FINAL ORDER/JUDGEMENT
SMT. SUKLA SENGUPTA, PRESIDENT
Complainant filed this case U/s 12 of CP Act, 1986.
It is stated by the complainant that the OP-2 is carrying on his business outside the jurisdiction of this forum and the remaining OPs are running their business within the jurisdiction of this forum.
The concerned application U/s 11 (2) (b) of CP Act, 1986 has been filed by the complainant with a prayer to allow him to continue the case against the OP-2 before this forum along with other OPs. The prayer was allowed by this forum vide order dated 21.08.2019.
The fact of the case in brief is that the complainant purchased an insurance policy from the OP for the period of 09.06.2018 to 08.06.2019. The policy amount is of Rs. 1,00,000/-.
It is further stated by the complainant that he claimed a sum of Rs. 84,135/- from the OPs on 28.09.2017. The OP Insurance Co. made a short payment of Rs. 42,226/- which was arbitrarily sent by the OPs to the bank A/c of the complainant on 28.09.2019. The complainant raised objection and alleged that the OPs did it illegally for their unfair trade practice on technical basis.
It is further stated that the complainant was affected by prostate infection and he was admitted at B. P. Poddar Hospital and Medical Research Ltd. and the hospital bill was of Rs. 47,688/- . The complainant claimed Rs. 84,135/- but he received an amount of Rs. 42,226/- thereafter the complainant filed a complaint for illegal repudiation of claim on 11.03.2019.
It is further stated by the complainant that he filed a case being No. 229/2019 which is not pressed on 17.07.2019 for mis-joinder of necessary parties.
It is further stated by the complainant that the policy was of Rs. 1,00,000/- but the complainant only claimed for Rs. 84,135/- which is below the insured policy but the OP paid only Rs. 42,226/-. Hence, the case is filed by the complainant with a prayer to give direction to the OPs to pay insurance value of Rs. 1,00,000/- , compensation of Rs. 1,00,000/- along with litigation cost of Rs. 25,000/-.
The OP-1 United Insurance Co. Ltd. has contested the case by submitting the WV/objection denying all the material allegations levelled against him.
It is further stated by the OPs that the subject policy was issued in favour of the insured for the period on and from 09.06.2017 to 08.06.2018 bearing the policy No. 0504002817P104314692 having the insured amount of Rs. 1,00,000/- only. The amount claimed by the complainant is of Rs. 77,235/-and the claim was settled for Rs. 41,909/- following the terms and condition of policy and the sum of Rs. 35,326/- was deducted as those are not as admissible as per policy. It is denied that the Insurance Co. made a short payment which is arbitrarily as alleged.
It is further case of the OP-1 that the payment was made to the complainant as per the terms, condition and exclusion clauses of the policy and the complainant is not entitled to get any further amount.
It is further stated by the OP-1 that the case is not within the pecuniary and territorial jurisdiction of this forum.
Hence, the case is liable to be dismissed with cost.
The OPs 2 and 3 of this case did not file WV. Hence, their opportunity to file WV was closed by this forum vide order No. 16 dated 23.12.2021.
In view of the above stated pleadings following points of consideration are as follows:-
- Is the case maintainable in its present form and law?
- Has the complainant cause of action to file the case?
- Is the complainant a consumer?
- Is there any deficiency in service on the part of the OPs?
- Is the complainant entitled to get reliefs as prayed for.?
- To what other relief or reliefs is the complainants entitled to get?
Decision with Reasons.
All the points of consideration are taken up together for convenience of discussions and to avoid unnecessary repetitions.
As per complainant case, he purchased a Health Insurance Policy form the OP-1 Insurance Co. on payment of the appropriate premium for the period of 09.06.2018 to 08.06.2019. Admittedly, the insurance amount is of Rs. 1,00,000/-.
It is the further case of the complainant that he was affected by prostate infection and was admitted at B. P. Poddar Hospital and Medical Research Ltd.. The hospital bill (medical expenditure ) was of Rs. 47,688.22/- but the complainant placed the claim to the OPs of a sum of Rs. 84,135/-. The OP Insurance Co. and other OPs settled the claim on Rs. 42,226/- and sent to the bank account of the complaint on 28.09.2019 . The complainant became aggrieved and filed this case but from the document as filed by complainant along with his petition of complaint, it appears that he placed the claim of Rs. 77,235/- along with service charge of Rs. 6,900/- i.e. the amount of Rs. 84,135/- and paid amount of Rs. 42,226.00 .
From the complainants document, It is found that admittedly a sum of Rs. 47,688.22 was the medical expenditure of the complainant during his stay at hospital and the OP Insurance Co. rightly settled the amount of Rs. 42,226/-. Admittedly which was accepted by the complainant in his bank A/c on 28.09.2017. So, this forum is failed to understand why the complainant placed the claim of Rs. 84,135/- to the OP Insurance Co. and the OPs when his hospital expenditure was of Rs. 47668.22. Surprisingly, It is the claim of the complainant that the insured value of his policy was of Rs. 1,00,000/-. So, he is entitled to get a sum of Rs. 1,00,000/- . That cannot be.
The forum is of view that the OP Insurance Co. along with other OPs rightly settled the amount on Rs 42,226/- in favour of the complainant out of his actual medical expenditure of Rs. 47688.22. Though, the Consumer Protection Act, is meant for giving relief to the consumer but it is not meant for make the consumer to get more money than the amount actually entitled to get. A consumer cannot use the Consumer Protection Act, to fulfil his greed. In the instant case, the complainant being a consumer wanted to get more money actually which he entitled to get. He spent a sum Rs. 47,688.22 of his hospital expenditure during his treatment but he claimed a sum of Rs. 84,135/- from the OP Insurance Co. as the insured amount of Rs. 1,00,000/- which is baseless claim and it cannot be entertained by this forum.
Hence, though the complainant is a consumer and the OPs are the service provider but considering the entire fact and circumstances, of this case as well as the evidence on the record.
This forum is of view that there is/was no deficiency in service on the part of the OPs rather after getting the claim they settled the same as early as possible and paid a sum of Rs. 42,226/- to the complainant in his bank account on 28.09.2019 actually which the complainant is entitled to get.
In view of discussion made above, this forum is of view that the complainant is failed to prove his case beyond all his reasonable doubt and is not entitled to get relief as prayed for.
The case is properly stamped.
The points of consideration are thus considered and decided accordingly.
Hence,
Ordered
that the case be and the same is dismissed on contest without any cost against all the OPs.
Copy of the judgment be supplied to the parties free of cost as mandated by the CP Act. The Judgement be uploaded forthwith on the website of the Commission for perusal of the party.
