Date of Filing-16.11.2017

Order No. 15                                                                                Dt.- 27.04.2018

INAL ORDER/JUDGEMENT

Smt. Bina Chaudhury, Ld. Member

The complainant has filed the present complaint petition u/s 12 of the Consumer Protection Act 1986. The fact of the case of the complainant in brief is that he was a policy holder of opposite parties company under its Swastha Kavach Policy (Mediclaim) vide ID NO.52600051-1-0, Policy No. 31/SKP/52600051 which was valid from 21.3.2016 to 20.03.2017.

The complainant on 01.05.2016 visited Dr. C.P. Sharma at Nivedita Nursing Home with complaint of occasional chest pain, shortness of breath, tiredness, insomnia and generalized weakness. As per advice of the consulting doctor she was admitted there and had undergone treatment till 10.05.2016 and he had to pay Rs.1,25,314/- (Rs.One lac twenty five thousand three hundred fourteen only) to the aforesaid nursing home towards his costs of treatment. On the date of her admission it was intimated to the call centre of the O.Ps Company. After completion of her treatment the complainant submitted her claim to the O.Ps Company, which was duly registered, vide Claim I D No.201662388790 and she submitted entire details of Hospital Bills and treatment expenses as per requirement of O.P. But by a letter dated 20.12.2016 from the O.P. the complainant came to learn that her claim has been repudiated on a flimsy ground. So, complainant has compelled to file the present complaint against the opposite parties company, for their unfair trade practice and deficiency in service.

The O.P. Nos. 1 to 3 has contested the case by filing written version denying                                                       all the material allegations made in the petition of complaint stating, inter alia, that the present petition is not maintainable either in law or in facts. The petitioner is not a consumer and the petition is barred by law of limitation and also there is no cause of action for filing the present case.The specific case of the O.Ps. is that as per records supplied by  the  complainant and of the internal survey it reveal that the complainant could have been treated as an outpatient basis and which is excluded from the scope of coverage under the policy terms and conditions. Thus the claim is repudiated under exclusion clause No.14 and also under definition of words No, 12 of SKP Policy terms and conditions.

So, the complainant is not entitled to get any relief as alleged and as prayed for as there is no unfair trade practice or deficiency in service on the part of the O.P. and the case is liable to be dismissed with cost.

                            POINTS FOR CONSIDERATION  

1)  Is the complainant a consumer as per C.P. Act?

2) Is the complaint petition barred by law of limitation?

3) Is there any cause of action for filing the present petition of complaint?

4) Is there any unfair trade practice and deficiency in service on the part of the opposite parties?

5) Is the complainant entitled to get any relief, as prayed for and to what extent?

                                    DECISION WITH REASONS

            In the instant case the complainant and the opposite parties submitted before the Forum that they would neither file any affidavit- in chief, nor would adduce any oral evidence, nor would adduce any further documentary evidence. They also submitted before the Forum to pass Final Order/Judgment on the basis of the petition of complaint supported by affidavit along with documents annexed therein and the written version supported by affidavit along with documents annexed therein treating them as their evidence on affidavit. Accordingly, we have carefully gone through the petition of complaint, written version and the documents filed on behalf of the parties accepting them as their respective evidence on affidavit. We have also carefully perused the B.N.A. filed by both the parties. We have also heard arguments of both parties in full and at length.

           All the points are taken up together for the sake of convenience and discussion.

The Ld. Advocate on behalf of the complainant submitted that the complainant is a bona-fide policy holder of Health Insurance (mediclaim) under the opposite parties on payment of premium.

The O.P. in his written version in Para No. 7 has denied that the complainant is not a consumer from the document annexure 4 annexed by the complainant, a letter Dt. 12.08.2016 sent by the O.P. to the complainant, we find that the O.P. has demanded some documents which are required in order to process the claim of the complainant in respect of her policy being No. 31/SKP/16/5260005. As such we are inclined to hold that the complainant availed the service of mediclaim from the O.Ps on payment of premium so the complainant is a Consumer u/s 2(d) of the C.P. Act 1986.  

The complainant in her complaint petition supported by affidavit has stated that she was admitted in the nursing home on 01.05.2016 and after treatment she was discharged on 10.05.2016. She also stated that it was intimated to the O.Ps company on the date of her admission which was registered by the O.Ps company vide claim No-201662388790 and the complainant submitted entire details of Hospital Bill and expenses towards her treatment as per demand of the O.P. From the documents annexure 1(DISCHARGE SUMMARY), ANNEXURE 7,8 and annexure 9 repudiation letter dt.20.12.2016 sent by O.P. to the complainant, we find the complainant has filed the complaint petition on 16.11.2017.

As such we find and hold that the complainant has filed the complaint petition within the law of limitation and there is cause of action for filing the case as per C.P. Act, 1986.

The Ld. Advocate on behalf of the complainant submitted that the complainant having complication of occasional chest pain, shortness of Breath, tiredness, insomnia and generalized weakness visited Dr. C.P. Sharma, a renowned Pulmonologist and a registered medical practitioner at Nivedita Nursing Home for her treatment and the Doctor after clinical observation and considering the diagnostic reports and considering the significance of dissease advised the complainant for admission for her treatment so the complainant took admission there and her treatment continued till her health improved and discharged. Thereafter the complainant lodge her claim before the O.Ps but the O.Ps unlawfully without any valid reason repudiated the claim with a plea that the patient could have been treated as OPD patient and admission was not necessary. He also argued that the insurances company is basically deciding the course of treatment of the complainant which actually needs to be decided only by the treating doctor. The Ld. Advocate further stated that the O.P.S relied on the exclusion clause No. 14 which is not at all relevant to the present case because in this case the patient was admitted in a nursing home and she was not treated as outpatient. And in respect of Definition of words No.12 he argued that the Insurance Company is not the authority/competent person to decide the requirement of hospitalization of the patient, necessary level of care to the patient and scope, duration and intensity of such care. He also stated that Insurance Company does not have any authority to dispute the line of treatment of the complainant.  The opposite parties company is bound by the treatment administered upon the patient by the qualified treating doctor. In this case the doctor is a registered Medical Practitioner and a Pulmonologist and intensivist.

In reply the Ld. Advocate on behalf of the opposite parties submitted that the claim is repudiated on 20.12.2016 as per records as supplied by the complainant and internal survey it revealed that the complainant could have been treated as an outpatient basis, since any treatment could be treated in O P D is excluded from the scope of coverage under the policy terms and conditions. Thus the claim is repudiated under exclusion clause NO 14 and also under definition of words NO.12 of SKP policy terms and conditions. The Ld. Advocate further stated that going through the IPD Records, it has been observed that at the time of admission there was no medical indication of immediate hospitalization as she was admitted for occasional history of chest pain, occasional shortness of breath associated with tiredness, insomnia and generalized weakness. And for first two days the patient was only managed with oral medication without any short of supportive mechanism, as required for hospitalization till the evening of 02.05.2016 and the same medication could have been given on outpatient basis. He further stated on 02.05.2016 around 10.P.M. the patient was shifted to ICU for complaint of SOB, but the nursing treatment chart submitted to the O.Ps suggest that this patient does not require intensive care for breathlessness for further stay in hospital and as per records patient developed loose motion and vomiting on 05.05.2016 but fluid therapy was not given as a primary, line of management. And there after on 06.05.2016 and on 08.05.2016 as per IPD records it revealed that there was no necessity to stay in the nursing home as the patient was gradually improved over the days without any significant complains. So, the O.Ps came to a conclusion that the patient party in collusion with the nursing home authority in view of the intentional wastage of public money trying to illegally procure the claim through the insurance policy, so there is no deficiency in service on the part of the O.Ps Company. 

We have gone through the case record annexure 1 to 9 filed to by the complainant, carefully. From annexure 1 ‘Discharge summery’ of the complainant we find that she was admitted at Nivedita Nursing Home and Policlinic, Siliguri on 01.05.2016 at 9.10 P.M. under Dr. C.P. Sharma, MD, DM (Pulmonology) with a final diagnosis i.e. acute Gastroenteritis, pharyngitis and GERD and she was discharged on 10.05.2016 from there after completion of her treatment. It is the Doctor only which entitled to say whether the patient should be treated as endor patient or and outdoor. The O.Ps did not file any expert opinion to prove that the illness of the complainant did not justify to got herself admitted in the nursing home. In the absence of any contrary evidence from the other side we must rely upon the decision of the Doctor under whom the complainant was  medically treated as in patient to the nursing home. So the treatment of the complainant does not come within the exclusion clause No. 14.

From annexure 2 and 3 we find that the complainant lodged her claim along with all relevant documents which were duly received by the O.Ps Company.

From annexure 4 ‘discrepancy letter’ dated 12.08.2016 sent to the complainant by the O.Ps we have find that the O.Ps demanded some information’s which were required in order to process the claim of the complainant from her and from annexure 5 and 6 we have find that the complainant has submitted all the required documents along with Doctors certificate to the O.Ps company. However the O.Ps Company by a letter dated 20.12.2016 (annexure 9) to the complainant  repudiated her claim on the ground under exclusion clause 14 and definition of words No. 12.

We have gone through the entire case record carefully but there is no iota of evidence on the part of the O.Ps to show or prove their plea that there was no necessity for the treatment of the complainant as IPD patient and that the patient could have been treated as OPD basis. As such we have no hesitation to say that the O.Ps miserably failed to substantiate their plea. In our opinion it is very ridiculous to say that the patient has to decide or prove that whether her treatment would be as IPD or OPD patient.

The opposite parties company repudiated the claim only to bypass their duty and responsibility towards the complainant who is a bona-fide mediclaim policy holder of the company for their wrongful gain and wrongful loss to the complainant which is gross violation and deficiency in service and also unfair trade practice on their part.

In view of the above discussions and circumstances we do hold and opine that the complainant is able to prove her case and accordingly she is entitled to get relief and the O.Ps are liable and guilty for deficiency in service and unfair trade practice.

Thus, the case succeeds.  

             Hence, it is

O R  D  E  R  E  D

That the complainant petition is allowed against the opposite parties No.1 to 3 with a litigation cost of Rs. 5000/- to be paid by the O.Ps No, 1 to 3. The complainant is also entitled to get the claim amount of rs.1,25,314/- she is also entitled to get Rs.30,000/- only towards compensation for the harassment, mental pain and agony.

The opposite parties are directed to pay jointly and / severally a sum of Rs.5,000/-+ Rs.1,25,314/- +Rs.30,000/- i.e. in total Rs.1,60,314/- by A/C payee cheque in the name of the complainant Smt. Ranjana Dhar within one month from the date of this order, failing which the entire amount shall carry interest @9% p.a. from the date of filing of this case i.e. on and from 16.11.2017 and will also deposit a sum of Rs.50 per day towards punitive charges in the Bank A/c of the Consumer State Welfare Fund, W.B. from the date of  order till realization.

            Let the original documents, if any, filed by the parties and the extra sets be returned on proper receipt

Let a plain copy of the final order be supplied to the contesting parties free of cost on ;proper acknowledgement receipt on be sent by ordinary, post in terms of Rule 5(10) of W.B.C.P. Rules, 1987. 

      (Sri S.Sarkar)                                                                (Smt. B.Choudhuri)

          President,                                                                              Member                    

DCDRF, JALPAIGURI                                                    DCDRF, JALPAIGURI