OFFICE OF THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAMRUP,GUWAHATI
C.C.81/2015
Present:-
1)Md.Sahadat Hussain, A.J.S. - President
2)Smti Archana Deka Lahkar - Member
Smti Manju Medhi -Complainant
W/O- Late Mahesh Medhi
R/O-Lachit Nagar,Kanaklatapath,Bye lane No-1,
H.No-14,Near Hub Shopping Mall ,Guwahati
-VS-
ICICI Lombard GIC -Opp.Parties
ICICI Lombard Health Care, ICICI Bank Tower
Plot No-12, Financial District,Nanakram Guda,Gachibowli
Hyderabad-500032,Andra Pradesh
Appearance-
Learned advocate for the complainant Mr Nabajit Bharali, but none appears for the opposite parties.
Date of argument- 29.06.2017
Date of judgment- 25.08.2017
JUDGMENT
This is a complaint u/s 12 of the Consumer Protection Act, 1986.
- The complaint filed by the complainant Smti Manju Medhi was admitted on 16-10-2015 and notices were issued to the opposite parties. Notices deemed served . The opposite parties did not file written statement. This forum passed an exparte order on 11-05-2016. Thereafter , on 25-10-2016 Sri Prasenjit Medhi who is the policy holder as well as the son of the complainant Smti Manju Medhi filed his exparte evidence on affidavit. The complainant side filed exparte written argument on 02-03-2017 . We heard the exparte oral argument of Ld advocate Mr Nabajit Bharali for the complainant and today we deliver the judgment which is as below:-
- The gist of the complaint is that the complainant is an existing beneficiary to an insurance policy of ICICI Lombard General Insurance Company , since the year 2010 till date vide policy No-40341/FFH/76278263/00/000 under Family Health Insurance Policy . The complainant has been renewing her aforesaid family health insurance policy through her son namely Shri Prasenjit Medhi, who is the policy holder has been renewing the aforesaid health insurance policy on each and every year with an expectation and desire that in the event of any medical emergency the beneficiary i.e. the complainant will be protected under the aforesaid health insurance policy and the opposite party company would take care of her payments and expenses and would reimburse / repay /settle her medicines/ medical bills and expenses . With these expectations the complainant through her son the policy holder has been paying the regular premium for the aforesaid health insurance policy as referred above to the opposite party insurance company. The complainant is a senior citizen and such the opposite party is duty bound both legally and morally to honour and settle her insurance claims in time. The complainant was admitted to GNRC Hospital, Guwahati because of severe chest pain coupled with epigastric pain, nausea and vomiting on 31-08-2013 where she was treated for several days and on recovery she was released from the aforesaid hospital on 07-09-2013 . During the course of her treatment the total hospitallization bill/ charges/cost came to Rs.1,45,274/-( Rupees one lakh forty five thousand two hundred seventy four only) which is being duly paid to the concerned GNRC Hospital .The aforesaid ailments as well as the treatment of the complainant was duly intimated and informed to the opposite party insurance company by her son/ policy holder. The total bill amount for the aforesaid medical treatment of the complainant came to Rs.1,45,274/- and out of this bill amount an amount of Rs.90,000/- was being paid to the GNRC Hospital directly by the youngest son of the complainant namely Shri Samarjit Medhi through his Reliance General Insurance Company Policy No-RGIC 9029668 (under Family Healthcare TPA Ltd) which was a Family Healthcare Policy. The complainant paid an amount of Rs.10,000/- in cash on the day of her admission into the hospital and Rs.43,000/- on the day of her release from the hospital in cash as the opposite party insurance company was having no cashless arrangement with the aforesaid GNRC Hospital ,Guwahati . In total Rs.53,060/- was paid in cash by the complainant to the GNRC Hospital ,Guwahati. The opposite party insurance company was / is having absolute knowledge and information about such payment of hospital bills in cash by the complainant as all the hospitalisation documents ,papers ,bills and money receipts in original were submitted to the opposite party insurance company through the policy holder Shri Prasenjit Medhi after she was being released from the hospital. As the insurance company is having no cashless facility with GNRC Hospital Ltd. As such the cash amount of Rs.53,060/- had to pay by the complainant. The opposite party insurance company registered the claim of the complainant as claim No-22010024584 and their investigator verified the documents and papers of the complainant in GNRC Hospital , Guwahati and also visited the place of residence of the complainant to enquire and see whether she was actually got the treatment or not. On being satisfied with all the documents , papers and other particulars , the aforesaid investigator of the opposite party company opined that the aforesaid claim will be settled without any difficulties as everything is in order. But till date the opposite party has not settled /reimburse the claim amount of the complainant . The claim amount of Rs.53,060/- is not released by the opposite party . The complainant through her advocate sent a legal notice dtd.21-08-2015 to the opposite party asking and demanding the amount of Rs.53,060/- in her favour with interest accrued thereon on commercial rate.
- We have perused the complaint as well as the evidence of Shri Prasenjit Medhi, son / policy holder of the complainant Smti Manju Medhi. It is found from the evidence of Shri Prasenjit Medhi , son of the complainant Smti Manju Medhi that Shri Prasenjit Medhi is the policy holder of ICICI Lombard GIC Insurance Company Limited vide policy No-4128i/iHr/97552601/00/000. Smti Manju Medhi , the complainant is the beneficiary and the date of joining of beneficiary Smti Manju Medhi is 21-12-2010 (Exhibit-1).
- It is found from the evidence of Shri Prasenjit Medhi , the policy holder that policy No- 4034i/FFH/76278263/00/000 was issued on 20-12-2012 in the name of Shri Prasenjit Medhi for the period from 00:00 hrs 21-12-2012 to midnight of 20-12-2013 by ICICI Lombard GICInsurance Company Limited in which the complainant Smti Manju Medhi is covered as Family Member under the said policy ( Exhibit-2). It is found from the evidence of Shri Prasenjit Medhi, the policy holder that Health Care Card was issued bearing Card No-100705025 in the name of Smti Manju Medhi , the beneficiary from the period from 21-12-2012 to 20-12-2014 by the ICICI Lombard Health Insurance (Exhibit-3).
- After perusing the evidence of complainant’s witness , it appears to us that the complainant was admitted to GNRC Hospital ,Guwahati because of severe chest pain coupled with epigastric pain , nausia and vomiting on 31-08-2013 where she was treated for several days and on recovery she was discharged from the aforesaid hospital on 07-09-2013 (Ext-5) .During the period of her admission in the hospital and during the course of her treatment the total hospitalization bill/ charges/ cost came to Rs.1,45,274 ( one lakh fourty five thousand two hundred and seventy four only) (Ext-16) which is being duly paid to the concerned GNRC Hospital ,Guwahati. It is found that the out of the aforesaid bill amount of Rs.1,45,274 /- an amount of Rs.90,000/- was being paid to the GNRC Hospital by the youngest son of the complainant namely Shri Samarjit Medhi through his Reliance General Insurance Company Policy No-RGIC 9029668 (under Family Healthcare TPA Ltd.) which was a Family Healthcare Policy. An amount of Rs.10,000/- was paid on the day of admission of the complainant into the hospital and an amount of Rs.43,000/- on the day of release of the complainant from the hospital . In total an amount of Rs.53,000/- was paid to the GNRC Hospital, Guwahati.
It is found from the evidence of the complainant’s witness that on 27-09-2013 the complainant claimed the amount of Rs.53,000/- to the opposite party insurance company as per procedure by filing claim form (Ext-8). Medical bills in respect of the treatment of the complainant (Ext-9 and 10) , prescriptions and bill of medicine at GNRC Hospital in respect of the complainant, {Ext-11- (1) } to 11(29), Registration card and the Gate pass issued by the GNRC Hospital , Guwahati (Ext-12 and 13) are filed along with the claim form before the opposite party insurance company.
It is found from the evidence of the son of the complainant that the policy holder contacted and communicated with the opp. party insurance company through email on several occasions {Ext-14 (1)} to 14(4).The opp. party insurance company communicated and sent emails to the policy holder i.e. the son of the complainant {Ext-15(1) } to 15(3) in respect of the claim number being 22010024584 filed by the complainant.
It is found from the evidence of the complainant’s son that the complainant Smti manju Medhi sent a legal notice through registered post dtd. 21-08-2015 to the opposite party for release the claim amount of Rs.53,000/- in her favour with immediate effect along with the interest accrued thereon on commercial rate(Exhibit No-17 and 18). Therefore, we hold that complainant has justified ground to approach the opposite parties to release the amount of Rs.53,000/-. It is seen from Ext. No-15(1) and 15(2) that the opposite parties informed the complainantside that their request is under process . But it is found that knowing the fact also the opp. party side did not settle the claim/ reimburse the amount of the complainant. So, on that ground the complainant is entitled to get the amount from the opp. parties. On these premises,we also hold that by ignoring to release the amount to the complainant by the opp. parties although the complainant has legitimate ground to get the money paid by her, the opposite parties committed deficiency of service towards the complainant and on that count the opp. parties are liable to pay proper compensation to the complainant for causing harassment to her by ignoring to release the amount.
We also hold that after complying the conditions of insurance policy on each and every year which the complainant entered with the opp. parties, the complainant, failed to get the insured amount from the opp. parties and then being compelled the complainant has to file the complaint against the opp. parties and incurred certain cost in that pursuit. So, the complainant is entitled to certain amount as cost of the proceeding . We are of opinion that the opp. parties are liable to pay Rs.10,000/- as compensation for causing harassment to the complainant and Rs.5,000/- as a cost of the proceeding.
Because of what has been discussed as above, we hold that complaint has merit .Accordingly the complaint against the opp. party is allowed on exparte with a direction to the opp. party to make payment to the complainant the amount which had already been paid i.e. Rs.53,060/- (Fifty Three Thosand Sixty Only) by the complainant to GNRC Hospital , Guwahati with interest @12% per annum from the date of her demand (7-9-2013) and also to pay her Rs.10,000/- as compensation for causing harassment to her and Rs.5,000/- as a cost of the proceeding , to which,the opp. party is jointly and severally liable .The opp. party is directed to make payment within 45 days, in default , other two amounts shall also carry interest in the same rate.
Given under our hand and seal of the District Forum, on this the 25th day of August , 2017.
Free copies of judgment be delivered to the parties.
( Smti A.D.Lahkar) (Md S.Hussain)
Member President
