West Bengal

South 24 Parganas

CC/547/2014

Sri Kalyan Chowdhury. - Complainant(s)

Versus

1. The Senior Manager, The Oriental Insurance Co. Ltd. Behala Branch. - Opp.Party(s)

29 May 2015

ORDER

      DISTRICT CONSUMER DISPLUTES REDRESSAL FORUM

SOUTH 24 – PARGANAS , JUDGES’ COURT, ALIPORE KOLKATA-700 027

 

C.C. CASE NO. _547_ OF ___2014___

 

DATE OF FILING : 13.11.2014     DATE OF PASSING JUDGEMENT:  29.5.2015__

 

Present                        :   President       :   Udayan Mukhopadhyay

 

                                        Member(s)    :    Mrs. Sharmi Basu

                                                                             

COMPLAINANT             :   Sri Kalyan Chowdhury, Bidhangarh Santoshpur, Kolkata - 66

 

-VERSUS  -

 

O.P/O.Ps                            :    1. The Senior Manager, The Oriental Insurance Co. Ltd. Behala Branch, P.S Behala, 496, Diamond Harbour Road, Kolkata – 34.

                                                2.     The Chairman & Managing Director, The Oriental Insurance Company Ltd. “Oriental House”, A-25/27, Asaf Ali Road, New Delhi-110 002.

                                            3.     The Office-In-Charge, Vipul Medcorp TPA Pvt. Ltd. 16/2, Lord Sinha Road, Kolkata – 700 071.

 

________________________________________________________________________

 

                                                            J  U  D  G  E  M  E  N  T

 

Sri Udayan Mukhopadhyay, President                                    

             The case of the complainant, in short, is that he is a senior citizen and Oriental Mediclaim Policy Holder bearing no.311603/48/2014/41  valid from 17.4.2013 to midnight of 16.4.2014 with cashless facility. 

            On 20.6.2013 complainant’s wife got admission at Kothari Medical Centre and immediately it was informed to the O.P. On the date of release on 25.6.2013  the TPA asked to know the cause of indoor admission and Dr. Anil Malhotra ,who treated my wife, forwarded a reply to the TPA vide Kothari Medical Centre’s Fax dated 25.6.2013 mentioning that “Patient Smt. Manjusree Chowdhury was not in condition to be treated as an outdoor patient”. On the same day TPA vide their Fax denied cashless facility and advised to submit claim for reimbursement of medical expenses along with original documents. Complainant was puzzled by that time because large amount was needed for release of his wife and he was actually not prepared  and he had to collect huge amount from his relatives . Lastly he submitted the claim on 1.7.2013 but the same was repudiated on the ground that investigating doctors of TPA expressed their opinion that the patient was admitted with complaint of Anorexia, Nausea & vomiting and treated conservatively. There is no urgent indication of hospitalization and patient could have been treated in the out patient department …………the claim merits repudiation under clause 2.3 of individual mediclaim policy”. The repudiation being most illegal and unethical , this case has been filed with a prayer to pay Rs.35,421/- together with interest @12% p.a from 1.8.2013 to the date of actual payment and litigation cost.

            O.P 1 and 2 contested the case by filing written version and have denied all the allegations leveled against them . It is the contention of the contesting O.Ps that there is no deficiency in service on the part of the O.Ps and this complaint is misleading , manipulated with the forged documents and filed this case unnecessary and the complainant is not a consumer of the O.ps.

            It is the positive case of the O.Ps that the claim has been rightly repudiated as per terms and conditions under clause 2.3 of the mediclaim policy since the claim is not permissible under the terms and condition of the policy. It is further alleged that in the discharge certificate dated 25.6.2013 it was not clearly stated by the Doctor and Kothari Medical Centre as to why the patient Smt. Manjusree Chowdhury could not be treated as an outdoor patient as asked by the TPA and as such without proper and logical clarification the claim of the complainant cannot be allowed. It has further stated that Manjusree Chowdhury was not required to get hospitalized for treatment since there is no prior advice of any doctor for such hospitalization. It has claimed that treatment of Smt. Manjusree Chowdhould should have been done in O.P.D  without admission as she was treated with oral medicine. It has strongly claimed that in order to get mediclaim complainant admitted deliberately in the hospital with malafide intention to have illegal monetary gain from the Insurance Company. The O.P also mentioned the ruls of Kothari Centre and also cited one judgement of Hon’ble National Commission as well as Judgement of Hon’ble Supreme Court and prays for dismissal of the case.

            O.P-3  is not contesting the case inspite of service of summon. Accordingly the case is running against O.p-3 exparte.

             

            Points for decision in this case is (i) whether the complainant is a consumer or not within the definition as laid down in the C.P.Act, 1986.

            (ii)    Is the repudiation of claim of the complainant justified ? If not whether the O.Ps fall under the purview of deficiency of service.

 

                                                                        Decision with reasonsa

            Issue no.1:-  We have perused that complainant’s wife Smt. Manjusree Chowdhury is also insured person and some sum insured is Rs.75000/- and it also appears that  domiciliary hospitalization limit is Rs.15000/-. It is well known to us that privity of contract came to an end the moment complainant accepted the amount unconditionally. Here in the instant case premium amount was accepted and policy is also accepted. So, definitely there is relationship within the purview of consumer since the complainant although was not a patient but his wife is a patient who is also insured as well as beneficiary of the policy. Thus the contention of the contesting O.Ps is go-bye and we hold that the complainant is a consumer.

            Regarding the next point we have perused the repudiation letter issued by the Branch Manager , Oriental Insurance Co. to the complainant on 30.10.2013 ,wherefrom we find that grounds for repudiation is “Investigating doctors of TPA expressed their opinion that the patient was admitted with complaint of anorexia, nausea and vomiting and treated conservatively. There is no urgent indication of hospitalization and patient could have been treated in the out patient department since procedures /treatment is usually done in O.P.D are not payable under the policy even if converted today  Care Surgery Procedure or as impatient in hospital for more than 24 hours. Hence, as per their opinion the claim merits repudiation under clause 2.3 of individual Mediclaim policy”.

            We have perused the condition no.2.3 and found that Ld. Advocate of the O.P has marked in the red ink of one note in connection with 2.3 condition of the policy which is reproduced hereunder:

            :Procedure/treatment usually done in out patient department are not payable under the policy even if converted to day cares surgery/procedure or as in patient in the hospital for more than 24 hours”.

            Thus we find from the repudiation clause as well as the ground of repudiation that the O.Ps failed to keep confidence upon the admission of Manjusree Chowdhury in the Kothari Medical Centre . It may be mentioned here that  O.P-3 already enquired the matter of admission with the Kothari Medical Centre by sending a Fax Massage on 25.6.2013 while cashless facility was asked for. We should reproduce the query of TPA to the Kothari Medical Centre as follows:-

1.   As per the submitted documents the patient is on oral medication and is being evaluated as in patient . Hence kindly let us know why patient cannot be evaluated and managed on OPD basis?

Doctors of Kothari Medical Centre has informed on the said date that “ Mrs. Manjusree Chowdhury was admitted under Dr. A. Malhotra in KMC Bed no. 6074. She had severe vomiting and nausea for one and half weeks (about 10 days) and Anorenia also for 10 days . She was treated with IVF , iv medications and also with oral medicines. She was not in a condition to be treated as case of OPD patient”.  This was the reply of doctor of Kothari Medical Centre on 25.6.2013 and said doctor also mentioned his registration number.

 

      We have nothing to disbelieve and departure from the opinion of the doctor under whom and guidance she was treated. Apart from that, Insurance Company failed to produce any believable opinion of doctor to departure us from the view of the doctor of Kothari Medical Centre relating to indoor treatment of the patient. We are sorry to inform that nowadays attitude of the Insurance Companies has become more than a doctor. If that be so, they can open one super-speciality Hospital where the patient will be treated , then they can obtain any nature of certificate to save money of the Insurance Company. We are really astonished to see the highhandedness of the Branch Manager of the Insurance Company who has repudiated the claim after more than four months, since the claim was submitted on 1.7.2013 and date of repudiation is 30.10.2013which is against the IRDA guidelines. Moreover, there is nothing mentioned in the repudiation letter as to delay of repudiation in view of the guidelines of the IRDA. It may be mentioned here that IVFR iv medications is required after admission. From the medical certificate of the treating doctor Anil Malhotra we find that during the stay of hospital she was diagnosed  UTI Hypothyroidism, Cholelithiasis, Hansen Disease, Left Ulnar Nerve Palsy, Mononecurity Multiplex, Hyperuricaemia, Multiple Pancreatic Cyst. So, from the treatment given from the date of admission i.e. from 20.6.2015 to 25.6.2015 and when Doctor has opined that condition of the patient was not to be treated as a case of OPD patient and patient required hospitalization, it is interesting to point out that inspite of receiving the query of Kothari Medical Hospital regarding the treatment as indoor patient why not Insurance Company placed all the medical documents before similar type of doctors or better medical institute to get valued opinion . We are sorry we cannot departure from the doctor of Kothari Medical Centre. We are also of the opinion that the repudiation is not justified which amounts to unfair trade practice and deficiency in service.

 

      Hence,

                                                                              Ordered

That the application under section 12 of the C.P Act is allowed on contest against O.P nos. 1 and 2 and exparte against O.P-3 with cost of Rs.2000/-.
 

O.P nos. 1 and 2 are directed to pay Rs.35,421/- to the complainant within one month from this date of this order, failing which, interest @9% p.a will carry from the date of this order till its realization.

O.P nos. 1 and 2 are further directed to pay Rs.10,000/- towards compensation to the complainant within 30 days from the date of this order and to pay penalty of Rs.5000/- within that stipulated period, which will be deposited in the Consumer Legal Aid Fund.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

Let a plain copy of this judgement be handed over to the parties free of cost.

 

 

 

                                                            Member                                                           President

 

Dictated and corrected by me

 

 

 

                        President

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The judgement in separate sheet is ready and is delivered in open Forum. As it is ,

 

Ordered

That the application under section 12 of the C.P Act is allowed on contest against O.P nos. 1 and 2 and exparte against O.P-3 with cost of Rs.2000/-.
O.P nos. 1 and 2 are directed to pay Rs.35,421/- to the complainant within one month from this date of this order, failing which, interest @9% p.a will carry from the date of this order till its realization.

O.P nos. 1 and 2 are further directed to pay Rs.10,000/- towards compensation to the complainant within 30 days from the date of this order and to pay penalty of Rs.5000/- within that stipulated period, which will be deposited in the Consumer Legal Aid Fund.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

Let a plain copy of this judgement be handed over to the parties free of cost.

 

 

 

                                                            Member                                                           President