment was done by the hospital for ailment of he patient / complainant. Therefore, we are strongly of the opinion that the repudiation of the claim of the insured / complainant by the insurer / The Oriental Insurance Co. Ltd. (o.p. nos.1 and 2) is not at all justified and tantamounts to deficiency in service on the part of the o.p. nos.1 and 2 within the meaning and ambit of the definition of ‘deficiency’ and ‘service’ as mentioned in the C.P. Act, 1986. It is also pertinent to mention that in this regard Hon’ble National Commission has been pleased to observe that if the claim of the ‘insured’ is repudiated by the ‘insurer’ without any valid reason then the ‘insurer’ shall be liable for deficiency in service. In limelight of the above discussion we are of the opinion that o.p. nos.1 and 2 have committed deficiency in service and for their this activity the complainant to suffer financial loss, harassment and mental agony.
As the o.p. no.3, TPA is appointed by the insurer i.e. by the o.p. nos.1 and 2 and only insurance company (o.p. nos.1 and 2) are the service provider to the complainant / consumer. Therefore, only o.p. nos.1 and 2 are responsible for repudiation of the claim and for this act of the o.p. nos.1 and 2, the complainant has to suffer mental agony, harassment and financial loss also.
Hence, ordered,
That the case of the complainant is allowed in part with cost on contest against o.p. nos.1 and 2 and ex parte without cost against o.p. no.3. O.p. nos.1 and 2 are directed to pay to the complainant the claim amount of Rs.79,990/- (Rupees seventy nine thousand nine hundred ninety) only together with interest @ 9% p.a. from the date of repudiation till the date of realization. O.p. nos.1 and 2 are further directed to pay the complainant compensation of Rs.30,000/- (Rupees thirty thousand) only for harassment and mental agony and litigation cost of Rs.3000/- (Rupees three thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 9% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties.
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MEMBER MEMBER PRESIDENT
