Date of Filing: 14.11.2013 Date of Final Order: 13.03.2015
The Complaint has been filed by Sri Prakash Ch. Datta, S/o. Late Pratap Ch. Datta was a Special Assistant and formerly attached with Allahabad Bank, Cooch Behar, before the Forum U/S 12 of the C.P Act, 1986 against the O.P. No.1, Universal Sompo General Insurance Company Ltd., and the O.P. No.2, The Senior Branch Manager, Allahabad Bank, praying for issuance a direction upon the O.P. No.1 to make payment of Rs.30,231/- with 12% interest per annum from the date of filing of the case till the date of final payment, Rs. 20,000/- for unfair trade practice and deficiency in service, Rs.30,000/- for mental pain & agony and Rs.10,000/- for litigation costs, besides other relief(s) as the Forum deem fit, as per law & equity.
The brief facts of the case, as culled out from the record, is that the complainant is a permanent member of the O.P. No.1 and his family (wife & son) are the permanent insured persons of the O.P. No.1 vide USGI No.0000032551 to USGI No.0000032553 under Family Health Plan (TPA) Ltd. and all the critical and non-critical illness are covered under this Family Health Plan. On 16-07-2011 the son of the complainant namely Neelabha Jyoti Datta became seriously ill with a history of Solitary rectal ulcer syndrome with bleeding per rectum and thereby he was admitted at Appollo Gleneagles Hospital, Kolkata under Dr. M.K. Goenka, on 21-07-2011 he was discharged from the said hospital with some medical advice.
The main allegation of the complainant, Prakash Ch. Datta is that he was incurred a sum of Rs.44,875.48/- towards the treatment of his ailing son namely Neelabha Jyoti Datta. Thereafter, the complainant submitted the claim for hospitalization benefit under Allahabad Bank, scheme for Group Medical Insurance Policy with Group Personal Accident Insurance coverage for officers and employees along with their wholly dependent family members to the O.P. No.2 and thereafter a sum of Rs.14,644/- was sanctioned and allotted to the complainant by the O.P. No.2, Allahabad Bank vide their office Memo No.20/Slg/Admn/Medi/11/1214 dated 30-09-2011 and the balance claim of Rs.30,231.48/- was forwarded to the O.P. No.1 by the O.P. No.2 for payment to the complainant, Prakash Ch. Datta. But the O.P. No.1, Universal Sompo General Insurance Company Ltd. whimsically, arbitrarily and illegally repudiated the claim of the complainant vide their letter dated 16-11-2011 corresponding to claim under Policy No.2816/50632080/01/000, Claim ID 165924, Employee ID 23000.
It is the case of the complainant that by such willful act or omission and commission of the O.P. No.1, the complainant has suffered a lot and therein clear deficiency in service by the O.P. No.1for which the Complainant compelled to file this case for getting proper justice and relief (s).
The O.Ps. have contested the case contending inter-alia that the present is not maintainable in the eye of law. The O.P. No. 1 entered its appearance through Ld. Agent and by filing a petition contended that the present case is bad for non-joinder of necessary parties. The office of the O.P. No. 1 at Mumbai and the Policy in question was issued from Mumbai, all are the subject matter under the jurisdiction of Mumbai as such the present case suffered from lack of proper jurisdiction. Further contention of this O.P. is that this O.P. has India wide Network Hospital system which is cashless hospitalization facilities in connection with the Family Health Plan (TPA) Limited but if any policy holder took treatment as an outpatient or if he/she admitted for investigation/evaluation these are not covered under the policy. It is the duty of the policy holder as per terms and condition of TPA that before taking any treatment he/she informed the matter to the O.P. within 24 hrs. then the O.P. refer the matter to nearest Network Hospital. This Complainant did not give any information before treatment of his son or did not file any claim for which this O.P. has no deficiency in service. The Complainant files this case only to harass the Complainant thus this present proceeding deserves to be dismissed.
The O.P. No. 2 in its turn by filing W/V contested the case contending inter-alia that the present case is not maintainable before this Forum also bad for non- joinder and mis-joinder of necessary parties. This O.P. admitted the fact of insurance and averred that the O.P. No. 1 is sole authority to settle the insurance claim and this O.P. has no liability for which this complaint liable to be dismissed against this O.P.
Both parties have filed Evidence on affidavit. On perusal the evidence we find no new points that differ from the Complaint as well as the Written Version.
In the light of the contention of the complainant, the following points necessarily came up for consideration.
POINTS FOR CONSIDERATION
- Is the Complainant is a Consumer as per Section 2(1)(d)(ii) of the C.P. Act, 1986?
- Has this Forum jurisdiction to entertain the instant complaint?
- Have the Opposite Parties any deficiency in service by repudiating the claim of the Complainant and are they liable in any way?
- Whether the Complainant is entitled to get relief/reliefs as prayed for?
DECISION WITH REASONS
We have gone through the record very carefully, perused the entire documents in the record also heard the argument by the parties. Perused also the Evidence of both parties.
Point No.1
The Complainant being a policy holder of the O.Ps is the consumer and there is no dispute. Thus this point is decided in favour of the Complainant.
Point No.2
The office of the O.P. No. 2 is situated in this district also the Complaint value is far less than the prescribed limit. Thus no doubt this Forum has every jurisdiction to try this case.
Point No.3&4.
Undisputedly, the Complainant and his family members all are insured under Family Health Plan Limited of O.P. No. 1 vide USGI No.0000032551 and USGI 0000032553 covering the risk of all critical and non-critical illness. The son and the wife of the Complainant are the dependent as per Group Medical Insurance Policy.
It is the specific case of the Complainant that the son of the Complainant admitted in the Appollo Gleneagles Hospital, Kolkata under Dr. M. K. Goenka on 27.01.2011with a history of Solitary rectal ulcer syndrome with bleeding. For this purpose the Complainant incurred a sum of Rs. 44,875.48/- and preferred claim for Hospitalization benefit to the O.P. No. 2. The O.P. No. 2 sanctioned Rs. 14,644/- and the balance claim forwarded to the Opposite Party No. 2 for payment to the Complainant but the O.P. No. 1 repudiated the genuine claim of the Complainant.
It is the case of the Opposite Party No. 1 that the son of the Complainant has been treated in which Hospital is not enlisted as per the policy also the Complainant did not informed the O.P. No. 1 before taking treatment or within 24 hrs. that violate the terms and condition of the policy. It is the further case of the O.P. No. 1 that medical opinion of the doctors of Network Hospital is that the treatment took by the son of the Complainant in which manner that beyond the terms and condition of the policy for which the claim of the Complainant has been repudiated.
On giving a close look to the materials on record it is seen that the son of the Complainant as a dependent of the Complainant is covered under Family Health Plan (TPA) Limited being HID no. USGI. 0000032551 issued by the O.P. No. 1 another in the name of Neelabhajyoti Datta being HID no. USGI.0000032553. The terms and condition printed in the overleaf which are already stated by the O.P. No. 1 in its W/V. The O.P. no. 1 has taken pleas that the Complainant took treatment of his son by violating the terms and condition of the policy but no where we find any documents adduced by the O.P. No. 1 as to the list of Cashless Hospital, the report of the doctors of Network Hospital for which it is very difficult to say that the patient took treatment in a hospital which is not enlisted as per the policy. Moreover, the Patient Discharge Record of the Apollo Gleneagles Hospitals, Kolkata reveals that the patient was admitted there from 16.07.2011 to 21.07.2011 and some investigation, treatment done by the doctors and we did not find any cogent ground to hold that there is no necessity for admission for which the plea of the O.P. No. 1 is not sustainable. The Opposite Party No. 1 by a letter dated 16.11.2011 repudiated the claim of the Complainant on a flimsy ground which is not tenable in the eye of law.
The O.P. No. 1 vehemently argued that the Apollo Hospital and its attached Dr. from whom the Complainant took treatment of his son are required to made parties in this case. It is pertinent to mention that the Forum relied upon the authentic documents adduced by the parties treating the papers as Evidence and there is no need to made party such Company/ Officials/ institution/Doctor/ Nursing Home etc. residing at far distance of this Forum.
There is no dispute that the son of the Complainant took treatment within the policy period and submitted some bills and there is no cogent ground to disbelieve the same. The Complainant did not pray any relief against the O.P. No 2. The letter dated 30.09.2013 of the higher authority of the O.P. No. 2 reveals that they already sanctioned Rs. 14,644/- in favour of the Complainant in connection with the Mediclaim Policy and further claim of Rs. 30.09.2011 forwarded to the O.P. No. 1. As and when a part amount already has been paid then it is not reasonable to raise any question for further payment in the same ground. Thus, considering all above we have no hesitation but to hold beyond any manner of doubt that the Complainant proved his case against the O.P. No. 1 and the O.P. No. 2 be relieved from this proceeding. So, the Complainant is entitled to get Rs. 44,875.48-Rs.14,644.00 = Rs.30,231.48/- only.
All the questions are answered affirmatively and the Complainant is entitled to get relief.
ORDER
Hence, it is ordered,
The complaint be and the same is allowed on contest against the O.P. No. 1 and dismissed against O.P. No. 2 with cost of Rs. 5000/-.
The O.P. No. 1 is hereby directed to pay the Complainant an amount of Rs 30,231/-(rounded off) for treatment of his son in connection with the Policy and further Rs 10,000/- as compensation for deficiency in service.
The O.P. No. 1 is further directed to pay the aforesaid amount within 45 days i./d it shall to pay Rs. 50/- for each day’s delay and the amount to be accumulated shall be deposited in the State Consumer Welfare Fund.
Let plain copy of this Final Order be supplied, free of cost, to the concerned parties/Ld. Advocate by hand/be sent under Registered Post with A/D forthwith for information and necessary action, as per Rules.
Dictated and corrected by me.
Member President
District Consumer Disputes District Consumer Disputes
Redressal Forum, Cooch Behar Redressal Forum, Cooch Behar
Member Member
District Consumer Disputes District Consumer Disputes
Redressal Forum, Cooch Behar Redressal Forum, Cooch Behar
