West Bengal

Paschim Midnapore

CC/79/2015

Smt. Tapati De - Complainant(s)

Versus

The Oriental Insurance Co.Ltd. - Opp.Party(s)

21 Dec 2015

ORDER

                                                             DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

and  

                                                                                         Debi Sengupta, Member.

   

                                                     Complaint Case No.79/2015

                                                       

Smt. Tapati De………….………Complainant

Versus

                                                               1) The Oriental Insurance Company Ltd.;

                                                               2) Vipul Mederop TPA Pvt. Ltd .…..Opp. Parties.

 

 

 For the Complainant : Mr. Asim Kumar Dutta, Advocate.

 For the O.P.              : Mr. Akshoy Kumar Khamrai, Advocate.

 

Decided on: - 21/12 /2015

                               

ORDER

                     Bibekananda Pramanik, President - Case of the complainant, in brief, is that Asok Kumar De, the husband of the complainant, purchased a Mediclaim policy from the opposite party no.1 and the policy was valid from 30/07/2013 to 20/07/2014.  Said policy also covered the name of the complainant along with his husband Asok Kumar De.  The complainant suffered from “Asymptomatic Fibroid Uterus” and Dr. B.D. Roy advised for operation.  Complainant was immediately treated by the doctor of Christian Medical College, Vellore and after thorough investigation, the senior Gynecologist advised the complainant that there was no need for surgical intervention.  After laps of some times, the complainant suffered from same problem and she was medical examined by Dr. Bimal Raj and Madhusudan Laga at Medinipur Town and after thorough investigation, Dr. Madhusudan Laga advised the complainant for

Contd…………………...P/2

 

( 2 )

immediate operation and as per advice of Dr. Laga, she was admitted at Medinipur Nursing Home on 16/06/2014 under Dr. Madhusudan Laga.  After her admission on 16/06/2014, husband of the complainant informed the opposite party no.2 regarding such admission with details policy number and card number and also requested to take necessary action.  The complainant was discharged from Medinipur Nursing Home on 22/06/2014.  After discharge, the complainant deposited all medical bills, discharge certificate and all other relevant papers of individual Mediclaim. After receiving all documents, opposite party did not settle the claim till now but only two mobile massages were sent by opposite party on 23/07/2014 and 01/08/2014, requesting the complainant to provide the bank details for NEFT transfer.  Complainant deposited her bank details but even after lapse of one year, the opposite party withheld the Mediclaim and trying to avoid payment by various ways and such type of act by the opposite party tantamount to repudiate her claim and it also amounts to deficiency in service.  Hence the complaint, praying for directing the opposite party to pay a sum of  Rs.44,862/- with interest @ 12% from the date of filing of the application and litigation cost of Rs.10,000/-.

                  Opposite party no.2 received notice of this case but in spite that, opposite party no.2 did not appear to contest this case for which the case was ordered to be heard ex-parte against opposite party no.2. 

                 Opposite party no.1-Oriental Insurance Company Ltd. has contested this case by filing a written objection.  Denying and disputing the case of the complainant, opposite party no.1 admits that the husband of the complainant Asok Kumar De purchased individual Mediclaim policy but said policy was valid from 20/07/2013 to 22/07/2014 and not from 30/07/2013 to 20/07/2014 as stated by the complainant.  It is denied by the opposite party no.1 that after receiving all medical papers, they withheld the claim of the policy and tried to avoid in various ways for payment of Mediclaim to the complainant.  It is submitted by the complainant that she made correspondence with opposite party no.2 but the husband of the complainant gave wrong policy number, wrong effective date and requested for necessary action by referring policy of the previous year.  Although, it was informed that the complainant was admitted in nursing home on 16/06/2014 but the date of operation was not informed.  The complainant has not stated the date of her operation.  However, by mobile message, opposite party no.2 acknowledged on 23/07/2014 regarding receipt of claim of Rs.44,862/- and opposite party no.2 informed the complainant on 01/08/2014 that her claim was under query  for processing the same.  The Mediclaim of Rs.44,862/- does not tally with the actual

Contd…………………...P/3

 

( 3 )

amount of bill paid i.e. Rs.41,587/- and required time for inquiry by the opposite party no.2 for processing the claim. Account number of the complainant was asked for with a view to keep it on record in advance for quick payment directly through the bank.  As the amount of claim was a matter of dispute and the policy reference was not correct, so enquiry in processing the claim was being delayed.  The enquiry in the matter was processing but before the completion of enquiry, the present complaint has been filed.  This opposite party has no intention to delay the payment of just Mediclaim.  Had there been any intention to deny the claim of the complainant then the opposite party could have repudiated the claim and therefore there is no deficiency in service on the part of the opposite party. Op  therefore claimed dismissal of the case.   

Point for decision

                                                              Is the complainant entitled to the reliefs, as prayed for?

 

Decision with reasons

                        At the very outset, it is to be stated here that  neither the complainant nor the opposite party adduced any evidence, either oral or documentary, but in support of her case, the complainant has filed few  copies of documents.

                      It is not denied and disputed that the husband of the complainant Asok Kumar De purchased individual Mediclaim policy and the said policy was valid from 20/07/2013 to 22/07/2014.  According to the complainant, on 16/06/2014 she was admitted in Medinipur Nursing Home under Dr. Madhusudan Laga for operation and she was discharged on 22/06/2014.  It is also not denied and disputed by the opposite party that the husband of the complainant informed the opposite party no.2 regarding such admission of the complainant in Medinipur Nursing Home and after discharge, they submitted claim for medical reimbursement under such Mediclaim policy.  According to the opposite party, the husband of the complainant gave him the wrong policy number with wrong effective date.  The referred policy was also for previous year.  Further according to the opposite party, although the date of admission and discharge from the hospital were informed but the date of operation was not at all informed.  Admittedly by a mobile massage, opposite party no.2 sent two massages on 23/07/2014 and 01/08/2014 requesting the complainant to provide the bank details for  NEFT.  Although, in her petition of complaint, the complainant has alleged that after receiving all documents, opposite party withheld the claim and such type of act tantamount to deficiency in service,  but from the written objection filed by and on behalf of opposite party no.1, we find that they are in process of settling the Mediclaim

Contd…………………...P/4

 

( 4 )

of the complainant but they are unable to do so as the complainant did not inform the exact date of operation to them and they were supplied to wrong policy number with wrong effective  date. It is also the case of the opposite party no.1 that the complainant has also not stated the date of submission of Mediclaim after such discharge.  The said case of the opposite party no.1 has not been denied by the complainant by adducing evidence.  It thus appears that the claim of the complainant is under process and the same has not been repudiated by the opposite party.  It also appears that the Op has stated that the claim for Mediclaim reimbursement under that Mediclaim policy is under process by the opposite party and for wrong submission of policy number with wrong effective date and for non supplying  the date of operation, the opposite parties are unable to settle the claim of the complainant.  Thus, we find that there is no deficiency in service on the part of the opposite party in settling the claim but the delay which has been caused by the opposite party is due to wrong information regarding policy number and non submission of the date of operation.  Admittedly, the claim of the complainant has not yet been repudiated by the Op.  So, we are of the view that the present complaint is pre-matured and there is no cause of action to file the present complaint.  The petition of complaint is, therefore, liable to be dismissed.   

                                         Hence, it is,

                                                           ORDERED,

 

                                                               that the complaint case no.79/2015 is hereby dismissed on contest without cost.

             Dictated & Corrected by me

                             Sd/-                                    Sd/-                                 Sd/-

                        President                              Member                          President

                                                                                                      District Forum

                                                                                                  Paschim Medinipur