Dt. of filing- 21/11/2017
Dt. of Judgement- 04/10/2018
Mrs. Sashi Kala Basu, President.
This petition of complaint is filed under Section 12 of the Consumer Protection Act, 1086 by Shri Ajit Sarathi alleging deficiency in service on the part of the Opposite Parties namely (1) National Insurance Company Ltd. and (2) Sri Dipy Halder.
Case of the complainant in short is that the Complainant is a mediclaim Policy holder of National Insurance Co. for the last 07 years and last Policy No. is 100300501610005889, effective from 26.11.2016 to 25.11.2017 and his previous Policy No was 10030048158500008309. Complainant paid the premium of the policy through Opposite Party No.2 who is an agent of National Insurance Co. Ltd. On 27.09.2016 petitioner was admitted at Rabindra Nath Tagore International Institute of Cardiac Science for severe heart attack followed by open heart surgery and subsequently cerebral attack. He remained admitted in the said Institute from 27.09.2016 to till 13.10.2016. A sum of Rs. 3,35,000/- was spent towards the treatment . Complainant thus claimed the said sum of Rs. 3,35,000/- as total sum assured towards the policy was Rs.3,50,000/- but on 31.08.2017, Opposite Party No.1 sent a letter denying the claim of the petitioner. Repeated request by the complainant went in vein. OP Insurance Co. did make part payment of Rs.1,10,000/- . Initially complainant was paid only Rs. 85,000/- by OP No.2 and he had retained Rs.25,000/-. However, subsequently after police complaint was lodged by the complainant O.P No.2 paid Rs. 25,000/-. Opposite Party is liable to provide Mediclaim benefit to the petitioner of total sum assured. There is deficiency in service on the part of Opposite Party no.1 and thus this consumer complaint is filed by the complainant for directing Opposite Party no.1 to pay Mediclaim amount of 3,50,000/-, compensation of Rs. 2,00,000/- for mental pain , agony and harassment and Rs, 10,000/- towards litigation cost.
Complainant annexed with the complainant, copy of the relevant portion of the Policy, letter of OP No.1 dated 31.08.2017 repudiating claim, discharge voucher dated 10.10.2017, copy of F.I.R. lodged by the complainant at Jadavpur Police Station and final bill of medical treatment at Rabindranath Tagore International Institute of Cardiac Science.
Opposite Party No.1 contested the case by filing the written version denying and disputing all the material allegations contending inter alia that this Consumer Forum does not have territorial jurisdiction to entertain t the claim. Complainant was admitted for the period from 27.09.2016 to 13.10.2016 but the Policy of Insurance relied upon by the complainant is actually valid for the period from 26.11.2016 to 25.11.2017. During the relevant period of admission, complainant was actually covered by the Policy valid from 26.11.2015 to 25.11.2016 and the total sum insured in the said Polity was Rs,1,00,000/- and RS. 10,000/- was cumulative Bonus. Accordingly, Rs. 1,10,000/- has been paid to the complainant towards full and final settlement. So the Opposite Party No.1 has prayed for the dismissal of the case.
O.P No.2 did not take any step and thus case proceeded ex-parte against him.
Both the parties adduced their evidences followed by cross –examination in the form of questionnaire and reply thereto.
During the course of argument, Ld. Advocate for the complainant filed the Brief Notes of Argument.
Ld. Advocate for the OP No.1 also filed BNA. He has argued that this Forum has no territorial jurisdiction and the actual Policy of insurance by virtue of which complainant was covered during his relevant period of hospitalization was valid from 26.11.2015 to 25.11.2016 under which sum insured was Rs. 1,00,000/- only and add on cumulative bonus of Rs.10,000/- .
Ld. Advocate for the OP also argued that the complainant signed the discharge voucher admitting the Full and Final settlement of the claim.
Ld. Advocate for the OP has relied upon the following case laws : (1) AIR 2000 Supreme Court at Page 62 (2) IV (2017) CPJ 14 (NC) and (3) III (2017) CPJ 585 )NC).
POINTS FOR DETERMINATION
- Whether the complainant is a Consumer?
- Whether there is deficiency in providing service on the part of the Opposite Party?
- Whether the complainant is entitled to the reliefs as prayed for ?
Decision with reason
Both these points are taken-up together for comprehensive discussions in order to avoid repetition.
On a careful perusal of the petition of complaint, it appears that this District Forum lacks the territorial jurisdiction to entertain this case. The cause title for the consumer complaint reveals that the address of the OP No.1 falls outside the territorial jurisdiction of this Forum. No address of the OP No.2 has been mentioned in the petition of complaint. It is only stated “C/o. of O/C Jadavpur”. How could OP No.2 have the address in the case of O/C Jadavpur ? He admittedly was an agent of OP No.1 and according to complainant, he had been paying the Premium through said OP No.2 If that be so, he ought to have known his address, but no address of OP No.2 has been stated in the complaint petition. So in the absence of specific address of the OP No.2, and specific averment, the argument by the Ld. Advocate for the OP that no part of cause of action arose within the territorial jurisdiction of this Forum cannot be ruled out.
Coming to the merits of the case, admittedly complainant was admitted at Rabindra Nath Tagore International Institute of Cardiac Science for the period from 27.09.2016 to 13.10.2016. According to complainant, he underwent open heart surgery and bill of Rs.3,35,000/- was paid by him towards his treatment of open heart surgery. Even though copy of final bill is filed but discharge summary of the hospital has not been filed by the complainant. However, be that as it may, it is evident from the complaint and the copy of the Policy filed that the validity period of the Policy relied upon by the complainant is from 26.11.2016 to 25.11.2017 which actually started much after the hospitalization of the complainant. In such a situation, it is rightly argued that the actual policy which would be applicable in the case of complainant is the insurance policy which was effective for the period from 26.11.2015 to 25.11.2016. There is no dispute that the sum insured in the policy of 26.11.2015 to 25.11.2016 was Rs. 1,00,000/- ( one lack) and there was a cumulative Bonus of RS.10,000/- . Said insurance amount of Rs.1,10,000/- has already been paid to the complainant by the OP No.1. It is true that the complainant renewed his policy on 26.11.2016 whereby he raised the assured sum to Rs. 3,50,000/- but renewal or enhancement of sum ensured will not relate/date back to his earlier policy. It is to be pointed out that complainant was discharged on 13.10,2016 as appears from the final bill of the hospital. The total final bill of hospital was Rs.3,37,250/- towards treatment. Complainant renewed the policy thereafter and sum insured was Rs.3,50,000/- which is more or less similar to the amount in the final bill of the hospital. So it indicates that the sum insured was afterthought.
Since it is clear that the insurance policy under which the complainant was covered was of RS.1,00,000/- and complainant has already been paid RS. 1,11,000/-,there cannot be any deficiency in service on the part of the OP insurance company.
OP insurance company has filed a discharge voucher dated 10.10.2017 which is annexure –‘B’ with the written version. Said document reveals that complainant signed on it. It is clearly mentioned therein that Rs.1,10,000/- has been paid towards full and final settlement of the claim. In the evidence on behalf of OP No1, it is specifically sated that the complainant signed in the discharge voucher accepting full and final settlement of the claim. But the questionnaire filed by the complainant shows that complainant has not challenged or disputed that he did not sign in any such document. If that be so, then in view of the legal proposition in the case law referred to above reported in IV (2017) CPJ 14 (NC) and III (2017) CPJ 585 (NC),no deficiency in service can be attributed on the part of the OP Insurance Company and in the given situation of this case, complainant cannot be consumer within the Provision of the Consumer Protection Act,1986. Thus this complaint case is liable to be dismissed.
These points are answered accordingly.
Point No.3 :
In view of the discussions as highlighted above, complainant is not entitled to any reliefs as prayed for.
In the result consumer complaint fails.
Hence,
ORDERED
CC/662/2017 is dismissed on contest against Opposite Party No.1 and ex –parte against Opposite Party No.2.
