DATE OF FILING : 20-12-2013.
DATE OF S/R : 21-03-2014.
DATE OF FINAL ORDER : 30-10-2014.
Sri Rama Prasad Banerjee,
P.O. & Village - Janai, P.S. Chanditala,
District –Hooghly,
PIN – 712304.------------------------------------------------------------------- COMPLAINANT.
- Versus -
1. The Senior Branch Manager,
Liluah Brnach Officer,
National Insurance Company Ltd.,
1st floor, Narayan Niwas, Pushpanjali, Phase I,
268, G.T . Road, Howrah,
PIN – 711204.
2. The Officer in Charge,
Medsave Health Care ( T.P.A.) Ltd., Kolkata,
PIN – 700016.
3. The Senior Manager,
Bank of India Duttapur Branch,
Village – Duttapur, P.O. Krishnarampur,
District – Hooghly, West Bengal,
PIN – 712702. -----------------------------------------------------OPPOSITE PARTIES.
P R E S E N T
President : Shri T.K. Bhattacharya, M.A. LL.B. WBHJS.
Member : Shri P.K. Chatterjee.
Member : Smt. Jhumki Saha.
F I N A L O R D E R
1. It is the specific grievance of the complainant, Sri Rama Prasad Banerjee, that
in spite of receiving the renewal premium every year since 2008, o.p. no. 1 has arbitrarily and illegally repudiated the mediclaim of the complainant for an amount of Rs. 13,300/- incurred for his left eye treatment.
2. Brief fact of the case is that complainant took a mediclaim policy of o.p. no. 1
through its corporate agent i.e., o.p. no. 3 on payment of stipulated premium amount. As the complainant maintains an S.B. A/c with o.p. no.3, the premium amount is always debited directly from o.p. no.3. And the complainant always maintained sufficient balance in his S.B. A/c being no. 425610100006089 held with o.p. no. 3. But it is alleged by the complainant that although it was the duty of the o.p. no. 3 to deduct the premium amount for renewal, o.p. no. 3 reluctantly did not do so in time on many occasions. However, complainant got his left eye cataract operation on about 29-11-2011. As he was having cashless benefit under his mediclaim policy valid for the period 27-12-2010 to midnight of 26-12-2011, the hospital authority sent proposal to o.p. no. 1. But o.p. no. 2, being the TPA of o.p. no. 1 sent a rejection letter with a direction to submit the claim form with actual bills for reimbursement of his expenditure. So, the complainant had to go for a less costly operation for his left eye cataract. However, he submitted his claim along with all relevant document to o.p. no. 1 through o.p. no. 3 vide Annexure 7. But he did not receive his claim amount even after having discussion with o.p. no. 1 in presence of Branch Manager of O.P. no. 3. Thereafter complainant made several representation to all the o.ps. vide Annexure 3, 4 & 5 etc. But no effective result came out. Lastly, complainant sent one lawyer’s notice dated 06-06-2013 vide Annexure 12 to o.p. no. 1 with copies to o.p. nos. 2 & 3. After receiving that notice, o.p. no. 1 sent a reply dated 20-6-2013 stating therein that already they sent a repudiation letter to the complainant on 18-05-2012 for necessary information. Again, complainant’s lawyer sent a reply notice dated 24-07-2013 to o.p. no. 1 with a request to provide proof of delivery of their letter dated 18-05-2012. O.p. no. 1 sent a reply on 02-08-2013. But it alleged by the complainant that his claim is still pending before o.p. no. 1 as they did not release his legitimate claim amount till the filing of the case.
3. Notices were served upon o.ps. Only o.p. no. 1 appeared and filed written version. Other o.ps. neither appeared nor filed any written version. Accordingly, case was heard on contest against o.p. no. 1 and ex parte against o.p. nos. 2 & 3.
4. Upon pleadings of both parties two points arose for determination :
i) Is there any deficiency in service on the part of the O.Ps. ?
ii) Whether the complainant is entitled to get any relief as prayed for ?
DECISION WITH REASONS :
5. Both the points are taken up together for consideration. It is the specific plea taken by o.p. no. 1 in the written version that the claim was repudiated by o.p. no. 2 as the policy was a lapse one due to nonpayment of premium in time since 3rd November, 2010 and it was renewed with effect from 28-12-2010. And complainant underwent his eye operation on 13-12-2011 as it is reflected from claim form and discharge summary given by hospital authority. So, due to break up of the policy, o.p. no. 2 had repudiated the claim lawfully as it is hit by Clause no. 4.3 of the terms and condition of the policy which means exclusion clause meant for the first year of policy. Here it is to be kept in mind that complainant obtained mediclaim policy of o.p. no. 1 in the year of 2008 for the first time. And o.p. no. 3 is their corporate agent. It was entirely the duty of o.p. no. 3 to debit the premium amount in time and deposit the same in time for the interest of its subscribers. Actually, it is the unfair trade practice that o.ps. 1 & 3 adopted to harass their consumers. O.p. no. 2 also issued Health Card in favour of the complainant, but no effective result could be yielded at the time need. Cashless benefit was refused. Then why people should go for all these mediclaim policies at all ? Only to manage the sudden extra monetary burden on treatment, people buy these medi claim policies on payment of premiums. But the organizations like o.ps. have no regard for the necessity of the people. While they have accepted the proposal of the complainant for mediclaim, they should also be very careful about their responsibility towards the same. But they have behaved in the most negligent manner by way of withholding the legitimate claim of the complainant for a very long time which should not be allowed to be perpetuated any more. Accordingly, we are of the candid opinion that it is a fit case where the prayers of the complainant should be allowed. Points under consideration are accordingly decided.
Hence,
O R D E R E D
That the C. C. Case No.443 of 2013 ( HDF 443 of 2013 ) be allowed on contest against o.p. no. 1 with cost and ex parte against o.p. nos. 2 & 3 with costs,
That the O.P. no. 1 is directed to release the claim amount of 13,300/- within one month i.d., 10% p.a. interest shall imposed upon o.p. no. 1 till actual payment.
That the o.ps. are directed jointly and severally to pay to the complainant an amount of Rs. 3,000/- as compensation and Rs. 1,000/- as litigation costs, totaling Rs. 4,000/- to be paid within one month i.d., the amount shall carry 10% p.a. interest till full realization.
The complainant is at liberty to put the decree into execution after expiry of the appeal period.
Supply the copies of the order to the parties, as per rule.
DICTATED & CORRECTED
BY ME.
( Jhumki Saha )
Member, C.D.R.F.,Howrah.
