Order No. 15 Dt. 20.05.2015
This is an application u/s. 12 of C.P. Act filed by petitioner Tapan Kr. Roy Chowdhury praying for an order for Medi Claim of Rs. 15800/- along with litigation cost of Rs. 10000/- and Rs. 100000/- for mental harassment and agony against O.P. 1 to 3 for their non-compliance to the term of medi-claim policy.
The case of the petitioner is that he is being a retired Sub-Assistant Engineer of Govt. of West Bengal under Water Resources Investigation and Development Department (W.R.I.D.D.) resides at Vill-3 No. Govt. Colony under English Bazar P.S. of Malda District and O.P.1 O.P.2 and O.P.3 are Govt. Officials of West Bengal Government holding posts in Medical Cell and In W.R.I.D.D. The further case of the petitioner is that he is being a Consumer under the West Bengal Health Scheme 2008 and also a policy holder of United India Insurance Co. Ltd. and within the insurance period he is being seriously ill due to coronary artery disease, he took treatment from R.N. Tagore International Institute of Cardiac Service(RTIICS) and B.M. Birla Heart Research Centre (B.M.B.H.R.C) and in the process incurring an amount of Rs. 191338/- and out of which he received Rs. 125000/- from united India Insurance Company and out of rest claim of Rs.66000/- the Government sanctioned only Rs. 50200/-, and thus he is still to get an amount of about Rs. 15800/- from Government but Government did not pay heed to his claim and hence this case.
O.P. 1 to O.P.3 contested the case with a single written version stating that the allegations are vague, unjustified and not supported by law and hence the suit is not maintainable according to law. O.P.3 also raised some questions regarding form filling up methods in such claims and agreed treatment expenditure of Rs. 176928/- from B.M.B.H.R.C. but denied complainant’s claim expending of Rs. 14630/- for treatment in R..T.I.I.C.S. for non-production of “essentiality certificate –cum – statement of expenditure” and also denied claiming of Rs.1728/- (Rs.200/-+ Rs.1528/-) as consultation fee and medicine expenses for not giving supporting documents and acted rightly paying net admissible amount of Rs.50200/- thus complying claim petition of petitioner as per norms and prayed for dismissal of the case.
O.P.4 contested the case filing W/V submitting that they have made payment of Rs.125000/- as per insurance norm after checking the total bill of Rs. 191338/- attached with documents and wanted to have dismissal of the case.
On the basis of the same following issues are framed:-
- Whether the case is maintainable?
- Whether there is any cause of action to file this case?
- Whether there has been any deficiency in service on the part of the ops?
- Whether the complainant is entitled to get the relieves as prayed for?
:DECISION WITH REASONS:
Issue Nos. 1,2,3 and 4
All the issues are taken up together for the sake of brevity and convenience of discussion.
In support of his claim the petitioner appeared as P.W.-1 and filed 09 documents marked as Ext.-1 to Ext.-9. Ext.-1 is Memorandum of Govt. of W.B. related W.B.H.S. 2008 wherein norms for filing medi-claim and approved rate etc. are recorded. Ext.-2 is the certificate of United Indian Insurance Co. Ltd., Ext.-3 is Form III related to settlement of claim for reimbursement. Ext.-4 is Form IV and is related to statement of Expenditure –cum- Certificate, Ext. 5 is Form V related to Checklist, Ext. – 6is Discharge Summary of BMBHRC, Ext-7 is Memorandum of Government related to Rabindra Nath Tagore International Institute (RTIICS) treatment and related norms. Ext.-8 is Bill details of BMBHRC amounting to payment of Rs. 175000/-. Ext.-9 is actually Ext.-2 and it is likely to be an extra copy and marked inadvertently.
O.Ps. 1 to 3 filed 22 documents with firisti. As per Serial No.1 documents, which is T.R. Form No. 68A and is prepared by concerned officer of Government of W.B. for payment of medical charges and is a document for proof of receiving by concerned applicant. This T.R. Form No. 68A have shown expenditure of Rs. 176928.00 for Rabindra Nath Tagore International Institute No. 0411008 and of Rs.125000.00 for B.M. Birla Heart Research Centre with Code No. 0411007. This is an authentic document stamped and signed by Govt. Officials and also signed by recipient. Serial No.6 which is also Ext. 2 and is a certificate of United India Insurance Co. Ltd. which certifies that as per submitting relevant documents, the claim has been assessed by United India Insurance Co. Ltd. for Rs. 191579/-. The document written as Srl. No. 19 is the letter of petitioner claimant and is signed and stamped by concerned Govt. Official wherein expenditures of RTIICS and BMBHRC shown separately and distinctly as it is Rs.14360.00 for RTIICS and Rs.176978.00 for BMBHRC and supporting three bills cum receipts of RTIICS for Rs.14360.00 ( Rs.250/- + Rs.1570/- +Rs.12540/-= Rs.14360/-). The three receipts having Srl. Nos. 20, 21 and 22 which are hand written like all 22 documents.
Looking into the evidence of petitioner and the documents filed by both parties, this Forum finds that there exists a mismatch between two documents filed by O.Ps 1 to 3. Document under Serial No.1 showed the expenditure amount of Rs.1,76,928.00 in the name of RTIICS and Rs.125000/- in the name of BMBHRC which is grossly wrong. This is T.R. Form No. 68A and is a government document stamped and signed as per actual expenditure Rs.14630/- for RTIICS and Rs.176978.00 for BMBHRC. On the other hand when we look into the O.Ps document under Srl. No. 19 it clearly depicts that there are expenditure of Rs. 14360.00 for RTIICS and Rs.176928.00 for BMBHRC and serial nos.20, 21, and 22 are three documents served by RTIICS for receiving money of Rs.250.00, Rs.1570.00 and Rs.12590.00 totaling to Rs.14360.00 as total expenditure of the patient cum claimant cum petitioner for his treatment at RTIICS. Petitioner in course of witness and argument stated the expenditure documents incurred at RTIICS are not with him and they are remaining with O.Ps. On the other hand petitioner submitting expenditure document of BMBHRC for Rs.176928.00 already with his submitted document as Ext. 8 which is not at all disputed. But the dispute that remains for a claim of Rs.14360.00, after receipt of Rs.50200.00 by the petitioner from Government, in view of Government’s disagreement with the petitioner’s view of submitting expenditure bill of RTIICS and O.Ps not finding those documents. But this is quite contrary from the availability of the documents related to expenditures at RTIICS being lied with O.P’s themselves but this is an eye-opener for us for the paraphernalia embedded in the process of claim clearance and is of course there is chance for such oblivion in the lengthy steps of and the consumers getting relief in medical expenditures, suffer from the delayed payment of medical reimbursements. On the other hand the documents under Serial Nos. 20, 21, 22 which are retained by the O.Ps amply proves that the expenditure of Rs.14360.00 was duly incurred by the petitioner cum consumer of the health scheme and his submission of claim for both the expenditures of BMBHRC and RTIICS are lying for a long time with O.Ps in the extended process of examining, excavation, monitoring and exactness. So the petitioner is entitled to his claim of Rs. 14360.00 as per his prayer and submission. The case succeeds in favour of the petitioner.
Proper fee paid.
Hence, ordered
that Malda D.F.C Case No. 45/2014 is allowed on contest against the O.P.s 1 to 3. with cost. Complainant do get an award for payment of Rs.14360.00 towards the expenditure incurred for treatment at RTIICS Kolkata but without any other costs against O.P. 1 to O.P.3 who are liable to ensure payment of the aforesaid sum to the complainant within 45 days from the date of this order failing which they will be bound to pay interest @ 9% p.a. from this day until recovery and the petitioner is at liberty to put the decree in execution.
A copy of this order be supplied to each of the parties free of cost.
