Before District Consumer Dispute Redressal Forum, Darjeeling.
24, M.C.Road, Chotta Kak Jhora, Darjeeling.
P.O. & Dist. Darjeeling, Pin – 734101
Heading of the Judgement
PRESIDENT : SHRI SANDIPAN BANDYAPADHYAY
MEMBER : Ms. SUJATHA AGARWAL
MEMBER : SHRI PRADIP KUMAR SIDDHANTA
Consumer Case No. 14/D/2017
Shri Ashwani Agarwal,
C/O Modern English School,
59/14 J.M. Goenka Road,
Kurseong -734 203,
District Darjeeling. ………………………….. Complainant.
V-E-R-S-U-S
1. The Branch Manager,
United India Insurance Co. Ltd.
41 D.B. Giri Road,Chota Kakjhora, ................................ Opposite Party No. 1.
Dist. Darjeeling.
2. The Manager,
Kurseong Micro Office,
United India Insurance Co. Ltd.
Hill Cart Road,
Kurseong - 734 203 ....................................... Opposite Party No. 2.
For the Complainant ………… Complainant himself.
For the O.Ps. …………The name of the advocate representing the O.P.is not
mentioned only signature in initial is there.
Date of Filing : 26.10.2017
Date of Disposal : 08.05.2018
Time Taken : 168 days
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Judgement.
C.C.Case no.14/D/2017
The instant case has been filed on 26.10 .2017 under sec. 12 of the C.P. Act by Shri Ashwani Agarwal,
C/O Modern English School,59/14 J.M. Goenka Road,Kurseong -734 203,District Darjeeling against 1)The Branch Manager,United India Insurance Co. Ltd., 41 D.B. Giri Road,Chota Kakjhora, Dist. Darjeeling and 2) The Manager, Kurseong Micro Office,United India Insurance Co. Ltd.Hill Cart Road,Kurseong - 734 203
The brief fact of the case is that the complainant is a Mediclaim Insurance(Health Insurance) Policy Holder being Policy no.031986/48/15/97/00000003 valid from 19.4.2015 to 18.4.2016 jointly with his wife Smt.Pooja Agarwal .
On 21.09.2015 the complainant's wife was taken to Medica North Bengal Clinic, Siliguri and was examined by one lady Dr. Reba Roy(DGO) .An intimation in advance was sent to the O.P. on 21.09.2015 through Global Express Courier . Smt. Pooja Agarwal was admitted to the hospital on 21.09.2015 at 11.51 a.m. and after the treatment she was released on the same day at about 5.48 p.m.After her discharge the complainant immediately filed his claim of Rs. 9685/- vide his letter dt. 28.09.2015 sent by Superfast courier. Thereafter, several reminders were sent to the O.Ps. but with no positive results.
Being aggrieved the complainant filed the instant case praying for the following reliefs:
1. Direction to the O.Ps to make payment of Rs. 8853/- along with the medicines bill of Rs. 488/,feeding cup/spoon Rs. 60/,BD syringe Rs. 84, consultation fee Rs. 200/- ,totalling amount of Rs. 9685/- along with compensation of Rs. 20,000/-, incidental charges Rs. 3,000/- and litigation cost of Rs. 8000/-.
2. An interest @ 18% on Rs. 3486.60p.
The complainant filed the following documents in Xerox:
- Policy papers( 6 pages)
- Letter dt. 21.9.2015.
- Courier receipt dt. 21.9.2015.
- Letters dt. 28.9.2015
- Courier receipts dt. 28.9.2015 and 6.4.2016( 2 pages)
- Draft Repudiation statement ( 2 pages).
- Letter dt. 22.8.2016
- Claim Form ( 3 pages)
- Letter dt. 31.8.2016.
- Letter dt. 01.09.2016
- Registration for NEFT/RTGS payment form.
- Letter dt. 6.10.2016.
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Judgement.
C.C.Case no.14/D/2017
The O.Ps. entered appearance on 22.11.2017 and filed written argument on 12.12.2017.
The complainant filed affidavit in chief on 27.2.2018.
Questioner was filed by the O.P. on 16.03.2018 and reply in affidavit was filed by the complainant on 20.3.2018.
Hearing of the C.C. case was taken up on 6.4.2018.
In their written version the O.Ps. have stated that they made payment of Rs. 6690/- to the complainant with respect to hospitalization expenses on 25.11.2016 vide UTR No.16BP54147M7D2143. The O.Ps. further stated that Rs. 100/- for registration charge is not payable as per the Policy clause No. 4.21. The detail break up of other charges is not provided in the said bill. Hence, a claim of Rs. 250/- is not payable. The O.Ps. further stated that Rs. 24/- for drugs is not payable as the detail break up is not provided and further a sum of Rs. 804.83 is not payable as per Policy Clause no. 4.21 which states that service charge is excluded. Rs. 984.33 is not payable as no detail break up is provided in the bill. Rs. 488/-for the medical cash memo no. 20455 dt. 23.9.2015 is not payable as the bill submitted was for 23.5.2015. and not 23.9.2015 and as per their Policy No. 3.30 Pre Hospitalisation Medical Expenses are not payable and the bill amounting to Rs. 60/- and another bill amounting to Rs. 84/- are also not payable as they do not come under medical expenses as per Clause 4.20. The Bill receipt no. 906977 dt. 23.9.2015 amounting to Rs. 200/- is also not payable as per Clause no. 1.2 note No. 2.
The O.Ps. have filed the following documents in Xerox:-
- Copy of E mail given by the M.D. India (2 pages)
- Copy of Health Insurance Policy of Ashwani Agarwal( 17 pages).
Points for Consideration.
- Is there any negligence and deficiency in service on the part of the O.Ps.?
- Is the complainant entitled to the reliefs as claimed for?
Decision with Reasons.
Both the points taken together as they are inter related. Perused all the materials on record.
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Judgement.
C.C.Case no.14/D/2017
From the Policy documents Clause no. 1.2 under the title coverage(Note 2) it is mentioned that no paymentshall be made under 1.2 C other than as part of the hospitalization bill.
The complainant had paid Rs. 200/- to Dr. Reba Roy on 21.9.2015 and on the same day the complainant was admitted. This Rs. 200/- was included in the hospitalization bill. Hence, the O.Ps has wrongly repudiated claim of Rs. 200/- The O.Ps. have mentioned that there is nodetail break up for bills amounting to Rs. 250/-, Rs. 24/-, Rs. 984.33. This repudiation is also not justified since the claims is supported by proper bills. The O.Ps have rightly stated that Rs. 804.83 is not payable under Clause 4/20 being the service charges charged from the complainant and the bill amounting to Rs. 488/-, which is dated 23.5.2015 is also rightly repudiated. The feeding cup/spoon that amounting to Rs. 84/-also does not come under the medical expenses and hence this also has rightly repudiated by the O.Ps.
Hence, we are of the opinion that the complainant is entitled to get Rs. 1458.33 p. against his total revised claim of Rs. 2995/-. As the rest of the amount comes under the exclusion clause. The repudiation of the part amount of the claim of the complainant amounts to gross negligence and deficiency on the part of the O.Ps. and hence, the complainant is entitled to the reliefs as claimed for but inpart.
Hence, it is
O R D E R E D
that the C.C. case no. 14/D/17 be and the same is hereby partly allowed on contest with costs against both the O.Ps.
The O.Ps., are jointly and severally, directed to settle the said claim of Rs. 1458.33 of the complainant along with compensation of Rs. 3000/- and litigation cost of Rs. 3000/-
The order has to be complied with within 30 days from the date of order, failing which the O.Ps. shall be liable to pay additional interest @ 6% p.a. on the entire decreetal amount and the complainant shall be at liberty to proceed with Execution Proceedings u/s 25/27 of C.P. Act.
Let the copies of the order be supplied free of cost to the parties under the provision of Order 5,Rule 10 of W.B.C.P. Rules.
