IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MURSHIDABAD AT BERHAMPORE.
CASE No. CC 39/2013.
Date of Filing: 28.03.2013. Date of Final Order: 25.11.2016.
Complainant: Aliul Islam, S/O Late Basiruddin Ahmed, Vill.& P.O. Andi, P.S. Burwan,
Dist. Murshidabad. Pin 742101.
-Vs-
Opposite Party: 1. United India Insurance Co. Ltd. 3/20/A, K.K Banerjee Road,
P.O. Berhampore, Dist. Murshidabad. Pin 742101.
2. Heritage Health T.P.A. Pvt. Ltd, Nicco house, 5th Floor, 2 Hare Street,
Kolkata – 700001.
Present: Sri Anupam Bhattacharyya ………………….President.
Sri Samaresh Kumar Mitra ……………………..Member.
FINAL ORDER
Sri Anupam Bhattacharyya, Presiding Member.
The instant complaint is u/s 12 of C. P. Act, 1986 praying for payment of Rs.4 lakhs towards cost of treatment as per family medi-care policy and Rs.10,000/- for harassment and for mental pain and agony
The complainant’s case, in brief, is that the complainant took family medicare policy of Rs.5 lakh from OP No.1 through Op No.2 for the period from 7.6.12 to 6.6.13 for s elf, wife, one son and one daughter. His wife was undergone hysterectomy operation and as a result she admitted in G.D. Hospital, Kolkata on 3.11.12 and she was discharged from the said hospital on 8.11.12 . Thereafter, the complainant informed the matter to the OP No.2 on 4.12.12 and also sent bills available at that time. As per advice in the discharge certificate the complainant along with his wife were attended by Dr. P. K. Nanda on 11.11.12 and the doctor prescribed some medicines and requested to attend after one month . The petitioner has submitted all the bills for the treatment during that period. But the OP No.1 did not pay any amount to the complainant. On the other hand, the OP No.1 repudiated his claim. Then the complainant has filed the instant complaint for award of cost of treatment of Rs.4 lakhs for Mediclaim and compensation of Rs.10,000/- . Hence, the instant complaint case.
The written version filed by the O No.1, in brief, is that the patient was discharged on 08.11.2012 after the operation but on 04.12.2012 the complainant sent the bills and related documents to the Opposite Party. The OP No.1 has rightly repudiated the claim of the complainant and for that the claim is liable to be rejected. Hence, the instant written version.
Considering the pleadings of both parties the following points have been raised for the disposal of the case.
Points for consideration
- Whether the case is maintainable in its present for and in law?
- Whether there is any cause of action to file the present case?
- Whether the case is barred by law of limitation?
- Whether the Complainant is a consumer under the C. P. Act, 1986?
- Whether the complainant is entitled to get relief as prayed for?
- To what other relief/reliefs the complainant is entitled?
Decision with Reasons.
Point Nos. 1 to 6.
All the points are taken up together for the sake of convenience.
The instant complaint is for payment of Rs.4 lakhs towards cost of treatment as per family medi-care policy and Rs.10,000/- for harassment and for mental pain and agony.
The complainant’s main case is that in spite of valid family medi claim the OP No.1 has not paid the cost of treatment of the wife of complainant both for Hysterectomy Operation and post operative treatment.
On the other hand the OP No.1 –Insurance Company‘s main case is that they have rightly repudiated the claim as per Clause 5.4 for non-submission of bills within the prescribed period.
This case was filed on 28.3.13 and since then the instant case is pending.
From the record it appears that the complainant contested the case by filing hazira through his Ld. Lawyer up to 10.11.14 and thereafter order was passed to show cause by the complainant on different occasions, show cause filed and accepted and complainant was absent without any steps and last show cause order was passed on 19.6.15 and since then no steps taken by the complainant and lastly on 3.11.16 the Ld. Lawyer for the complainant filed hazira without show cause and again absent without steps on 11.11.16 and on that day the case has been taken up for disposal on merit.
In this case the complainant has not filed any evidence on affidavit and documents as to cost of treatment and not argued in this case.
Admittedly, the complainant sent the bills and related documents on 4.12.12 to the OP long after 15 days from the date of discharge from the hospital on 8.11.12.
After 15 days from the discharge from the hospital on 8.11.12 means the delay is only for 11 days.
It is not clear from the written version of the OP-Insurance Co. whether the bills and documents were received on 4.12.12 by OP No.1 or OP No.2 where it is mentioned that on 4.12.12 the complainant sent the bills to the OP.
According to Clause 5.4 of the policy the complainant must have to produce all the documents relating to the claim with the T.P.A within 15 days from the date of discharge from the Hospital.
It is true that the complainant has not filed any documents to show that he sent the bills and documents to OP No.2 within 15 days from the date of discharge from the hospital.
Be that as it may, it is clear that there is only eleven days delay.
There is nothing to show that this clause is mandatory.
Also, the OP has not referred to any such ruling showing that this Clause is mandatory and delay cannot be condoned in any circumstances.
Considering the above facts and circumstances though the complainant has not filed any evidence and document as to expenses and date of submission of bill and documents, we are of view relying the admitted facts of receiving the bill and absence of any reported decision as to the point that Clause 5.4 is mandatory provision that the delay be condoned and the complainant is entitled to get the claim as per terms of the policy.
On the basis of above discussions we find that all the points are disposed of in favour of the complainant in part and as such the complainant is entitled to get the claim settled by the OP No.1 as per terms of the policy within two months for medical expenses including post operation expenses without any compensation.
Hence,
Ordered
That the Consumer Complaint NO. 39/2013 be and the same is allowed on contest in part without any order as to cost.
The OP No.1 is directed to settle the claim of the complainant for his medical expenses including post operation expenses without any compensation on the basis of the bill and documents already received within two months from this day, in default, the OP No.1 is to pay fine @Rs.50/- per day’s delay and the amount so accumulated shall be deposited in the Consumer Legal Aid Account.
Let a plain copy of this order be made available and be supplied free of cost, to each of the parties on contest in person, Ld. Advocate/Agent on record, by hand under proper acknowledgment / be sent forthwith under ordinary post to the concerned parties as per rules, for information and necessary action.
Member Member President
