This appeal is directed against the final order dated 31.12.2019 in Reference to CC No. 23 of 2017 of D.C.D.R.F., Malda, the fact of the case in nutshell is that one A.K. Agarwal registered a Consumer Complaint raising claim of 1,53,123/- for deficiency of service and unfair trade practice on the part of the United India Insurance Company Limited that the complainant purchased a Medi claim policy for his daughter Neha Agarwal in the year 2000 and it was renewed time to time. During the Insurance period in July 2014 his daughter Neha received serious ancle injury and was treated at Apollo Hospital where an ancle surgery was done there on 15.08.2014 and the said treatment was duly intimated to the Insurance Company by the complainant. Thereafter, he submitted a bill of Rs. 1,23,123 for realization of the treatment cost as per provisions of the said Medi claim policy. The Insurance Company has reduced the said amount to the tune of Rs. 62,385/- illegally and without any justification credited the said amount to the Bank account of the complainant by NEFT. The complainant then claims the rest amount in repeated occasions from the Insurance Company which was not entertained and for that reason he registered the Consumer Complaint. The Insurance Company has contested the case by filing Written Statement and contended that the alleged injury was held in the year 2013 where the sum insured over the said policy was fixed at Rs. 2,25,000/- and as per provisions of the said policy only 1% of the face values of the policy was to be provided for Room boarding and nursing expenses as provided by the Hospital/Nursing Home including nursing care RNO charges Latin fluids, blood transfusion, injunction and administration charges and similar expenses. So, as per provisions of clause 1.2 of the policy the amount was settled at Rs. 62,385/- and that amount already paid and for that reason the instant Consumer Complaint was liable to be dismissed. The complainant side has recorded the evidence and produced all the necessary documents marked as exhibit 1 to 6 before the Ld. Forum. On the other side the Insurance Company did not adduce any evidence.

Ld. Forum after hearing arguments of both sides has delivered the impugned order while observing that Insurance Company was rightly assessed the compensation amount to the tune of Rs. 62,350/- and for that reason the complainant was not entitled to get any other relief and ultimately the complaint was dismissed on contest. Being aggrieved with the said order, this appeal follows on the ground that Ld. Forum has failed to appreciate the evidence and has committed an error in holding that the complainant was responsible for wrong calculation of claim and the said order of Ld. Forum was challenged in the appeal. The appeal was admitted in due course and notice was sent to the respondent Insurance Company who has contested the case through Ld. Advocate appointed by the Company. Argument of both sides was heard.

Decision with Reasons

There is no dispute that the complainant purchased the Medi claim policy in the name of his daughter Neha who was a student at that point of time. According to the complainant Neha received the ancle injury in the month of July, 2014 while the Opposite Party/Insurance Company has relied on the medical documents where it was apprised that Neha received the said ancle injury in the year 2013. On the other hand, all the medical papers clearly speak that Neha was admitted at Apollo Hospital, Chennai on 14.08.2014 and she had to undergone ancle surgery on 15.08.2014 as an indoor patient and discharged from the Hospital after post-surgery pending couple of days at the Hospital. It is not disputed that the complainant has intimated about the said surgery to the Insurance Company on 14.08.2014 and he raised the claim for reimbursement or medical cost in due course. The Insurance Company has tried to

establish that though the Medi claim policy was subsequently enhanced to the tune of Rs. 4 Lakh in the year 2014 while Neha received the injury in the year 2013 when the policy coverage was up to the tune of Rs. 2,25,000/- and for that reason as per clause 1.2 of the policy the Insurance Company settled the claim at the rate of 1% of the sum insured and for that reason Rs. 62,350/- was fixed for such reimbursement and the said amount was transferred to the Bank Account of the complainant by adopting the NEFT procedure.

Now the question is whether the calculation or assessment of the reimbursement amount adopted by the Insurance Company was correct or justifiable or not. The Insurance Company has relied upon the position that in the year 2013 while the insured received the ancle injury the amount of sum assured fixed at Rs. 2,25,000/-. But the fact of the case speaks otherwise. May be the victim Neha received the injury in the year 2013 but her uncle was operated surgically on 15.08.2014 and at that point of time the quantum of sum assured of the policy was fixed on Rs. 4 Lakh and for that reason the complainant raised the claim of Rs. 1,23,123/- whereas, the curtailment of the said amount on the part of the Insurance Company is not acceptable in the eye of law. So, the complainant deserves the right to get the balance amount (1,23,123 - 62,385) 60,738/-. The complainant cum appellant had to run from pillar to post to get the said amount since 2015 and for such harassment he deserves the right to get compensation for harassment to the tune of Rs. 20,000/- and for litigation cost he deserves the right to get Rs. 5,000/-. Therefore, considering all aspects this Commission finds that the order of Ld. Forum suffers from irregularity and liable to be set aside. Thus, the appeal succeeds.  

Hence it is ordered

That the appeal be and the same is hereby allowed on contest without any cost. The final order of Ld. D.C.D.R.F., Malda dated 31.012.2019 in Reference to CC Case No. 23 of 2017 is hereby set aside. The O.P./respondent United India Insurance Company Limited hereby asked to pay Rs. 60,738/- as balance amount of claim, Rs. 20,000/- as compensation for harassment and Rs. 5,000/- as litigation cost to the complainant within 45 days, failing which interest at the rate of 6% Per-annum shall be carried on over the entire awarded money.

Let a copy of this order be supplied to the parties of appeal free of cost and the same to be communicated to the Ld. D.C.D.R.F., Malda for doing the needful.