West Bengal

Birbhum

CC/14/144

Shyam Sundar Ghosal - Complainant(s)

Versus

1.Branch Manager, United India INS Co. Ltd - Opp.Party(s)

Paresh Nath Banerjee

27 Sep 2018

ORDER

The case of the complainant Shyam Sunder Ghosal, in brief, is that he obtained a health insurance policy on 29.03.2014 under O.P No. 1 Ins. Co. and said policy remained valid for the period 29.03.2014 to 28.03.2015.

It is the further case of the complainant that during validity of the said policy he became seriously ill for acute pain in neck and was taken to Apollo Hospital, Chennai. He was firstly examined on 02.04.14 and several tests were done in the said hospital for proper investigation of his diseased which was continued upto 05.04.14 and was consulted several reports and thereafter his treatment was started under supervision of Dr. Rajasekhar B and was advised to undergo the treatment and as such as per advise of concerned doctor he was admitted in the hospital as patient on 06.04.14 for treatment of Ankylosing Spondylitis under the department of Rheumatology under supervision of Dr. Raja Shekhar B and for which he was incurred an amount of Rs. 88959/- inclusive of all. And he submitted receipt in this regard and final bill was issued to him and he was discharged on 07.04.14.

It is the further case of the complainant that the bills and hospital records including other necessary documents concerning his treatment at Chennai was submitted to O.P No.1 for making payment of bill to meet up the expenditure but the O.P No.1 after acknowledging the same has repudiated his claim on 14.10.14.

It is the next case of the complainant that acts of the O.Ps are highly illegal and unlawful which amounts to deficiency in service and illegal trade practice and the complainant is entitled to get compensation from the O.Ps.

Hence, this case for directing the O.Ps to pay Rs. 88959/- i.e. bills paid by him with compensation for mental harassment and agony.

O.P No.1 and 2 have contested the case by filing written version denying all material allegations of the complaint contending inter alia that the case is not maintainable and the complainant has no cause of action to bring this case.

It is the specific case of the O.P No.1 and 2 that complainant Shyam Sunder Ghosal was admitted to Apollo Hospital, Chennai on 06.04.14 for treatment of Ankylosing Spondylitis and for his said treatment injection Remicade was administered to him on 07.04.14 and he filed claim application claiming Rs. 84594/- for his said treatment.                                                                                                                              

 

It is the further case of the O.P No.1 and 2 that on perusal of the claim form and relevant documents submitted by the complainant it was found that he was given Remicade injection, IV in fusion for his said treatment. The time taken for giving IV injection like Remicade injection is more than two hours and less than three hours if no adverse reaction happened and accordingly this type of injection can be administered in a day care centre and this type of procedures / treatment neither falling under the definition of hospitalization nor included in the listed procedure for consideration under day care centre as per clause No.2.1 and clause No. 2.1(note)(1) of the policy condition. Accordingly such type of treatment is excluded from the policy coverage.

Ultimately the O.P No.1 and 2 prayed for dismissal of the case.

Inspite of due service of notice O.P No.3 Heritage Health TPA ltd. has not appeared and contested the case and the case was heard ex parte against them.

Point for determination.

1.  Whether the complainant is a consumer under Sec. 2(1)(d)(ii) of the C.P. Act.?
2. Whether this Forum has jurisdiction to try this case?
3. Whether there is any deficiency in service on the part of the O.P.?
4. Whether the complainant is entitled to get any other relief or reliefs as prayed for?

DECISION WITH REASONS

During the trial the complainant Shyam Sunder Ghosal has been examined as PW1 and also filed some documents.

OPW1, Susil Mondal, O/C of O.P No.1 Ins. Co. Suri. Branch has been examined and also filed some documents.

Heard argument of both sides.

Point No.1:: Evidently the complainant has obtained a health insurance policy of the O.Ps by paying premium.

So, the complainant is a consumer U/s 2(1)(d)(ii) of the C.P. Act.

Point No.2:: O.P No.1 has Branch Office within jurisdiction of this Forum.

The total valuation of the case is Rs. 99959/-, which is far less than maximum limit of the pecuniary jurisdiction of the Forum i.e. Rs. 20,00,000/-.

So, this Forum has pecuniary and territorial jurisdiction to try this case.

Point No. 3 and 4:: Both points are taken up together for convenience of discussion as they are related to each other.

            Admittedly the complainant Shyam Sunder Ghosal obtained a Health Insurance Policy and he was admitted to Apollo Hospital, Chennai on 06.04.14 for treatment of Ankylosing Spondylitis and for his said treatment injection Remicade was administered to him on 07.04.14.

            It is also admitted fact that the complainant submitted claim application for Rs. 84594/- for his medical treatment.

            It is also admitted fact that the claim of the complainant was repudiated by sending letter dated 14.10.14 to him.

            We find that it is the main case of the O.P Ins. Co. that for getting compensation under Health Insurance policy the complainant must have to stay in hospital for more than 24 hours. But in the present case he was stayed there for 20 hours.                                                                                          

 

            So, he is not entitled to get any compensation.

            We find from the clause 2.1 and note of the policy condition of Health Insurance policy that stay in hospital must be 24 hours or more for admissibility of the reimbursement of the medical expenses.

            But copy of 1^st interim bill dated 07.04.14 filed by the O.Ps shows that the complainant Shyam Sunder Ghosal was admitted to the hospital on 06.04.14 and he was stayed there from 06.04.14 at 5.53.49 p.m. to 07.04.14 at 3.53.54 p.m. i.e about 22 hours.

At the time of passing of final order on 20/12/2017 the complainant filed copy of a patient bill showing that the Complainant Shyam Sunder Ghosal was admitted to Apollo Hospital, on 06/04/2014 at 5:53:49 p.m. and discharge on 07/04/2014 at 6:53:54 p.m.

            We find that in present case stay of complainant at Apollo Hospital from 06/04/2014 to 07/04/2014 is very much crucial to decide the case and to ascertain whether he stayed there more than 24 hours or less than 24 hours.

            We find that copy of the patient bill issued by Apollo Hospital shows that the Complainant was admitted there on 06/04/2014 at 05:53:49 p.m. and discharged on 07/04/2014 at 06:53:54 p.m.

 

On the other hand copy of the final interim bill of complainant issued by the Apollo Hospital filed by the insurance company shows that the Complainant admitted there on 06/04/2014 at 5:53:49 p.m. and discharge on 07/04/2014 at 3:53:54 p.m.

            Considering such discrepancy in two documents issued by same hospital mentioning two different time of discharge of complainant, an explanation was called form said hospital and said hospital on 16/07/2018 submitted the report.

            We find that said hospital admitted that both documents were issued form their hospital.

             We find that in their report the Apollo Hospital submitted that regarding two Bills pertaining to the patient Shyam Sunder Ghosal indicating different time of discharge, we submit that hospital would generate a draft/interim bill for the cashless patient prior to discharge in order to get the approval from the Insurance Company. Draft/interim bill may differ from final bill, because Doctor fee, tariff, consultation will have to be included in the final bill as per the approved company terms and conditions as agreed in Memorandum of Understanding. Final bill shall not be generated before getting the final approval from Insurance Company. After getting the final approval only we can deduct that approved amount in the total bill amount and collect the balance if any, from the patient.

            So it is clear form said report that draft/interim bill may differ from final bill as Doctor fee, tariff, consultation fee are to be included in the bill and final bill amount is finally assessed at that time of issuance of final bill.

            But there is no such explanation that why reputed hospital like Apollo Hospital issued such two documents in respect of same person for same date mentioning two different time of discharge that is 3:53:54 p.m. and 06:30:54 p.m. (on 07/04/2014).

            Considering overall matter in to consideration and material on record we think the present bill dated 07/04/2014 issued by Apollo Hospital mentioning time of discharge on 07/04/2014 at 06:53:54 p.m.  is very much doubtful and no reliance can be placed upon said document.

 

 

We find that it is the further case of the O.P No1 and 2 that after administration of Remicade injection only 2 to 3 hours stay in hospital is enough but he stayed there for more than 20 hours without any complication and did it only for getting compensation.

As per down loaded version of Google server a Remicade infusion usually done in hospital and takes about two hours. You’ll need to wait for another 1-2 hours before you go home in case you develop any side effects.

 

We further find in this case the complainant has failed to produce any document to show that he was stayed in hospital for more than 20 hours on advice of any treating doctor rather in reply of question

No.3 put to him i.e. have you filed any written advice from the concerned doctor, which revealed that after administering the said Remicade injection you felt any inconvenience or serious illness or adverse reaction which compelled you to stay in hospital for more than 20 hours. He stated nothing.

Considering overall matter into consideration and materials on record we find no deficiency in service or illegal trade practice on the part of the O.Ps and the case is liable to be dismissed.  

Thus these points are decided against the complainant and the case fails.

Proper fees have been paid.

 

Hence,

O R D E R E D

that C.F case No. 144/2014 be and the same is dismissed on contested against O.P No. 1 and 2 exparte against the O.P No. 3 without any order as to cost.

            Copy of this order be supplied to the parties each free of cost.