DISTRICT : SOUTH 24 PARGANAS
BEFORE
THE HON’BLE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BARUIPUR, SOUTH 24
PARGANAS.
Case
No. of 2017
In
the matter of :
An application under section 12 of the Consumer
Protection Act’ 1986;
AND
In
the matter of :
Shri Krishna Kumar
Jalan, Son of ___________________________,
residing at Premises being no. 14/6,
Bediadanga 1st Lane, Kolkata – 700039, West Bengal.
…………Complainant
-
Versus –
1.
National Insurance Company Limited,
having it’s Office at Turner and Morison Building, 6, Lyons Range, 2nd
Floor, Kolkata – 700 001.
2.
National Insurance Company Limited, having
it’s Branch Office at Baruipur Branch, Natgora, Baruipur, Near St. Xavier’s
Collegiate School, Kolkata – 700 144, District South 24 Parganas
3.
Genins India Insurance TPA Ltd, having
it’s office at Premises being no. 15, Ganesh Chandra Avenue, 3rd
Floor, Kolkata – 700 013.
4.
NH Rabindranath Tagore
International Institute of Cardiac Sciences, at Premises being no. 124, Eastern Metropolitan Bypass, Premises No: 1489, Mukundapur,
Kolkata- 700 099, West Bengal.
5.
Dr. Jyotishka Pal, of NH
Rabindranath Tagore International Institute of Cardiac Sciences, at Premises being no. 124,
Eastern Metropolitan Bypass, Premises No: 1489, Mukundapur, Kolkata- 700 099,
West Bengal.
6.
Dr. Rakesh Sharma, of NH
Rabindranath Tagore International Institute of Cardiac Sciences, at Premises
being no. 124, Eastern Metropolitan Bypass, Premises No: 1489,
Mukundapur, Kolkata- 700 099, West Bengal.
………………..Opposite
Parties
The humble Petition
of the above Named Complainant Shri Krishna Kumar Jalan, most respectfully;
Sheweth as under :
1.
That the complainant is a practicing
advocate, who ordinarily practicing at Hon’ble High Court at Calcutta and he is
residing at the address as given in the cause title of this application under
Section 12 of the Consumer Protection Act’ 1986.
2.
That the Complainant beg to states
that the Respondent nos. 1 & 2 needless to emphasis about their business
activity in the field of insurance in our country as well as they are earning
their business activity with their branch office as the address given in the
cause title above which well under the territorial jurisdiction of this Learned
forum in terms of provision of the Section 11 of the Consumer Protection Act’1986.
3.
That the Complainant beg to states
that the complainant is a policy holder having Mediclaim Policy being No.
101600/48/15/8565000410 i.e. Mediclaim
policy with the opposite parties nos. 1 & 2, in its continuation over 20
years.
4.
That the Complainant beg to states
that the complainant visited R.N. Tagore International Institute of Cardiac
Sciences, Kolkata with his high fever and headache on 21.05.2016, and therefore,
he was suggested to meet Dr. Jyotishka Pal and consequently Dr. Jyotishka Pal
advised him to be admitted in the Hospital i.e. R.N. Tagore International
Institute of Cardiac Sciences, at premises being no. 124,
Eastern Metropolitan Bypass, Premises No: 1489, Mukundapur, Kolkata- 700 099, West
Bengal.
5.
That the Complainant beg to states
that according to advise of Dr. Jyotishka Pal consultant intensive care medicine, of R.N. Tagore
International Institute of Cardiac Sciences, Kolkata, the complainant was admitted
in the R.N. Tagore International
Institute of Cardiac Sciences, 124, Eastern Metropolitan
Bypass, Premises No: 1489, Mukundapur, Kolkata- 700 099, West Bengal,
under the consultant Dr. Jyotishka Pal (DCH, MD, IDCC, FNB (CCM), EDIC –
Consultant of Critical Care Medicine) & Dr. Rakesh Sharma (MD, FNB
(Critical Care Medicine) – Consultant – Intensive Care Medicine) on 21.05.2016,
for urgent need of treatment.
6.
That the Complainant beg to states
that as the complainant having Mediclaim Insurance Policy of National Insurance
Company Limited, at the time of his admission at the Hospital, he
submitted the copy of Insurance policy being no.
101600/48/15/8565000410, along with a
TPA card issued by Genins India TPA Ltd for cashless claim but at the time of
discharge your petitioner, he was informed through the corporate desk of the
Network hospital of National Insurance Company Limited i.e. R.N. Tagore
International Institute of Cardiac Sciences, 124, Eastern
Metropolitan Bypass, Premises No: 1489, Mukundapur, Kolkata- 700 099 that the concern TPA refused the cashless
claim rather advised to submit the claim through reimbursement.
7.
That the Complainant beg to states that
in such a compelling circumstances, the complainant was bound to pay all the
amount as of Rs.40,563/- (Rupees Forty Thousand Five Hundred Sixty three) Only, to the Hospital Authority while discharging as on 24th May,2016, as entire and full payment thereof.
8.
That the Complainant beg to states
that the complainant after releasing from the Hospital placed his claim to the
insurance company for reimbursement on 11.08.2016, 12.08.2016, 02.10.2016
to 25.10.2016 accordingly
as advised by the corporate desk of R.
N. Tagore Hospital.
9.
That the Complainant beg to states
that thereafter the complainant received one letter from the concerned
insurance company dated 25.07.2016 in place of claimed
amount, by which the insurance
company repudiated the genuine claim of the complainant, for the reason stated as
“hospitalization was not necessary in the said case”.
10.
That the Complainant beg to states
that more over as a matter of fact that the complainant was not admitted in the
Hospital with his own opinion or advice or wish. The complainant was admitted with the valuable
advice of Dr. Jyotishka Pal, practicing doctor at R.N. Tagore International Institute of
Cardiac Sciences, Kolkata as consultant, intensive care medicine and as per the suggestion and advice of Dr.
Jyotishka Pal another consultant Dr. Rakesh Sharma was being attached along
with him in the treatment process of the complainant for the period commencing
from 21.05.2016 to 24.05.2016.
11.
That the complainant beg to states
that the complainant would like to draw attention that during his
hospitalization the representative from TPA office has met your petitioner at the time of their visitation in
hospital. But at the same time they did
not comment on the treatment process or to suggest or advice the complainant in
any manner, whatsoever.
12.
That the complainant beg to states
that the complainant is a patient admitted with unbearable headache and high
fever according to advice of the Doctor of the said Hospital i.e. R.N. Tagore
International Institute of Cardiac Sciences, Kolkata and it is not a amusement
park where the people visit for enjoyment and said hospital is a network
hospital of National Insurance Company Limited.
13.
That the Complainant beg to states that it is
very much unfortunate that the complainant has hold the mediclaim policy above
20 years but did not get his claim on his requirement, so far as arose in the
given circumstances, as described herein above.
14.
That it is pertinent to states that the
admission in the hospital allowed according to the advice of their own
consultant and according to discharge summery it is clear that diagnosis,
observation, and treatment was performed for the period of 21.05.2016 to
24.05.2016 and according to the reason shown to repudiate the claim by the
insurance company raised the question on the eligibility of the concern Doctor,
as well as their network hospital, but it is unfortunate that only the
complainant became victim herein.
15.
That the Complainant beg to states
that thereafter the complainant stated
entire facts and circumstances before the office of the Insurance Ombudsman,
Hindustan Building Annex, 4, C.R.
Avenue, 4th floor, Kolkata – 700 072 on 23rd March’2017
and that has been registered on 10th April’2017 and your complainant
was instructed to give his written consent in terms of Rule 12(2) of the
Redressal of the Public grievance Rules1998 for Ombudsman to act as a
mediator between the complainant and the
insurance company along with details of the complaint with the copies of all
the documents support of the claim grievance against the decision of the
insurance company and also directed to serve the copies of representation made
by the complainant to the insurance company against the final decision of the
company and the decision against the grievance of your complainant.
16.
That your complainant as per the
direction of the office of the insurance ombudsman submitted all the documents with the
stipulated time framed by the office of the insurance ombudsman and that was
acknowledged vide letter being reference no. KOL-G-048-1718-0003 dated 31.05.2017 and in the same letter your
complainant was directed to attend in the
hearing which would take place at office of the
Insurance Ombudsman, Hindustan Building Annex, 4, C.R. Avenue, 4th
floor, Kolkata – 700 072 on 16.06.2017 at 2.30 PM.
17.
That your complainant participated in
the hearing where your complainant saw that the network hospital of National
Insurance Company Limited i.e. R.N. Tagore International Institute of Cardiac
Sciences, Kolkata and the concern doctors are not the party while the admission
taken place according to the advice of the consultant of the network hospital
i.e. R.N. Tagore International Institute of Cardiac Sciences, Kolkata,
therefore it is pertinent to state that without presence of consultant Doctor
or competent authority of the hospital where your petitioner admitted, the authentic
and correct decision could not come up in this regards. So, one burning question raised- when a
person suffering with illness, where he or she used to go to take advice regarding
admission - to the Doctor ? or to the hospital? or to the Insurance Company ?
18.
That your petitioner became victim
either for the Doctor’s advice or the terms of the Insurance Company. So it is
very much needed to intervene into the matter for adjudication by the Forum or
otherwise your petitioner as well as the common people will suffer irreparable
loss and injury and unfair trade practice and got up between the Insurance
Company and their network hospital should be stopped.
19.
That the complainant also submit that
the Learned Forum has the jurisdiction to try, entertain and adjudicate the
instant complaint and pass necessary order/orders directing the opposite
parties to make payment as of Rs.40,563/- (Rupees Forty Thousand Five Hundred
and Sixty three) only with 18% interest from the date of discharge i.e.
24.05.2016 and further direct the opposite
parties to pay a sum of Rs.,50,000/- (Rupees Fifty Thousand) only as
compensation for the harassment and mental agony and also direct the Opposite
Parties to pay the sum of Rs.50,000/-( Rupees Fifty Thousand) only towards the litigation
cost.
20.
That the complainant is the bonafide
consumer under the definition of the Consumer Protection Act, 1986 (as amended
up-to-date). That the application is made within the period of limitation as enumerated
in the provision of Sec.24A of the Consumer Protection Act, 1986.
21.
That until and unless the prayer is
allowed, the complainant will be highly prejudiced and suffer with irreparable
loss and injury.
22.
That the Complainant is enclosing
herewith the following documents as relied on by him :
i.
Mediclaim Insurance Policy;
ii.
TPA Documents;
iii.
Claim Documents;
iv.
Letter of repudiation ;
v.
Ombudsman’s documents;
vi.
Medical papers and others.
23.
That this application is made bonafide
in the interest of administration of justice.
In the premises it is prayed that Your Honor would
graciously be pleased to allow this application and pass the following orders
for the interest of administration of justice:
(i)
To issue notice upon the opposite
parties;
(ii)
To direct the opposite parties to pay
the amount as of Rs. 40,563/- (Rupees Forty Thousand Five Hundred and Sixty
three) only as medical treatment amount along with 18% interest from the date
of discharging from the hospital, till the date of realization thereof to the
complainant, in the interest of administration of justice;
(iii)
To direct the opposite parties to pay Rs. 50,000/-(Rupees Fifty
Thousand) only as compensation for harassment and mental agony, to the
complainant, in the interest of administration of justice;
(iv)
To direct the opposite parties to pay
Rs. 50,000/- (Rupees Fifty Thousand) only towards litigation cost, to the
Complainant, in the interest of administration of justice;
And or to pass such other necessary order or
orders, as Your Honor may deem, fit,
and proper, for the end of justice.
And for this act of kindness your
petitioner, as in duty bound shall ever pray.
A
F F I D A V I T
I, Krinana Kumar Jalan, Son of __________________aged about ……years, by
faith- Hindu, by occupation- Business, residing at premises being no.14/6,
Bediadanga 1st Lane, Kolkata – 700 039, West Bengal, do hereby solemnly affirm and say
as follows:
1.
That I am Complainant in the present
Consumer application, before the Hon’ble Forum. I am Competent to swear this
affidavit.
2.
That I am Conversant with the material
facts as stated in the forgoing paragraphs of my application under Section 12
of the Consumer Protection Act’ 1986.
3.
That the content of paragraph nos.
_____________to __________, are true to the best of my knowledge and belief,
and the rests are my humble submissions before the Hon’ble Forum.
That the above statements are true to the best of
my knowledge and belief.
--------------------------- Deponent
Prepared in my
Chamber, Identified
by me
Advocate. Advocate.
Date :
___________2017.
Place : Baruipur,
Kolkata.
N
O T A R Y
VAKALATNAMA
District
: South 24 Parganas
Before
the Hon’ble District Consumer Disputes Redressal Forum, at Baruipur, South 24
Parganas.
Complaint
Case no. _________of 2017
Shri Krishna Kumar Jalan, ___________Complainant.
-
Versus –
National
Insurance Company Limited and Others, ____________Opposite
Parties.
KNOW
ALL MEN by these presents that
I / We, Shri
Krishna Kumar Jalan, Son of ___________________________,
residing at Premises being no. 14/6,
Bediadanga 1st Lane, Kolkata – 700039, West Bengal,
do hereby constitute and appoint the under
mentioned Advocate, Pleader, Vakils, jointly and each of them severally to be
pleader of take such steps and proceedings as may be necessary on my / our
behalf and for that purpose to make sign, verify and present all necessary
petitions, plaints, written statements and other documents and do nominate and
appoint or retain senior counsels, vakil, advocates and other persons, lodge
and deposits moneys and documents and other papers in the Ld. Court and the
same again withdraw and to take out of Court and to obtain or grant as the case
may be effectual receipts and discharge for the same and for all moneys which
may be payable to me / us in the premises. To enter into compromise with my /
our approval and withdraw, all moneys from the court AND GENERALLY to act in the premises and proceedings
arising there out whether by way of execution, review, appeal, or otherwise or
in any manner contested there with as effectually and to all intents and
purpose as I / We could act if personally present and such substitution and as
pleasure to revoke I / We hereby ratifying and agreeing to confirm whatever may
be lawfully done by virtue hereof.
In witness
whereof this Vakalatnama has been executed by me / us.
This the
…………………day of ………………2017.
Sri
Ashok Kumar Singh, Advocate. High Court Bar Association Room No. 15, High Court
at Calcutta. Mobile Number : 9883070666 / 9836829666. E-mail : aksinghadvocate@rediffmail.com
Sri
Anindya Chakraborty, Advocate. Sri Biplob Some, Advocate. Sri Pradip Kumar
Mondal, Advocate.
