- Chandilal Banerjee,
Adyama Abasan,
51A, A.C. Banerjee Road, Kolkata-57. _________ Complainant
____Versus____
- Branch Manager,
Medi Asist India TPA Pvt. Ltd.
53A, Rafi Ahmed Kidwai Road,
P.S. Park Street, Kolkata-16.
- The Oriental Insurance Co. Ltd.
Divisional Manager,
D.O. Howrah, P4, Dobson Lane,
-
- The Oriental Insurance Co. Ltd.
D.O. Howrah, P4, Dobson Lane,
-
Present : Sri Sankar Nath Das, Hon’ble President
Dr. Subir Kumar Chaudhuri, Member.
Smt. Samiksha Bhattacharya, Member
Order No. 16 Dated 28/09/2015.
The case of the complainant in short is that complainant had availed a mediclaim policy from o.p. nos.2 and 3 wherein o.p. no.1 was the TPA in the said mediclaim policy.
Complainant has been a regular subscriber of the said policy from o.p. nos.2 and 3 since 1993-94 and has been paying the premium regularly without fail.
Complainant started suffering from eye problems and accordingly was advised by his doctor to undergo cataract operation for both eyes which was done on 4.1.14 and 11.1.13 at Florid Nursing Home.
Complainant accordingly submitted the claim of Rs.22,316/- to o.p. no.1 with all necessary documents on 24.1.13.
Complainant could not submit the claim within the stipulated time as per insurance rules as the complainant is an old man of 77 years and had both the eyes operated so the complainant was taking time to recover and accordingly the complainant apologized for late claim submission vide letter dt.24.1.13.
Complainant sent a letter dt.5.2.13 to o.p. no.1 along with the biometry report with the hope that the claim would be settled at the earliest.
Complainant again sent a letter dt.22.2.13 with all necessary documents and another letter on the same ate explaining and apologizing for delay in submitting claim from o.p. no.1.
Complainant being utterly frustrated finally sent a legal notice to o.ps. vide letter dt.22.3.13 asking for justification for delay in settling claim within 14 days of the receipt of the said notice.
Decision with reasons:
O.ps. had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case. Ld. lawyer of o.ps. in the course of argument submitted that the case has got no merit and the same is liable to be dismissed.
It appears from the record that o.ps. stated that complainant was diagnosed of cataract of both eyes and the said cataract was to be operated, right eye first followed by left eye and was also advised for admission for cataract operation. It is further seen from the record that complainant did not take prioe approval for admission of such operation. O.ps. submitted that cataract operation is day care procedure and does not require hospitalization and there is no whisper of any cause by the doctor as to why the complainant needed hospitalization for a simple operation like cataract.
We have also gone through the pleadings of the parties, evidence and documents in particular and we find that Complainant has been a regular subscriber of the said policy from o.p. nos.2 and 3 since 1993-94 and has been paying the premium regularly without fail. Complainant started suffering from eye problems and accordingly was advised by his doctor to undergo cataract operation for both eyes which was done on 4.1.14 and 11.1.13 at Florid Nursing Home. Complainant sent a letter dt.5.2.13 to o.p. no.1 along with the biometry report with the hope that the claim would be settled at the earliest. Complainant again sent a letter dt.22.2.13 with all necessary documents and another letter on the same ate explaining and apologizing for delay in submitting claim from o.p. no.1.
In view of above findings and on perusal of the entire materials on record, we find that complainant could not submit the claim form within the stipulated period of time as per insurance policy. Therefore, we are constrained to hold that complainant has not substantiated his case and is not entitled to relief.
Hence, ordered,
That the case is dismissed on contest without cost against the o.ps.
Supply certified copy of this order to the parties free of cost.
