IN THE COURT OF THE LD. DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT S I L I G U R I.

CONSUMER CASE NO. : 34/S/2016.                     DATED : 14.12.2017.   

BEFORE  PRESIDENT              : SMT. KRISHNA PODDAR,

                                                              President, D.C.D.R.F., Siliguri.

                      MEMBER                : SRI. TAPAN KUMAR BARMAN.

COMPLAINANT             : SRI . SUVENDU BANERJEE,

  S/o. Sukumar Banarjee, R/O- Rangapani (North),

  Rangapani , Bagdogra, Dist.- Darjeeling-734012.     

O.P                                             :1. THE SENIOR MANAGER,

                                                     Life Insurance Co.of India,Jiban Prakash, 

     P.O. & P.S & Dist.- Jalpaiguri.

2. THE SENIOR MANAGER,

    Life Insurance Co. of India, Sevoke Road Branch,

    P.O.-Sevoke Road, P.S.- Siliguri,Dist-Drajeeling.

FOR THE COMPLAINANT         : Sri  Subhajit Bhattacharjee , Advocate.

J U D G E M E N T

Smt. Krishna Poddar, Ld. President.

Brief facts of the Complainant case is that the complainant is a commission agent with Life Insurance Co. of India, Siliguri Branch -1 & he is a BM’S  club member agent having code number 06824453 complainant is a mediclaim holder under OP no.2 and his  area of work being supervised under Siliguri Subdivision on 31.5.2014 the complainant encountered and accident whereby his prognosis & treatment was carried on by his own expenses firstly at North Bengal Medical College & Hospital & thereafter at Basu’s Hospital and Clinic. Complainant had to spent a sum of Rs.48000/- for his treatment . Complainant made various representation to the OPs for reimburssment Rs. 40,000/- only being the rightfull claim of the complainant and after discharge with his fragile health complainant ran from pillar to post to convince the Opposite parties for payment of his madiclaim amount Rs.40,000/- but of no good result .But unfortunately till date though complainant with his ran from pillar to post trying to convince the OPs for securing his mediclaim amount but of no good result. Thereafter, the complainant through his advocate served a legal notice dated 25.2.2016

Contd......P/2

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to the OP no.1 whereby the OP no.1 on 29.2.2016 replied in stating rather shifting the onus upon the Officer-in-charge  Medi Assistant India T.P.A private at Kolkata. Thereafter the complainant again on 18.3.2016 sent representation through his lawyer but unfortunately the same went unanswered. Complainant is a bonafide consumer of the Opposite parties and there has been gross negligence and deficiency in service on the part of the Ops to disburse the medicliam amount in favour of the complainant. Hence, this case.

The OP no1 & 2 contested and registered the case by filing edit inversion wherein the averments made in the complainants have been denied & it has been contented inter alia that the instant case is not the maintainable. It has been stated by the Ops that on receipt of the claim papers of the complainant the same had been sent along with other documents  to the T.P.A – the Medi Assist India Pvt. Ltd., 53A, Rafiamed Kidwai Road, Kolkta-700016.on 30.6.2014 by speed post & there after sent another letter to the T.P.A. at its address at Chandni Chawk Street, Kolkata-7007 for early settlement of the claim of the complainant by speed post on 13.10.2014. It has been further stated by the OPs that T.P.A – the Medi Assist India Pvt. Ltd., is an independent body and is the authority to the adjudicate the admissibility of the claim and  T.P.A makes contact with the complainant directly for any requirement or issue of claim settlement discharge voucher etc. and it is learnt that claim is pending

 for requirement of discharge card for hospitalization and  pre and post surgery x-ray film with reports and there is no deficiency of service or negligence on the part of the Ops and therefore this case is liable to be dismissed .

To prove the case, the complainant has filed the following documents:-

1.       Photo copies of application of mediclaim of the complainant.

2.       Premium payment acknowledgement of the complainant by the OP no.2. 

3.       Photo copy of bill receipts issued by Basu’s Clinic and Dr. Amuanjyoti Roy 24 number of receipts.

4.       Photo copy of legal notice with postal receipts dated 25.02.2016   

5.       Photo copy of intimation letter dated 30.4.16 issued by Medi assist.

6.       Photo copy of reply letter dated 24.5.16 along with postal receipt to the letter dated 30.04.2016.

          No document submitted on the side of the Opposite parties.

          Complainant has filed examination-in-chief supported by affidavit.

Complainant has filed written notes of argument.

Contd......P/3

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          OP has filed examination-in-chief but failed to submit Written Notes of Argument.

Points for determination

1.       Is there any deficiency in service on the part of the OP ?

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

Decision with reason

Both issues are taken up together for the brevity and convenience of discussion.

It is admitted position that the complainant is a commission agent with the OP no.2 Life Insurance Co. of India, Siliguri Branch.  He is a BM’s club member having code number 06824453and he is a mediclaim holder.

 This is the case of the complainant that on 31.5.14 he met an accident and his medical treatment was carried on by his own expenses at North Bengal Medical College and hospital and thereafter Basu’s Hospital and Clinic complainant made various representation to the OPs for medical amount of Rs. 40,000/- but the OP did not disburse the rightful claim of Rs.40, 000/- to the complainant till date

In order to substantiate the case the complainant has examined has P.W. no.1 moreover he has submitted certain documents. The OP also admitted in there written version as well as evidence that as soon they got the  claim papers of the complainant the same had been sent to the T.P.A. Medi- Assistant India Pvt. Ltd. , Kolkata for adjudication of the matter and now the OPs have no right or power to interfere with the affairs .

It has been stated by the Ops in the written version that group mediclaim insurance scheme for club member agents is a welfare scheme and is mandatory for the all the club member agents  up to the age of 85 yrs and complainant was a member of the scheme . From the reply dated 19.2.2016 of the Ops addressed to the advocate of the complainant it is found that Opps’ admitted that only club member agents are eligible for mediclaim policy which is governed by GIC (New India Assurance Pvt. Ltd.)

Contd......P/4

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and amount of medicalim premium is deducted from the commission of the agents at branch level and remitted To GIC through their higher office. In the said letter the Ops have further stated that there branch office has forwarded the claim paper of the complainant to the divisional office and division in turn forwarded the same to the T.P.A  and they have not received any data regarding claim settlement , and T.P.A directly communicates with the claimant. The OP cannot shift its burden by saying that the matter will be adjudicated by the T.P.A. The complainant made several corresponded with the OPs since 2014 and legal notice was also sent to the Ops for disbursement of mediclaim amount of Rs.40, 000/- which is the legal claim of the complainant when the Ops admitted the club member agent are eligible for mediclaim policy as governed by GIC and the amount of the mediclaim premium is deducted from the commission of the agents by the OPs. So, OP cannot avoid its liability to disburse the mediclaim amount of RS. 40,000/- in favour of the complainant here. We find that the Ops are negligente in payment of mediclaim amount to the complainant and there is deficiency in service on the part of the OPs. So, the complainant is entitle to get the mediclaim amount of Rs. 40,000/- from the Ops .

The complainant is  further entitled to get a sum of Rs. 20,000/- from the Ops towards mental agony suffering and harassment from the Ops.

 The complainant is further entitle to get a sum of RS.10, 000/- towards the litigation caused from the Ops in the result.

In the result, the case succeeds.        

Hence, it is

O R D E R E D

That the Consumer Case No.34/S/2016 is allowed on contest in part against the OP nos. 1 and 2 with cost.

 The complainant is entitled to get the mediclaim amount of Rs. 40,000/- from the Ops .

The complainant is further entitled to get a sum of Rs.20,000/- as compensation for mental pain, agony and harassment from the OPs.

The complainant is further entitled to get a sum of Rs.10,000/- towards litigation cost from the OPs.

Contd......P/5

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The OP Nos.1 & 2, who are jointly and severally liable, are directed to pay a sum of Rs.40,000/- by issuing an account payee cheque in the name of the complainant within 45 days from the date of this order.

The OP Nos.1 & 2, who are jointly and severally liable, are further directed to pay a sum of Rs.20,000/- by issuing an account payee cheque in the name of the complainant towards compensation for mental pain, agony and harassment within 45 days from the date of this order.

The OP Nos.1 & 2, who are jointly and severally liable, are further directed to pay a sum of Rs.10,000/- by issuing an account payee cheque in the name of the complainant towards litigation cost within 45 days from the date of this order.

Failing which the amount will carry interest @ 9% per annum from the date of this order till full payment.

Let copies of this judgment be supplied to the parties free of cost.