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. 13/D/2017
Shri Pratap Chand Agarwal,
Director, Modern English School,
59/14 J.M. Goenka Road,
Kurseong -734 203,
District Darjeeling. ………………………….. Complainant.
V-E-R-S-U-S
The Branch Manager,
United India Insurance Co. Ltd.
41 D.B. Giri Road,Chota Kakjhora,
Dist. Darjeeling. ……………………… Opposite Party.
.
For the Complainant ………… Complainant himself.
For the O.P. …………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.13/D/2017
The instant case has been filed on 26.10 .2017 under sec. 12 of the C.P. Act by Shri Pratap Chand Agarwal,Director, Modern English School,59/14 J.M. Goenka Road,Kurseong -734 203,District Darjeeling against the Branch Manager, United India Insurance Co. Ltd.,41 D.B. Giri Road,Chota Kakjhora,Dist. Darjeeling.
The brief fact of the case is that the complainant is a Mediclaim Insurance(Health Insurance) Policy Holder being Policy no.031903/28/15P101609948 jointly with his wife Smt. Annapurna Devi Agarwal under the O.P. The said policy period was from 13.05.2015 to 12.05.2016, the sum assured being Rs. 2,00,000/- for the complainant and Rs. 2,25,000/- for his wife. The premium for the said policy was made in cash of Rs. 24,656/- on 13.05.2015. The policy was renewed for one more year from 13.05.2016 to 12.05.2017 and a premium of Rs. 25,004/- was paid on 12.04.2016.
The complainant’s wife had some eye (health) problem and was taken to Dristi Eye Foundation, Meerut on 29.12.2015 for examination of her eye. On examination it was found that she had cataract in her left eye and advised for operation after the use of some prescribed medicines. On 31.12.2015 at 9.30 a.m. Smt Annapurna Agarwal was underwent her cataract operation which was done by Dr. Siddharath Sharma and she was discharged on the same day in the afternoon at 03.15 p.m.
The total expenses incurred on that operation including the lens was Rs. 28,500/-, out of which a sum of Rs. 17,500/- was directly paid by the TPA MD India Health Care Services Ltd. as cashless surgery although the actual expenses incurred was Rs. 28,500/-. The balance amount of Rs. 5000/- was paid by the complainant on 08.01.2016 when he took his wife for re examination. The Dristi Eye Foundation waived the balance amount of Rs. 6000/-.
After returning from Meerut to Kurseong, the complainant filed a claim of Rs. 5780/- on 23.01.2016 and the claim letter was sent vide courier, being receipt no. 03249003 on 25.04.2016, a reminder was sent for payment of the claim amount . On 14.08.2016, the complainant personally visited the office of the O.P. On 22.08.2016 a reminder was sent to the O.P. vide courier.
Being aggrieved the complainant filed the instant case praying for the following reliefs:
1. Direction to the O.P. to make payment of Rs. 36988/-
2.Interest @ 18% p..a. on the aboveamount till the payment is made
3.
Judgement.
C.C.Case no.13/D/2017
The complainant has given the details of the claim amount in his plaint.
The complainant has filed the following documents in Xerox to support his claim.
- Copy of OPD Receipt of Examination fee of Rs. 300/- dt. 29.12.2015.
- Copy of Prescription of Dr. Siddharath Sharma dt. 29.12.2015.
- Copy of Pre Operative Instruction of Medicines dt. 29.12.2015( 2 pages)
- Copy of Medical Bill of Bhavarth Medical, Meerut dt. 31/12/2015.
- Copy of Admission & Discharge summary of Dristi Eye Foundation dt. 31/12/2015.
- Copy of Money receipt of Rs.5000/- dt. 8.1.2016
- Copy of Medical Bill of Bhavarth dt. 14.1.2016.
- The following papers were sent to the Branch Manager, United India Insurance Co. Ltd., Darjeeling on 23.01.2016 by Courier Receipt No. 03249003 which has the list of his enclosures (Adm & discharge papers/original Receipt of 17500/- of TPA Medical Bills/Lens in plant ID Card.
- Copy of Courier Receipt No. 03249003 dt. 23.1.2016.
- Copy of his reminder letter of his claim dt. 24.4.2016 sent by regd.
- Regd. Postal R.No. A RW 7328653081N dt. 25.4.16 issued by Kurseong.
- Copy of Prescription dt. 14.1.16 of spectacles ( 2 pages)
- Copy of final reminder letter dt. 22.8.2016.
- Courier receipt No. 03249004.
- Copy of Health Insurance Policy issued by United India Ins. Co. for the period from 13.5.2015 to 12.5.2016(3 pages)
- Copy of Health Insurance Policy issued by United India Ins. Co. for the period from 13.5.16 to 12.5.2017(3 pages)
- Copy of Health Insurance Policy issued by United India Ins. Co. for the period from 13.5.17 to 12.5.18 ( 3 pages).
The O.P. entered appearance on 22.11.2017 and filed his written version on 12.12.2017.
In his written version, O.P. has submitted that the total estimated cost incurred in the treatments at Dristi Eye Foundation was Rs. 22,500/- and Rs. 6000/- was waived by the hospital. The admitted that they had paid Rs. 17500/- directly to the hospital and Rs. 800/- was paid for medicines by directly transferring the amount to the complainant’s account.
The O.P. has filed the following documents in Xerox:-
- Copy of E mail given by MD India Health Care Services Ltd.
- Copy of Health Insurance Policy of Smt. Annapurna Agarwal( 17 pages).
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Judgement.
C.C.Case no.13/D/2017
The complainant has filed his affidavit in chief on 07.02.2018/ Questioners were filed by the O.Ps for which reply in affidavit was filed by the complainant on 20.03.2018.
Hearing of the case was taken up on 06.04.2018.
The O.P. filed his written argument. Complainant also filed his written version.
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.
From the documents filed by the complainant, it is reflected that the complainant had paid Rs. 5000/- on 08.01.2016 to the Dristi Eye Foundation towards payment of balance for the cataract surgery conducted on 31.12.2015, the receipt is in the letterhead of Dristi Eye Foundation duly signed by the authorized signatory and with seal.
The O.P., in his written version, has stated that the complainant is not entitled to get Es. 300/- for cash receipt dt. 29.12.2015 as the bill is not the part of hospitalisation bill. The O.P. further stated that the complainant is not entitled to get a sum of Rs. 5000/- as the bill dt. 08.01.2016 does not bear the printed bill.
The reason filed by the O.P. regarding repudiation of the claim of Rs. 5000/- and Rs. 300/- is not justified.
Hence, we are of opinion that there is gross negligence and deficiency in service on the part of the O.P. with respect to repudiation of the claim of Rs. 5000/- and the complainant is entitled to the reliefs as claimed for but in part.
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Judgement.
C.C.Case no.28 /D/2017
Hence, it is
O R D E R E D
that the C.C. case no. 13/D/17 be and the same is hereby partly allowed on contest with costs.
The O.P. is directed to settle the said claim of Rs. 5300/- , being the amount paid to Dristi Eye Foundation 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.
