J U D G E M E N T
Sri Biswanath De, Ld. President.
The complainant’s case in brief is that he had obtained a mediclaim policy from the insurer (i.e., the OP Nos.1 & 2), and OP No.3 is the Third Party Administrator of the insurer. The complainant had renewed the mediclaim policy on some occasion. In November and December, 2013, the complainant was hospitalized for treatment of his diabetes. On that occasion he incurred expenses of Rs.40,577/- for his treatment. The complainant submitted claim application to the insurer praying for reimbursement of the medical expenses, but his claim was repudiated. The complainant submits that the repudiation
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was not proper and accordingly he filed this case praying that the insurers be directed to pay him the said sum of Rs.40,577/-, and he prays for compensation, and cost as well.
OPs appeared and filed written version denying inter-alia all the material allegations as raised by the complainant. It is stated that due observance and fulfillment of the terms and conditions laid in the policy has not been made for which in the present case the claim is not payable under clause 4.11 of the said policy. That charged incurred at hospital or nursing home primarily for diagnosis, x-ray or other diagnostic studies and not consistent with or incidental to the diagnosis and treatment of positive existence of any disease. It is also stated that the said hospitalization of the complainant is only for investigation and is not succeeded by an active line of treatment. Line of treatment does not support need for hospitalization and could not be managed on OPD basis. Accordingly, the claim was repudiated under clause 4.11 of the policy. The OP insurance company is not liable to pay the amount claimed by the complainant as the entire claim amount is irrational unlawful. So, the case is liable to be dismissed.
To prove the case the complainant has filed the following documents :-
1. Photocopy of the Policy being No.031900/48/12/97/00000923, valid from 27.12.2012 to 26.12.2013 (10 sheets).
2. Photocopy of the discharge summary of G.D. Hospital and Diabetes Institute, dated 19th December, 2013.
3. Photocopy of the claim letter submitted by the complainant dated 30th December, 2013.
4. Photocopy of the letter dated 21.02.2014 of the OP No.2, repudiating the claim of the complainant (2 sheets).
5. Photocopy of the prescription of Dr. P.D. Bhutia of Neotia Getwel dated 14.11.2013.
6. Photocopy of the bill of G.D. Hospital and Diabetes Institute, Kolkata dated 19.12.2013.
OP has filed the following documents :-
A. Individual Health Insurance Policy issued in the name of Ajit Kr. Prasad along with the terms and conditions etc.
B. Pre-Repudiation letter dated 14.02.2014 issued by the OP No.3.
C. Repudiation letter dated 21.02.2014 issued by the OP No.3.
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Points for determination
1. Whether there is deficiency of service on the part of the OPs ?
2. Whether the complainant is entitled to get relief as prayed for ?
Decision with reason
The complainant has filed evidence-in-chief. He has stated his case regarding purchase of the policy from the agent of the OP No.2. The said policy was renewed every year without break for at least 25 years. He did not take any claim from the OP. For last time mediclaim policy was renewed on 27.12.2013 and was valid till 26.12.2014. In the month of November he became ill and he was treated by Dr. P.D. Bhutia of Neotia Getwel, Matigara, Siliguri and uncontrolled diabetes was detected having Blood Sugar 311. He was advised by Dr. P.D. Bhutia for admission in the hospital/nursing home for optimization and better control of diabetes. Accordingly, he took advice. On 14.12.2013, he was admitted to G.D. Hospital and Diabetes Institute, 139, Lenin Sarani. As per statement in para 7 thus he got admission in the diabetic Institute, Kolkata as per advice of Dr. P.D. Bhutia, Neotia Getwel, Matigara. He was discharged from hospital on 19.12.2013. As a result of treatment in the hospital his blood sugar level and other parameters were brought under control. He also stated such treatment would not have been possible if he had tried to get himself treated as outpatient. As a result of treatment in G.D. Hospital and Diabetes Institute, he incurred an expenses of Rs.40,577/-. After discharge, he returned to Siliguri and submitted a claim on 30.12.2013 to the OP No.2. On 21.02.2014 he came to know through a letter of OP Nos.2 & 3, that his claim has been repudiated, as per policy terms and conditions laid down in 4.11 of the policy. Accordingly, this claim was lodged and complainant prays relief.
The OPs have adduced evidence. The OPs stated in their evidence that current hospitalization was for Type-2 DM, Hypertension, Non-Proliferative Diabetic Retinopathy, Cholelithiasis, Prostatomegaly patient has complaints of generalized weakness with lethargy since last 1.5 months, frequent urination with hesitancy in urination, difficulty in throat specially during eating, during hospitalization period, patient managed on oral medicine conservatively & investigated, glucose monitoring was done but as per monitoring chart available, no need for such monitoring because as per reading observed, it does
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not need hospitalization, no active line of treatment (like IV fluids, IV inject able etc) was given to the patient. Line of treatment does not support need for hospitalization and could be managed on OPD basis. Hence, the claim was repudiated. As per policy terms and conditions, claim is not payable under clause No.4.11. CRS explanation as per claim documents received it is observed that the treatment given to the patient does not support the need for hospitalization, hence the claim was repudiated. As per claim documents received it is observed that current hospitalization is only for investigation and is not succeeded by an active line of treatment hence the claim was repudiated as per the policy terms and conditions. On receipt of the aforesaid observation of the OP No.3, the OP No.2 finally repudiated the claim of the complainant by issuing a letter dated 21.02.2014 showing the cogent grounds and the said repudiation letter is lawful, valid, proper and rightful and is always binding on the complainant in all respects.
So, the OPs’ evidence and statement is based only on the Clause No. 4.11 of the Insurance Policy.
In the reply by complainant against question filed by the OPs, the complainant stated as per advice he visited G.D. Hospital and Diabetes Institute on 14.12.2013. Under advice of Dr. S. Chakraborty, MD, he was admitted in the hospital for treatment, sugar level was 552. He also stated in para 5 of reply, that Type-2 Diabetes Miletus (uncontrolled), hypertension, Prostatomegaly, mild NPDR. In para – 6 he answered regarding medicines advised by doctor i.e., Novorapid insulin 12.12.12 injection before meals, Lantus insulin 30 injection before dinner, Janumet (50/1000), Ecospirin AV 75, and Candace 2.5. In para-7 the complainant answered that Insulin Injection as per Doctor’s advice, Diet regulation and complete bed rest. Monitoring of sugar level 24 X 7.
In para-8 he stated he replied he was hospitalized as per his doctor’s advice and he submitted document. He was suffering from uncontrolled sugar level which affects heart, kidneys, and caused blindness. He again stated he got himself admitted only basis of medical advice to save his life. In para-9 he stated for effective treatment his doctor advised hospitalization considering uncontrolled sugar level. In para-10 he also stated after six days of hospitalization his sugar level were controlled and with proper supervised care he recovered, which would not have been possible if treated on OPD basis.
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It appears that the patient is of 65 years and such kind of disease might have chanced to attack a 65 years old man. Accordingly, his allegation of illness as stated before cannot be brushed aside, as it is reasoned and expectable.
So, the above statement of the complainant in cross-examination, which shows that under instruction of doctor and under compelling circumstances, when the sugar level was 552, the complainant was compelled to take admission in the hospital for his treatment and to save his life. So, before this evidence, the instruction laid down in the Clause No.4.11 of the Policy, the same is unable to stand because the complainant took admission for treatment. The cross-examination has unfolded the truth that under what circumstances, the complainant took admission in the hospital for treatment which could not be done in the outside of the hospital.
Accordingly, the contentions of the OPs that hospitalization are only for investigation and is not succeeded by an active Line of Treatment is not sustainable and is waste away by the evidence of the complainant. Accordingly, repudiation of the claim of the complainant by the OP Nos.2 & 3 is not sustainable as per evidence brought out by the cross examination in record.
It is stated that after returning from the hospital, the complainant lodged his claim on 30.12.2013 and his was repudiated on 21.02.2014 by OP Nos. 2 & 3.
It is admitted that there was a policy. So, after considering the claim of the complainant, which has been made after many years of the starting of the policy, the OPs have duty to act with due care and attention to preserve the interest of the complainant to give him protection of law and to act to meet his expenses incurred by the complainant during hospitalization. But the Insurance Company with bad intention and to deprive the complainant to get his basic need of treatment and with bad motive to deprive the complainant from his entitlement of cost during hospitalization repudiated the claim and compelled to the complainant who is 65 years old, to run before this Consumer Redressal Forum, Siliguri, with folded hands to get his demand fulfill. Such kind of conduct of the OPs is highly deprecated. Such act is nothing but showing disrespect to a senior citizen. It is pertinent to note that this complainant of policy holder of 25 years. The OP Nos.2 & 3 perhaps did not open their eyes to see and to judge the antecedent of this insured person. The
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OPs have grossly neglected in discharging their duties towards the insured person complainant. They have violated the aim and objective of the Indian Insurance Act, 1939 by depriving the common man for whose benefit the legislature has brought the Insurance Act into existence. Their activities constitute unfair trade practice and gross deficiency in service.
So, after deep deliberation over the material on record, evidence oral and documentary, we are strong conviction that the case succeeds and the complainant is to get benefit of law as laid down Section 14 of the Consumer Protection Act, 1986 and other benefit and cost of the treatment in the hospital.
Accordingly, the case succeeds on contest with the direction to the OP to act to be more vigilant in discharge their duties towards the common aged people.
Now let us consider the quantum of compensation and awards.
Obviously, the complainant is entitled to get all the expenses incurred in the hospital and laid down in the petition amounting Rs.40,577/- which was spent for his treatment in December, 2013 at G.D. Hospital, Kolkata.
In the result, the case succeeds.
Hence, it is
O R D E R E D
that the Consumer Case No.56/S/2014 be, and the same is hereby allowed on contest against the OP Nos.1 & 2 and the case is dismissed exparte against the OP No.3.
The complainant is entitled to get Rs.40,577/- which was spent for his treatment.
The complainant is further entitled to get Rs.20,000/- towards compensation for causing harassment and mental agony caused by the OP Nos.1 & 2.
The complainant is further entitled to get Rs.10,000/- for litigation cost from the OP Nos.1 & 2.
The OP Nos.1 & 2, who are jointly and severally liable, are directed to pay Rs.40,577/- which was spent for treatment of the complainant, by issuing an account payee cheque in the name of the complainant within 45 days of this order.
The OP Nos.1 & 2, who are jointly and severally liable, are further directed to pay Rs.20,000/- by issuing an account payee cheque in the name of
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the complainant towards compensation for causing harassment and mental agony caused by the OP Nos.1 & 2, within 45 days of this order.
The OP Nos.1 & 2, who are jointly and severally liable, are further directed to pay Rs.10,000/- by issuing an account payee cheque in the name of the complainant for litigation cost within 45 days of this order.
In case of default of payment, the complainant is entitled to get interest @ 9% per annum on the awarded sum of Rs.60,577/- from the date of filing of this case till full realization.
In case of default, the complainant is at liberty to execute this order through this Forum as per law.
Copies of this judgment be supplied to the parties free of cost.
-Member- -Member- -President-
