J. Bag, J. - (1.) THE present appeal is directed against the Order, dated 8.2.2013 of the learned District Consumer Disputes Redressal Forum, Unit -I, Kolkata, in CDF/Unit -I/Case No. 427/10, whereby, the complaint was allowed on contest with cost against O.P. No. 1 and ex parte without cost against O.P. No. 2. The complaint case, in brief, was as follows: The Complainant's father (natural guardian of the minor, namely, Master Aditya Poddar) had taken a Hospitalization Benefit Policy (2007) from the New India Assurance Company Ltd. for self and members of his family including minor sons on payment of premium of Rs. 3,509 only. The policy was renewed from time -to -time till 1.5.2011. In May, 2010, the Complainant's son, (Master Aditya Poddar) had some pain in groin area. The consulting Doctor diagnosed the ailment to be a case of Inguinal Hernia and advised for surgery. The Complainant in terms of the policy filed a Mediclaim Form issued by O.P. No. 1 for the period of treatment and all the treatment papers including bills, discharge summary and other medical reports were submitted along with a claim form on 9.6.2010 with a claim of Rs. 21,740 (Rupees twenty one thousand seven hundred and forty) only. The Insurance Company repudiated the claim citing Clause 4.1 of the policy terms according to which for no preexisting ailment policy benefits would be available within the first four years of the insurance. The Complainant sent a legal notice dated 13.7.2010. No response being received, a complaint was filed before the learned Forum below.
(2.) O .P. No. 1 had entered their appearance by filing W.V. whereby all material allegations were dented and dismissal of the case was prayed for. O.P. No. 2 did not contest the case and the matter was heard ex parte against O.P. No. 2. Learned Forum below having considered the pleadings of the parties, evidence and documents in particular, observed that the Complainant's father took Hospitalization Benefit Policy in 2007 and the policy was renewed from time -to -time on payment of due premiums. Learned Forum below relied upon the decision of the Hon'ble Supreme Court as reported in CTJ, May, 2010 Vol -8 No. Page 66, wherein Hon'ble Supreme Court held that for mere breach of policy condition Insurance Company cannot deprive the claim of the Complainant. It was concluded that the OPs had sufficient deficiency in service on their part and accordingly the complaint was allowed on contest with cost against O.P. No. 1 and ex parte without cost against O.P. No. 2. O.P. No. 1 was directed to pay (a) a sum of Rs. 21,740 only to the Complainant for the treatment; (b) compensation of Rs. 25,000 for harassment and mental agony; and (c) Rs. 7,000 as litigation cost within 45 days from the date of communication of the order, in default whereof an interest @ 9% shall accrue over the entire sum due to the credit of the Complainant till full realization. Being aggrieved by and dissatisfied with the order of the learned Forum below, the Appellant/Insurance Company has come up before this Commission with the prayer for direction to set aside the impugned order on certain grounds.
(3.) WE have gone through the Memorandum of Appeal together with the impugned order, petition of complaint and other documents including the W.V. filed by the O.P. before the learned Forum below, the policy document, request (format) for cashless payment to provider Hospitals and some other documents.;