In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No. 9 / 2011.
1) Dr. Pulokesh Banerjee,
34/8, Sahapur Main Road, Kolkata-700038. ---------- Complainant
---Versus---
1) The Family Health Plan Limited,
16/2, Lake View Road, Kolkata-700029.
2) United India Insurance Co. Ltd.,
Divisional Office-4, 2nd Floor, Posnett Bhawan, Ramkote,
P.O> Box. 144, Tilok Road, Hyderabad-500001. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri ,MEMBER
Smt. Sharmi Basu ,MEMBER
Order No. 14 Dated 24/04/2012.
The instant case has been filed by Dr. Pulokesh Banerjee against the o.ps. u/s 13 of the C.P. act, 1986 with al allegation of deficiency in rendering service.
In a nutshell, the case of the complainant is that the complainant herein obtained a medi-claim policy namely ‘Arogya Daan Policy’ vide no.050400/48/08/41/00000084 for a period from 9.6.07 to 8.6.08 from o.p. no.2 namely United India Insurance Co. which was sponsored by o.p. no.1, namely The family Health Plan Ltd. and marketed by o.p. no.3. This policy was renewed subsequently by the complainant for the period 9.6.08 to 8.6.09. As per agreed term the benefit of aforesaid health insurance was available for the complainant, his wife and his two wards. Wife of the complainant (now deceased) being sick was admitted at Calcutta Medical Research Centre Institute and she expired on 28.2.08. Thereafter, the complainant preferred a claim with o.p. no.1 with a copy to o.p. no.2 for reimbursement of the expenses incurred for the treatment of his deceased wife and when the o.ps. asked for original death summary, admission notes of concerned hospital etc. related to the treatment of his deceased wife, the complainant furnished all the abovementioned documents of the o.p. no.1. But, after repeated reminders to the o.p. no.s and o.p. no.2 till date the complainant neither received any communication with regard to status of that claim. Hence, the complainant has no alternative but to file the instant complaint for redressal of his grievance and complainant has prayed for reliefs as mentioned in the complainant.
After valid service of summon the o.p. no.1 and 3 did not contest the case by filing w/v and other documents and the case is heard ex parte against all the o.p. no.1 and o.p.ni.3. O.P. no.2 had entered into this case by filing w/v and denied all the material allegations labeled against it and prayed for dismissal of the case.
Therefore, all the submissions and documents of the complainant are considered by this Forum as unchallenged testimony and it seems to us that the o.p. no.2 and o.p.no.3 have virtually admitted the instant case of the complainant.
Decision with reasons:
After scrutinizing vividly complaint, evidence, BNA and all other documents brought to the notice of the Forum by the complainant we are of the opinion that the complainant is the ‘consumer’ of all the three o.ps. under provision of 2(1)(d)(ii) of the C.P. Act, 1986 and all the o.ps. are service provider within the purview of he C.P. Act, 1986.
To decide whether the o.ps. have committed of deficiency in rendering their service towards the complainant, following discussion is advised. After going through at every nook and corner of the records of the instant case and hearing the submission of he complainant, it is crystal clear that after submission of relevant documents as per demands of the o.ps., including the original death summary, admission notes of concerned hospital etc. related to treatment of the deceased wife of the complainant on 28.7.08., the complainant did not receive the claim amount and even received no communication from neither of the o.ps. In this regard we refer the remarkable judgment of the Hon’ble National Consumer Disputes Redressal Commission [reported in 2007 CTJ at 156 (NC)]. In this judgment, Hon’ble National Consumer Disputes Redressal Commission has been pleased to observe that “Delaying processing of the Insurance claim by the Insurer on flimsy grounds amounts to deficiency in service”. It is also held by Hon’ble National Consumer Disputes Redressal Commission in its reported judgment [reported in 2008 CTJ at 54] as – “when a public authority gets into the acts of harassing a common man or more appropriately a consumer, such behaviour generate into a store house of inaction leading to breeding of corruption. Then consumer is no more a king”.
In the light of above discussion we are of the opinion that the o.p. no1 &2 are duty bound to the complainant to inform about the status of the claim in question, whether it would be sanctioned penalty or as a whole or even it would be repudiated. As the o.ps.1 and 2 have failed to serve their duty, they are jointly and/or severally liable for deficiency in service u/s 2(1)(O) and 2(1)(r) of the C.P. Act.
Moreover, having ample of scopes to appear before this Forum and to contest the instant case the o.p. no.1 and 3 did not contest the complaint case and O.P.2 did not file evidence and nor appear on the date of hearing. Therefore, it is candid to us that o.p. no.1 and 3 have virtually admitted the case of the complainant and both the o.ps 1 and 2. have jointly and/or severally committed deficiency in service as they did not give the claim amount to the complainant and for this act of the o.ps. The complainant has to suffer loss, harassment and mental agony. We find no deficiency in rendering service on the part of the o.p.3.
Hence, ordered,
The case of the complainant is allowed in part ex parte with cost against o.p. no.1 and with cost against o.p.3 and is allowed on contest with cost against o.p. no.2. O.p. nos.1 and 2 are jointly and / or severally directed to pay the claim amount of Rs. 1,29,973.00 (Rupees 1 lakh twenty nine thousand nine hundred seventy three) only towards the treatment of the deceased wife of the complainant after completion of all required procedures as per rules and regulations to the complainant together with interest @ 9% p.a. from the date after two months from the date of submission of documents as claimed by o.ps. i.e. from 26.9.08 till the full and final payment of that claim amount. The o.ps. 1 and 2 are also jointly and / or severally directed to pay compensation of Rs.10,000/- (Rupees one thousand) only towards the loss, harassment and mental agony of the complainant and also to pay Rs.2000/- (Rupees two thousand) only as litigation cost.
All the above directions should be complied within 45 days from the date of communication of this order, i.d. an interest @ 9% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties.
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MEMBER MEMBER PRESIDENT
