: J U D G M E N T :
This is a case under Section 12 of the Consumer Protection Act. The facts of the case to put in a nutshell, are as below
The complainant, Sujit Kumar Raha purchased a mediclaim policy from United India Insurance Company Ltd. Krishnagar of Rs. 10,525/-. The date of validity of the said policy was from 29.06.13 to 28.06.13. The policy was covered with complainant, Chapa Raha, Saraswati Raha, Sampriti Raha and Sukriti Raha. On 09.06.14 Chapa Raha, the complainant’s mother suddenly fell down on the bathroom and her left leg was fractured. So the complainant’s mother visited to Dr. Susanta Kumar Biswas and the doctor advised her for immediate operation. Then she admitted to Rit-Tik Nurshing Home at Kolkata on 10.06.14 and she was discharged from that Hospital on 13.06.14 expending Rs. 42,930/-. Thereafter, the complainant informed the OP on 26.06.14 with all documents and bills for settlement of the mediclaim. On 09.07.14 OP Insurance Company sent Rs. 14,355/- to the complainant by N.E.F.T. but the complainant could not be able to withdraw the amount till now. Thereafter, the complainant submitted application on 14.07.14 to the Insurance Company but in vain. Finding no other alternative the complainant files this case praying for Rs. 28,575/- with accrued interest upon it @ 10% from the date of accident along with compensation and cost.
A written version was filed by the OP Insurance Company on 26.12.15 challenging the contentions of the complainant and denied all the allegations.
The sum and substance of the written version is as following:-
The petition / complaint is bad for defect of parties. The TPA, MD India Healthcare Services (TPA) Pvt. Ltd. is a necessary party in this case. The complaint is not maintainable as per Consumer Protection Act, 1986 and barred by law, estoppels waiver and acquiescence. The fact is long after discharge from the Hospital the complainant on 26.06.14 submitted some documents for treatment before the Insurance Company and on the self same date the OP forwarded the claim application to the TPA for settlement. After enquiry the TPA settled the claim of the complainant and accordingly Rs. 14,355/- was transferred to the account of the complainant on 09.07.14. Thereafter, the complainant submitted a representation which was duly forwarded to the TPA. As the TPA is the only claim settlement authority so he has no deficiency in service regarding settlement of the claim. Hence, the complainant is not entitled to get any relief.
POINTS FOR DECISION
- Point No. 1: Is the complainant a consumer?
- Point No. 2: Is the OP deficient in his service?
- Point No. 3: What relief the complainant is entitled to get?
REASOND DECISIONS
For the purpose of brevity and convenience all the points are taken up together for discussion.
We have meticulously gone through the pleadings of the parties, evidence, interrogatories and replies thereto. We have carefully gone through the written arguments filed by the complainant and the opposite party. Ld. Advocate for the complainant has submitted that the complainant is entitled to get Rs.42,930/- Rs.14,355/- equal Rs. 28,575/- while Ld. Advocate for the opposite party has submitted that the case is not maintainable as the TPA (MD India Healthcare Services Pvt. Ltd.) has not been made party in the instant case. It has been strongly argued that the bill was settled on 09.07.14 and the complainant did not challenge the settlement claim of the same date.
We have perused the claim-payment-settlement of noncashless claim dtd. 09.07.14 by virtue of Rs. 14,355/- was paid by cheque to Sujit Kr. Raha, complainant. Sujit Kumar Raha did not challenge the said claim payment settlement. It has been argued by the Ld. Advocate for the complainant that the complainant did not get challenge claim-payment-settlement.
It is admitted position that the complainant is a consumer. The deficiency of service on the part of the OP could not be established by oral and documentary evidence particularly when the TPA (MD India Healthcare Services Pvt. Ltd.) is kept out of the purview of the proceeding before this Forum. The higher claim is unsustainable in view of the forms of the policy.
We have meticulously perused the exclusion clause of the policy in the background of claim payment settlement. The claim was reduced being not payable on certain heads, for example, blood collection charges were not payable, non medical expenses were not payable. In view of 1.2 of Health Insurance Policy and 5.2 of the said policy, the complainant is not entitled to get any further amount.
Hence, all the points are disposed of against the complainant.
Hence,
Ordered,
That the case CC/2014/140 be and the same is dismissed on contest. No cost.
Let a copy of this judgment be delivered to the parties free of cost.
