This is a complaint case filed by the complainant U/S – 12 of the C.P. Act, 1986 against the O.Ps named above.
The case of the complainant, in brief, is that the complainant and his wife were covered by ‘Mediclaim Policy’ bearing no. 013902/48/13/97/00000692 with United Insurance Co. Ltd. i.e. O.P No. 1 which is valid from 10/11/2013 upto 09/11/2014.
The wife of the complainant Smt. Bani Sen was undergone a treatment of her right eye with a complaint of ‘Superior Hemi Retinal Venous Occulsion’ under Dr. Meghnad Bhowmick, an eye specialist in his Clinic-cum-Nursing Home ‘ Vision Care’ at Alipurduar. The treatment of the wife of the complainant commenced from 23/07/2014 and continued for a period of three months and after completion of treatment, claim form with all relevant original documents were submitted before O.P No. 1 / The Branch Manager, United India Insurance Co. Ltd., M.J.N. Road, P.S. – Kotowali, P.O. & Dist. – Cooch-Behar, Pin – 736101 which was registered as MD 12033059 and after that TPA, O.P No. 3 perform some queries time to time to the complainant.
The further case of the complainant that after lapse of long time no claim money was given to the complainant though complainant enquired into the matter in this regard several times which tantamount to deficiency of service on the part of the O.P. Later on the complainant came to know from the letter dated 05/06/2016 from O.P No. 1 that and amount of Rs. 19,054/- has been credited to the account of the complainant whereas the claim was made for Rs. 81,320/- out of which Rs. 61,770/- was incurred for medicines only. On several occasion the complainant made correspondence with the office but O.P did not pay any heed/
Hence, this case filed by the complainant with a prayer for directing the O.Ps to pay a sum of Rs. 61,770/-, and also prayed for an award of Rs. 30,000/- as compensation for unnecessary harassment from the O.Ps and also prayed for directing the O.Ps to pay a sum of Rs. 10,000/- towards litigation costs.
All the O.Ps have appeared before this Forum to contest the instant case by filing written version.
The O.Ps have denied all the allegations made by the complainant against them. O.Ps
Contd.
took plea that as per terms and conditions of the mediclaim policy the O.P side scrutinized the relevant documents of the complainant and paid Rs. 19,054/- to the complainant and as per terms and conditions of the policy mentioned in number 5.16 further claim is not recoverable.
The O.Ps have specifically denied that the complaint is not entitled to get any relief as per terms and conditions of the policy.
The complainant as well as the O.Ps have filed evidence-on-affidavit and written argument in support of their respective cases.
Both the parties have also filed some documents in support their cases.
We have gone through the materials on record very carefully and also heard the argument as advanced by both the parties.
Considering the above pleadings the following issues are necessarily come out for consideration to reach just decision of the case.
POINTS FOR CONSIDERATION
- Is the complainant a consumer u/s.2 (1)(d)(ii) of Consumer Protection Act, 1986 ?
- Has this Forum jurisdiction to entertain the instant case?
- Have the O.Ps any deficiency in service as alleged by the complainant?
- Is the complainant entitled to get any relief/reliefs as he prayed for?
DECISION WITH REASONS
As all the points are interlinked to each other as such all the points are taken uptogether for consideration for the sake of Brevity and convenience.
The complainant Sri Apurba Kumar Sen, S/O – Late Brojeswar Sen, Resident of New Town (Sukanta Pally), P.O. & P.S. – Alipurduar, Dist. – Alipurduar, Pin – 736121. O.P No. 4 is situated at Babupara, P.O., P.S. & Dist. – Alipurduar. It is admitted facts that the complainant and his wife were covered by ‘Mediclaim Policy’ bearing no. 013902/48/13/97/00000692 with United India Insurance Co. Ltd. through O.P No. 4 who is an agent of the United India Insurance Co. Ltd. Thus, the complainant became a consumer of the O.Ps as per provision laid down u/s.2 (1)(d)(ii) of the C.P. Act, 1986.
Contd.
Whereas the complainant is a resident of New Town (Sukanta Pally), P.O. & P.S. -Alipurduar, Dist. – Alipurduar, Pin – 736121 and whereas the O.P No. 4 resides under P.S. & Dist. Alipruduar as such this Forum has territorial jurisdiction to try this case and whereas the claim amount is less than the pecuniary jurisdiction of this Forum as such this Forum has ample jurisdiction to try this case.
On scrutiny of the materials on the case record it is revealed that the complainant has claimed the medical expenses amounting to Rs. 81,320/- against the O.Ps and out of which the O.P side has paid him amounting to Rs. 19,054/-. Therefore, the complainant has claimed for the remaining amount of Rs. 61,770/- from the O.P side by his letter dated 10/08/2014 and letter dated 01/12/2014 addressed to The Branch Manager, United India Insurance Co. Ltd., M.J.N. Road, P.S. – Kotowali, P.O. & Dist. – Cooch-Behar, Pin – 736101 and letter dated 28/01/2015 and letter dated 20/03/2015 addressed to the The M.D. India Health Care Service (TPA) Pvt. Ltd., 169, Sarat Bose Road, 3rd Floor, Kolkata – 700026 and letter dated 24/08/2015 and letter dated 15/12/2015 addressed to The Branch Manager, United India Insurance Co. Ltd., M.J.N. Road, P.S. – Kotowali, P.O. & Dist. – Cooch-Behar, Pin – 736101 and letter dated 02/02/2016 addressed to the The M.D. India Health Care Service (TPA) Pvt. Ltd., 169, Sarat Bose Road, 3rd Floor, Kolkata – 700026 and letter dated 30/05/2016 addressed to The Branch Manager, United India Insurance Co. Ltd., M.J.N. Road, P.S. – Kotowali, P.O. & Dist. – Cooch-Behar, Pin – 736101 and letter dated 11/06/2016 addressed to the The M.D. India Health Care Service (TPA) Pvt. Ltd., 169, Sarat Bose Road, 3rd Floor, Kolkata – 700026. These letters of the complainant lead to presume that he is in continuation in claiming his rest amount and inspite of his such efforts the O.P side has completely ignored the demand of the complainant resulting which having been constrained the complainant has filed this case for realization of the rest amount from the O.P side which also leads to presume that there is deficiency in service on part of the O.P side. Pre-hospitalization medical expenses or post-hospitalization medical expenses both are provided in terms and conditions of the policy mentioned in terms numbers 3.30 and 3.31 and those terms are immaterials to consider here. The limitation period in claiming such expenses has provided in terms and conditions number 5.16 in the Insurance Policy but considering the continuation of the complainant which has been proved by his above stated letters such provision has no application here.
Considering such facts and circumstances as discussed above we are of the view that it should be justified to decree the complainant for his realization of rest claim amount of Rs. 61,770/- together with cost of Rs. 15,000/- for his unnecessary harassment and mental agony + Rs. 5,000/- as litigation costs i.e. total Rs. 81,770/-.
Thus all the points are disposed of accordingly.
Fees paid are correct.
Hence, for ends of justice; it is;-
Contd.
ORDERED
that the instant case be and the same is allowed on contest with costs.
The complainant Sri Apurba Kumar Sen do get a decree of amounting to Rs. 61,770/- as his claimed balance amount and he do get a further decree of Rs. 15,000/- as compensation for causing his unnecessary harassment and mental agony and sufferings + Rs. 5,000/- as litigation costs against the O.P Nos. 1 & 2. Both the O.P Nos. 1 & 2 are hereby directed to pay the total decreetal amount of Rs. 81,770/- to the complainant within 30 days from this day failing which the complainant will be at liberty to put this decree into execution according to law.
In case of realization of the decreetal dues through execution in that event the complainant be entitled to 8% interest per annum on the decreetal dues Rs. 81,770/- from the date of filing of this case from 10/07/2017 till liquidation of the entire decreetal dues and the O.P Nos. 1 & 2 shall have to pay Rs. 50/- each as fine per-day to the Consumer Legal Aid Account of District Consumer Disputes Redressal Forum, Alipurduar.
Let a copy of this final order be sent to the concerned parties through registered post with A/D or by hand forthwith for information and necessary action.
