In the District Consumer Disputes Redressal Forum, Murshidabad
Berhampore, Murshidabad.
Case No. C.C.-137/2013
Date of filing: 03/12/2013 Date of Final Order: 13/03/2015
Sadhan Kumar Saha
Son of Lt. Sushil Kumar Saha,
Of 14 Turu Hazam Lane, Gorabazar,
P.O.+ P.S.- Berhampore,
Dist- Murshidabad ………………………… Complainant
-Vs-
United India Insurance Co. Ltd
3/20/A, K.K. Banerjee Road (1st. Floor)
P.O.- Berhampore, Dist.- Murshidabad. …………………. Opposite Party
Mr.Utpal Kumar Paul & Swapan Mukherjee, Ld. Advocates…………………………….for the Complainant.
Mr.Siddhartha Sankar Dhar, Ld. Advocate……………………………………………………….for the Opposite Party.
Present: Anupam Bhattacharyya ...…………………. President.
Samaresh Kumar Mitra ......…….…..………Member.
Pranati Ali ..............................................Member.
FINAL ORDER
Samaresh Kumar Mitra, Member:
The simple version of this complainant as enumerated in the complaint is that he has taken an Individual Health Insurance Policy-2010 being No.031405/48/11/97/00001152 for the period 08.02.2012 to 07.02.2013 from the OP. That the wife of the above named petitioner namely Chandana Saha was suffering from Tiger finger RT thumbs and she was treating before Dr.H.S. Batabyal attached with the Azimganj A. G. Hospital and following the instructions of treating doctor undergone a lot of medical tests and after perusing the reports it was advised to operate otherwise it could not be cured and also advised to visit Dr. Rudra Sinha who in his turn made advice to the wife of the petitioner to test further and as per advice she was admitted to Rabindranath Tagore Diagonistic centre, Berhampore on 16.06.2012 for operation which the complainant informed the OP before admitting in the nursing home. The said nursing home discharged the wife of the petitioner on 17.06.2012 and the treating doctor made a prescription on advising some medicine. Thereafter, the petitioner went to the office of the OP for filing a claim along with necessary documents after 4/5 days from the discharge from the nursing home. As per instruction of the OP the complainant filed claim Application Form to one Sourajjal Chakraborty employee of T.P.A. Pvt. Ltd. in presence of OP on 8.8.2012. That on 31.12.2012 the complainant received a letter that his claim has been rejected as it has been filed after the statutory period mentioned in the policy. Getting no alternative the complainant filed the instant complaint before this Forum for reliefs as prayed for in the prayer portion of the complaint.
The sole OP appeared before this Forum by its agent and filed Written Version on 21.10.2014 denied the allegations as leveled against him. He averred that the petitioner had an Individual Policy valid from 08.02.2012 to 07.02.2013 and as terms of the policy all the documenta must be filed with T.P.A within 15 days from the discharge from the hospital vide Clause No.5.5 of the policy. The patient was discharged from Hospital on 17.06.2012 but the documents relating to treatment were submitted a long after the stipulated period as such his claim was repudiated informing by a letter dated 31.12.2012. So there was no deficiency of service on the part of OP. The complaint is liable to be dismissed due to non-joinder of necessary parties as T.P.A i.e. Heritage Health Services Pvt. Ltd was not inserted as the necessary party.
The complainant filed Affidavit–in-chief on 26.11.2014 which is nothing but a replica of the complaint so it is needless to discuss.
Agent of the parties advanced argument and it was heard in full.
From the discussion herein above, we find the following Issues/Points for consideration.
ISSUES/POINTS FOR CONSIDERATION
- Whether the Complainant ‘Sadhan Kumar Saha’ is a ‘Consumer’ of the opposite party?
- Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?
- Whether the O.Ps carried on unfair trade practice/rendered any deficiency in service towards the Complainant?
- Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to him?
DECISION WITH REASONS
In the light of discussions here in above we find that the issues/points should be decided based on the above perspectives.
(1).Whether the Complainant ‘Sadhan Kumar Saha’ is a ‘Consumer’ of the opposite party?
From the materials on record it is transparent that the Complainant is a “Consumer” as provided by the spirit of section 2(1)(d)(ii) of the Consumer Protection Act,1986. As the complainant herein being the consumer of the OP, who insured his and his wife’s life before the OP company.
(2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?
Both the complainant and opposite party are residents/carrying on business within the district of Murshidabad. The complaint valuedRs.16,439/-ad valorem which is within Rs.20,00,000/- limit of this Forum. So, this Forum has territorial/pecuniary jurisdiction to entertain and try the case.
(3).Whether the opposite party carried on Unfair Trade Practice/rendered any deficiency in service towards the Complainant?
The opposite party being the largest Insurance Company of the Nation associated with the insurance of a lot of people throughout the nation since a long back with self generated assets i.e. goodwill of the business. So, the credibility of the OP Insurance Company is unquestionable and that is why the complainant insured his life before the said company without any doubt.
It appears from the INDIVIDUAL HEALTH INSURANCE POLICY-2010, SCHEDULE being policy No.031405/48/11/97/00001152 that the policy lying in the name of Sadhan Kumar Saha and in the column of insured persons, the name of Chandana Saha wife of the complainant was stated and premium of Rs.2,500/- was paid for the period of Insurance from 08.02.2012 to 07.02.2013. So, from the records it is crystal clear that the life of the wife of complainant is insured. From the complaint petition and arguments as advanced by the agent of the complainant it is stated that the complainant filed claim Form on 08.08.2012. The complainant filed a letter dated 15.06.2012 in which he informed the OP regarding the admission for treatment and the said letter is received by the OP. So, the OP cannot deny that the complainant did not inform the OP regarding the treatment of her wife within the stipulated date. The complainant filed the claim Form on 08.08.2012 which is admitted by the OP but the expenditure of treatment is not challenged, so it can be presumed that the wife of the complainant was treated as per the rules but submitted the claim Form after the mandatory period of fifteen days. The repudiation of his claim by the T.P.A i.e. Heritage Health Services was informed by a letter dated 31.12.2012 as such the OP is not responsible regarding the claim of the complainant. But the complainant being a law abiding citizen informed the OP regarding the treatment of her wife in time and also filed the claim Form after elapsing a month but not within the statutory period. Whatever it may be, as the claim is cogent and which is not challenged by the OP and the delay is not inordinate so he is entitled to get the amount of Rs.6,439/- which is spent for the treatment of his wife. The OP being a reputed Insurance Company throughout the nation should allow such a meager amount which was incurred for the treatment of the wife of the complainant just to show good gesture upon the consumer but not doing so the OP tried to evade its responsibility by repudiating the claim of the complainant on the pretext of delay of submission of claim Form.
As the complainant suffered from mental pain and agony at the behest of deficiency of service and unfair trade practice on the part of the OP, So the complainant is entitled to get the amount which was expensed for the treatment of the insured person from the OP as the complainant could prove his case beyond reasonable doubt and we are in a considered opinion to allow the claim of the complainant in part.
4. Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to him?
The discussion made herein before, we have no hesitation to come in a conclusion that the Complainant is able to prove his case beyond any doubt and the written version or the OP also contributed his role in such proof and the Opposite Party is liable to compensate the Complainant as we deem fit and proper.
-
Hence it is ordered that the complaint be and the same is allowed on contest against the Opposite party in part, without cost.
The Opposite party is hereby directed to pay the amount of Rs.6,439/- to this complainant, which is expensed for the treatment of her wife within 45 days from receiving this order.
No other relief is given to the complainant.
At the event of failure to comply with the order the Opposite Party shall pay cost @ Rs.50/- for each day’s delay, if caused, on expiry of the aforesaid 45 days by depositing the accrued amount, if any, by depositing in the State Consumer Welfare Fund.
Let a plain copy of this Order be supplied free of cost to the parties/their Ld. Advocates /Agents on record by hand under proper acknowledgement/sent by Registered Post with A/D forthwith, for information & necessary action.
Dictated and corrected by me.
Member, President,
District Consumer Disputes District Consumer Disputes
Redressal Forum, Murshidabad. Redressal Forum, Murshidabad.
Member, Member,
District Consumer Disputes District Consumer Disputes Redressal Forum, Murshidabad. Redressal Forum, Murshidabad.
