DATE OF FILING : 03-10-2013.
DATE OF S/R : 19-11-2013.
DATE OF FINAL ORDER : 29-10-2014.
Ashoke Mukherjee,
son of late Sushil Kumar Mukherjee,
residing at N.D. Block, P.O. & P.S. Bagnan,
District –Howrah,
PIN – 711303. -------------------------------------------------------------- COMPLAINANT.
- Versus -
1. The Senior Division Manager,
Life Insurance Corporation of India,
Divisional Health Unit,
Rallis Building, 4th floor, 16, Hare Street,
P.S. Hare Street, Kolkata – 700001.
2 Medicare TPA Services (I) Pvt. Ltd.,
6, Bishop Lefroy Road,
Kolkata – 700020.
3. The Manager,
L.I.C.I. Bagnan Branch, Jayanti Bhavan,
Bagnan College Road, P.S. Bagnan,
District – Howrah,
PIN – 711303. -----------------------------------------------------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. Complainant, Ashoke Mukherjee , by filing a petition U/S 12 of the C .P. Act,
1986 ( as amended up to date ) has prayed for a direction to be given upon the o.p. to release the medi claim amounting to Rs. 1,88,852.03, to pay ` 1,00.000/- as compensation and `. 50,000/- as litigation costs along with other relief or reliefs as the Forum may deem fit and proper.
2. Brief fact of the case is that complainant took a medi claim policy for his wife from o.p. no. 3 and o.p. no. 3 issue certificate being no. 437728068 and delivered Health Card in favour of his wife in the year 2008 vide Annexure. Thereafter, his wife was hospitalized on 22-04-2010 and 15-05-2010 for twice and discharged on 06-05-2010 and 22-05-2010 respectively vide annexure discharge certificate. Subsequently, he submitted all documents showing total expenditure of Rs. 1,88,852.03 before o.p. nos. 1 & 2 duly attested by o.p. no. 3 vide Annexure claim forms submitted by the complainant. O.ps. also vide their letters dated 05-06-2010, 15-06-2010, 18-10-2010, 22-11-2010, 14-12-2010 asked for some more documents to release the claim amount. And complainant complied with all their instructions. Still o.ps. rejected his legitimate claim vide letter dated 31-12-2010. Thereafter complainant visited several times to o.ps.’ office with the request to reconsider his legitimate claim but they paid no heed to that. Ultimately he lodged complaint with Consumer Affairs Department who arranged for tripartite meeting on different occasions i.e., on 16-05-2013, 22-08-2013, 27-09-2013 but o.ps. neither appeared nor filed any written version. Being frustrated and aggrieved complainant filed this instant case with the aforesaid prayers.
3. Notices were served upon o.ps. O.P. nos. 1 & 3 appeared and filed written version. O.p. no. 2 neither appeared nor filed any written version. Accordingly, case was heard on contest against o.p. nos. 1 & 3 and ex parte against o.p. no. 2.
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. O.p. nos. 1 & 3 have categorically stated that complainant did not comply with the formalities with regard to the submission of claim within 30 days from the date of discharge which fell on 22-05-2010. But o.p. received the same on 25-06-2010 vide their letter dated 14-12-2010 as is written in the annexure. But we find all the formalities were completed by 21-05-2-10 by the complainant from the xerox coy of claim form. Since o.p. no. 2 is also in existence, o.p. nos. 1 & 3 might have received the same after some time. Moreover, late filing of claim forms can never take away the merit of the claim. O.ps. have also taken a plea that complainant had suppressed her ailments at the time of taking the policy. It is our question, then, what for a series of medical tests are usually conducted by the o.ps. before issuing medi claim policy? With other arguments, like instant policy is not a medi claim policy as o.ps. are not in medi claim business, it is admitted by them that as per policy terms and condition, complainant is entitled to ` 525/- per day of hospitalization for two times as there was no major surgery. Even that ` 525/- per day is not allow able as there was pre existing disease. So, after going through their written version, particularly para 11, we are of candid opinion that o.ps. are in a mood to repudiate the claim of the complainant in any manner, whatsoever. By hook and crook, they want to reject the same. Complainant’s wife had expired on 02-06-2010. And since long he has been fighting for his legitimate claim which should not allowed to be perpetuated. Accordingly it is our 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. 353 of 2013 ( HDF 353 of 2013 ) be allowed on contest with costs against the O.P. nos. 1 & 3 and ex parte against o.p. no. 2 with costs.
That the O.Ps. are jointly and severally directed to pay Rs. 1,00,000/- ( sum assured under the policy in question ) to the complainant within one month from the date of this order.
That the o.ps. are further directed to pay Rs. 5,000/- as compensation and Rs. 2,000/-litigation costs to the complainant..
That the o.ps. are further directed to pay the entire amount of Rs. 1,07,000/- to the complainant within one month from the date of this order i.d., the aforesaid amount shall carry an interest @ 10% per annum 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.
