FINAL ORDER/JUDGEMENT

SMT. SUKLA SENGUPTA, PRESIDENT

The complainant filed the instant case U/s 35 of CP Act, 2019.

The fact of the case  in brief is that the complainant is a resident of Ulberia, Howrah and the OPs 1 and 2 Insurance Co. who used to provide various kinds of insurance policies against premium from the customers. OP-1 is the head office of the Insurance Co. and OP-2 is the divisional office of OP-1. Both the OPs are running their business under the jurisdiction of this commission.

It is the further case of the complainant that she purchased a mediclaim policy from the OPs on payment of required premium of Rs. 1,247/- being policy No. 100700501610011332 dated 15.03.2018.  The policy covered to the complainant’s medical expenditure for the period 15.03.2018 to 14.03.2019. The copy of policy is annexed as annexure “1”.  The complainant paid the premium to the OP-1 Insurance Co.

It is further stated by the complainant that she was under treatment as an outdoor patient in the Ramakrishna Mission Seva Pratisthan  at 99, Sarat Bose Road, Kolkata-700026 on  14.03.2018 where from she was transferred to ICU with abdominal pain. After various test, it was found that she was suffering from “SEAR Abdominal Endometriosis (2 cm x 2cm) was just above the rectus seath”. The  treating Dr. advised for immediate operation. The operation was done on 16.03.2018 successfully and the complainant was discharged on 18.03.2018 from the hospital.

It is further case of the complainant that through the registered agent of the OP-1 she submitted the claim of her medical expenditure of Rs. 8,831/- as hospital charge and medicine charge with all original bills and cash memos on 16.04.2018 to the OP-1. The copy of complaint has annexed as annexure “C” collectively. Thereafter, on 05.09.2018 the OP repudiated the claim of the complainant with observation “non submission of the required documents as noted below”:-

Under line cause of scar abdominal endometriosis ie how the scar was caused (to be certified by the treating surgeon).

Herein the claim filed is closed due to non-compliance of required documents by the insure. The repudiation letter has annexed as annexure- D.

The complainant further stated that being insured she is a consumer of the OPs but the OPs on the basis of vague observation has repudiated the genuine claim of the complainant.  So, finding no other alternative, she has come before this forum for getting relief. The OPs by repudiating her claim caused negligence, mental pain and agony to the complainant which is amounts  to deficiency in service on their part. So, they are liable to pay compensation and the claim amount of Rs.  8,831/- to the complainant.

The cause of action first arose on 05.09.2018 when the OPs repudiated the claim of the complainant. Hence, the instant case is filed by the complainant before this commission with a prayer to give direction to the OPs to settle the claim of the complainant of a sum of Rs. 8,831/- along with interest @ bank rate. She further prayed for awarding a sum of Rs. 5,000/- in her favour payable by the OPs for harassment, agony along with litigation cost of Rs.  3,000/-.

The OPs have contested the claim application by filing a WV/statement denying all the material allegation levelled against them.

The OPs have stated that the petition of complaint as filed by the complainant is mis- conceived one and the complainant has filed the petition of complaint with malafide intention  without any basis.

It is further stated by the OPs that the present petition of complaint is not maintainable in the eye of law. There is no cause of action on the part of the complainant to file this case.   

It is the  further case of the OPs that admittedly the complainant approached the agent of the OPs to avail a medical policy and he availed the same through the agent of the OPs being the medical policy No. 100700501610011332 dated 15.03.2018. The said policy was taken for the period of 15.03.2018 to 14.03.2019.

It is further stated by the OPs that the complainant was admitted as an outdoor patient  in Ramakrishna Mission Seva Pratisthan  at 99, Sarat Bose Road, Kolkata-700026  on 14.03.2018 and was transferred to ICU with abdominal pain. After going through various tests, she was diagnosed with CR abdominal endometriosis (2cmx2cm) was just above the rectus seath and he was advised by the  attending Drs. was undergone operation on  16.03.2018 and was discharged from the hospital on 18.03.2018. Thereafter, the complainant placed the claim of Rs. 8,831/-  to the OPs through the registered agent namely one “Devankur Biswas” bearing agent code No. 9000131038 along with original bills and cash memos on  16.04.2018. After receiving the claim document,  TPA sent a letter dated  07.05.2018 asking for documents as listed in the letter for settlement of the case. TPA did not      receive any response to the said letter. Thus, the claim was repudiated due to non compliance of required documents by the insured  vide letter dated  07.05.2018. Hence,  this case has been filed by the complainant.

The OPs further stated that the complainant claim of Rs, 8,831/- is illegitimate as the complainant was unable to furnish any documentary evidence  till date.  Under such circumstances,  the OPs are not lawfully bound to disburse any amount as by doing so that would be a great in-justice to public money. It is further case of the OPs that  in the instant claim in question the complainant was a defaulter and has failed to prove the same which is the  cause of such scar. Without such document,  the OPs could not be able to disburse the claim of the complainant.

It is the case of the OPs that the complainant did not come before this commission with clean hand and she has no cause of action to file this case. Thus, the case is liable to be dismissed with cost.

In view of above fact and circumstances of the instant case, the points of consideration are as follows:-

1. Is the present case maintainable in present form and in law?

2. Has the complainant any cause to file the case?

3. Is the complainant is a consumer?

4. Are the OPs are the service provider, if so is there any service on the part of the OPs?

5. Is the complainant entitled to get relief as prayed for?

Decision with Reasons.

All the points of consideration are taken up together for convenience of discussions and to avoid unnecessary repetitions.

From the materials on record, it appears that the case is well within the jurisdiction of this commission in all respect. 

Admittedly, the claim of the complainant of Rs. 8,831/- which was spent for her medical treatment was repudiated by the OPs vide its letter dated 05.09.2018. So, the cause of action of the complainant to file the case arose on and from that day. The complainant filed the case on 05.11.2020.  Thereafter, the complainant again requested the OPs to settle the claim but again on 05.09.2018 the OPs repudiated the claim and thereafter, it was continued till filing this case and the complainant filed a petition U/s 69 (2) CP Act, 2019 to condone the delay and that was allowed by this commission vide order dated 08.01.2021 from which it is held that the complainant has sufficient cause of action to file this case and the case is maintainable in eye of law.

From the admission of the OPs and also from evidence on record, it is palpably clear that the complainant purchased the medical policy being No. 100700501610011332 dated 15.03.2018 for the period of 15.03.2018 to 14.03.2019  on payment of required premium of Rs.  1,247/-. The insurance premium was received by the OP-1. Under such circumstances, it is held by this commission that the complainant is a consumer and the OPs insurance Co. are the service provider.

Let us see where there was any deficiency in service on the part of the OPs or not. It is admitted by the OPs in their WV as well as in their evidence and argument that the complainant was admitted as an outdoor patient in Ramakrishna Mission Seva Pratisthan  at 99, Sarat Bose Road, Kolkata-700026 on  14.03.2018 and due to emergency she was transferred to ICU with abdominal pain. As per advised of the attending Dr. that on the basis of report of various test made by the hospital it was found that “Sear Abdominal Endometriosis (2 cm x 2cm)   was just above the rectus seath” than the Dr. advised the complainant for immediate operation. The operation was done on  16.03.2018 successfully and  the complainant was discharged from the hospital on  18.03.2018. Thereafter the complainant placed the claim through the registered agent of the OPs namely Devankur Biswas agent code  9000131038  for getting the medical expenditure spent by her on a sum  of Rs 8,831/- along with all the original bills and cash memos and discharged summary of Ramakrishna Mission Seva Pratisthan  at 99, Sarat Bose Road, Kolkata-700026  on  16.04.2018. it is allegation of the complainant that she placed the complaint on  16.04.2018 to the OPs and the OPs without any making any query to her repudiated the claim vide letter dated  05.09.2018 mentioned in that there was no document regarding the cause of this scar there was no certified document issued by the treating surgeon  mentioning the cause of scar. Hence, the claim was repudiated. We have got the support of the allegation of the complainant from the content of the WV as well as written argument submitting by the OPs. They admitted the fact that the  cause of this scar was not mentioned   by treating surgeon in medical paper submitting by the complainant. So, the claim of the complainant was repudiated by them in support of their say. In this regard, the OPs have cited a case law which has been referred as IV (2009) CPJ 8 (SC). I have carefully gone through the observation  of the Hon’ble Apex Court and found that the fact and circumstances  of that case is something different from the fact and circumstances of the instant case. Thus, the case law as referred by the OPs mentioned above has no application in the instant case. 

In view of the discussion made above, it is found that the OPs did not give any chance to the complainant to supply the wanting documents and they arbitrarily repudiated the claim . On a close scrutiny  of the material on the paper as submitted by the  complainant along with the petition of complaint including discharge  summary issued by Ramakrishna Mission Seva Pratisthan .

. It is revealed that the complainant supplied all possible documents to the OPs along with her claim. But it was the mind set of the OPs that they will deprived the complainant  from her legitimate complainant and they repudiated the claim of the complainant of a sum of Rs.  8,831/- ie medical expenditure of the complainant illegally which they cannot. Actually, the Insurance Co. are always interested to look for the clauses to repudiate the claim of the policy holder in  most of the cases.  They repudiated the claim on flimsy ground like the instant case.

Under such circumstances, the commission is of view that the OPs have repudiated the claim of the complainant of a sum of Rs. 8,831/- which she spent for her  medical expenditure arbitrarily and such conduct of the OPs should be termed as deficiency in service which caused mental pain  agony harassment  and negligence  to the complainant. Such conduct of the OPs should not be indulged by the consumer commission and the OPs have compelled the complainant to rash to this commission for getting his legitimate claim  for which they should be liable to give compensation to the complainant.

on the basis of discussion made above, this commission is of view that there was deficiency in service on the part of the OPs which caused negligence, harassment,  mental pain and agony to the complainant  and thus the complaint could be able to prove her case beyond all reasonable doubts and she is entitled to get the relief as prayed for.

All the points are thus considered and decided favourably to the complainant.

The case is properly stamped.

 Hence,

Order

That the case be and the same is decreed on contest against the OPs 1 and 2 with cost of Rs. 5000/- .

The complaint do get the decree as prayed for.,

The OPs 1 and 2 are directed to settle the claim of the complainant and to pay a sum of Rs 8,831/-  to the complainant which she spent towards the medical expenditure either jointly or severally  within  45 days from the date of this order.

The OPs  1 and 2 are further directed to pay compensation  to the complainant  of a sum of Rs 3000/-  either jointly or severally within 45 days from the date of this order along with litigation cost of Rs1,500/-.

If the OPs will fail to comply the decree within stipulated period as mentioned above,  the complainant will be at liberty to execute the  same as per law.

            Copy of the judgment be supplied to the parties free of cost as mandated by the CP Act. The Judgement be uploaded forthwith on the website of the Commission for perusal of the party.