Judgment : Dt.30.6.2017

            This is a complaint made by one Sujash Ghosh Dastidar of 193/2, Rashsbehari Avenue, Kolkata-19, against Oriental Insurance Co. Ltd., Gariahat (OP No.1) and Vipul Medcorp TPA PVT. LTD., 19, R. N. Mukherjee Road, praying for an order  directing the Opposite Parties to pay a sum of Rs.31,836/- to the Complainant towards the remaining medical expenses and an order directing OP to pay Rs.50,000/- towards compensation and litigation cost of Rs.15,000/-.

            Facts in brief are – Complainant is a practicing Advocate. OP No.1 is a Renowned General Insurance Company having its branch at Kolkata, OP No.2 is TPA of OP No.1. Complainant is an old Mediclaim Policy holder of the OP No.1. The first Mediclaim Policy was issued to the Complainant on 25.11.1998, his mother, his wife and his daughter. The Medical coverage was Rs.25,000/- for the period of 29.11.2002 to 28.11.2003. The coverage was increased to Rs.45,000/- from Rs.25,000/-. But, it was not increased in respect of Complainant’s mother due to her old age. In the year 2006, OP No.1 took a decision that the minimum coverage decision that the minimum coverage of any person would be Rs.50,000/-. Accordingly, it was enhanced to that extent. On the application of Complainant the medical coverage was increased to Rs.1,00,000/- from Rs.50,000/-. In respect of wife and daughter of the Complainant further for the period 28.12.2014 to 27.12.2015 medical coverage of wife was increased from Rs.1,00,000/- to Rs.1,50,000/-. In the year 2015, OP No.1 took a decision that minimum coverage policy should be Rs.1,00,000/-.  Accordingly, the Policy for 28.12.2015 to 27.12.2016 was increased to Rs.1,00,000/- in respect of his mother also and in respect of Complainant, his wife and daughter, it was increased to Rs.2,00,000/-.

            On 9.8.2016 Complainant’s mother was admitted to AMRI Hospital, Dhakuria, which is a listed hospital. After the admission hospital made a request for Rs.95,000/- but TPA approved only Rs.25,000/-. Final Bill of Rs.81,836/- was issued from the hospital but TPA approved only Rs.50,000/-. Complainant made several requests for payment of rest of the amount. But, OP did not oblige. So, Complainant files this case.

            OP No.1 files written version naming it as ‘Written Argument’. In this written argument OP No.1 has stated that the policy falls under exclusion Clause No.4.19 pre-existing disease and Rs.50,000/- was paid. Further OP No.1 has referred certain decisions in this written argument/version and has prayed for dismissing the complaint.

            OP No.2 did not take any step. So, this complaint heard against OP No.2.

Decision with reasons

            Complainant filed Affidavit-in-chief where he has asserted the facts mentioned in the complaint petition against this OP No.1 has filed questionnaire to which Complainant has replied. Similarly, OP No.1 has filed evidence against which Complainant has filed questionnaire to which OP No.1 has filed affidavit-in-reply.

            Main point of determination is whether the Complainant is entitled to the reliefs or not.

            On perusal of respective evidences, questionnaires and affidavit-in-reply, it is clear that the mother of Complainant was insured with OP No.1 and the coverage amount was Rs.1,00,000/-. Further, there is no dispute that Complainant did not pay Rs.81,836/- to the AMRI Hospital. The bone of contention is that since TPA approved only Rs.50,000/-, OP No.1 paid this amount. No explanation is forth coming as to why only Rs.50,000/- was approved. The policy, as it appears, was continuing since 1998 and there was bona fide relation between Complainant and OP No.1. No doubt, OP No.1 has mentioned about Clause 4(1) for taking defence that Complainant’s mother suffered from pre-existing disease. But, no evidence is laid down. The burden of proof is upon OP No.1, which is missing here. So, we do not find any reason why OP No.1 did not pay the rest of the amount for which this complaint has been filed.

            Hence,

ordered

            CC/21/2017 and the same is allowed on contest against OP No.1 and ex-parte against OP No.2. OP No.1 is directed to pay Complainant Rs.31,836/- by an account payee cheque within two months of this order. In addition, OP No.1 is also directed to pay Rs.10,000/- as compensation to the Complainant and Rs.5,000/- as litigation cost within the above mentioned period, in default the total amount of Rs.46,836/- shall carry an interest of 10% p.a. from the date of this order.