Complainant Md Hamiduzzaman by filing this complaint has submitted that he is an employee of Danial India Ltd. and his office entered into an Insurance contract on behalf of the employees with the op partly Viz. Bazaz Allianz General Insurance Co. Ltd. and the said office issued health and wellness card in the name of the complainant being the ID Card No. DNL-14-231 with the validity till 30.06.2014 with the eligibility of cashless and reimbursement. Thus the complainant is the beneficiary of the policy. So, the complainant is entitled to get the reimbursement value. In the month of November, 2013 the complainant had abdominal pain and lower back pain and was admitted to C.M.R.I. Hospital on 14.11.2013. After treatment, the complainant was discharged from the hospital on 20.11.2014. Thus the complainant incurred total expenditure of Rs. 58,107/- and op is liable to disburse the amount in terms of insurance agreement.
After receiving the prayer for reimbursement of treatment, the op has repudiated the claim of the complainant stating that all charges are inconsistent. The office of the Consumer Affairs Department, West Bengal failed to solve the problem of the complainant. The ground to repudiate the claim is against the term of the insurance and the claim is whimsical and arbitrary.
The complainant prays for the amount of medical exparte, i.e. Rs. 58,107/- being the claim amount along with interest at the rate 9 percentp.a. from 10.12.2013 till realization of the amount. He also prays for a compensation of Rs. 50,000/- for suffering mental agony, harassment, negligence, deficiency of service and unfair trade practice. The complainant also prays for litigation cost of Rs. 10,000/-.
In the written version, the op states that the present dispute is outside the purview of C.P. Act, 1986. The present case is defective, incomplete. The case is not maintainable in the eye of law, so it should be rejected. The complainant has not made Danial India Pvt. Ltd. op in this case but they are necessary party. The op had one tie up policy of insurance with the employee of the complainant. By virtue of the said policy of insurance, the employees of that company are covered by virtue of a group health insurance policy. Being an employee of the company, the complainant is covered by virtue of group insurance policy. Such policy is subject to certain terms and condition as incorporated in the master policy of insurance.
It is an admitted fact that the complainant was admitted to CMRI Hospital from 14.11.2013 to 20.11.2013, but the complainant was admitted at that point of time for diagnosis, x-ray and laboratory examinations and such admission was not consistent with the diagnosis or treatment of the positive existence or presence of any ailment, sickness or injury for which admission was required at that point of time. Policy condition No. 4.10 explains that expenses incurred for as such the complainant could neither be provided with cashless claim facility nor his claim by the complainant was repudiated and the same was intimated to him on 10.12.2013. So, there is condition of the insurance policy, there is no liability of the op to pay to the complainant in respect of expenses incurred by him. As such op prays to the Ld. Forum to dismiss the instant case and direct the complainant to pay cost for causing harassment to the op.
Decision with reasons
On comparative study of the entire complaint including written version and particularly the argument as advanced by the Ld. Lawyers of both the parties, we have gathered that practically the complainant was aggrieved by the repudiation made by Bajaj Allianz op on 10.12.2013 on the ground that there was no such terms administration or any instant procedure being performed which supports the needs for hospitalization and as per defence the conservative treatment was done after hospitalization which was not required and it is specifically mentioned on final diagnosis that complainant suffered from Hypothyroidism, Hyperuricaemia, Dysllpidaemia, Obesity and Osteoarthritis.
Fact remains that the chief complaint of the complainant at the time of admission was low back pain after coughing for five years and also complainant with pain left lower abdomen known patient of Hypothyroidism, Hyperuricaemia and an important note is that there was a past history of Hypothyroidism, Hyperuricaemia, Dysllpidaemia, Obesity and Osteoarthritis.
Fact remains that she was admitted to Calcutta Medical Research Institute (CMRI) on 14.11.2013 and discharged on 20.11.2013. Only investigation was done. But practically complainant was asked to consult with his orthopedic surgeon for bi-lateral knee pain and for inguinal pain etc.
Considering the discharge certificate it is clear that complainant has been suffering from Hypothyroidism, Hyperuricaemia, Dysllpidaemia, Obesity and Osteoarthritis for which he was admitted to the Hospital from 14.11.2013 to 20.11.2013. But practically no factual treatment was made but only several clinical examinations were made. So, as per medical certificate, it is clear that during such treatment days he was given only oral pregabalin, oral Rejunex, IV Viteurin, physiotherapy and other conservative measures. Practically there was no medicine and on discharge he was advised to take some general tablets. From the final bill, it is clear that the physiotherapy, MRI, x-ray and such oral ointment etc. were used and some vitamin, injections were given and final bill was to the extent of Rs. 48,000/- and odd.
So, apparently considering the entire discharge certificate, it is clear that he was suffering from several type of diseases prior to purchase of those policies and in fact he has been suffering from pain in his both knees and other pain for inguinal pain and he was suffering for 5 years and that was not disclosed in time at the time of purchasing the said policy. So it is evident that complainant suppressed many things at the time of purchasing the said policy and he had his existing disease no doubt. Now the question is whether the said treatment can be made outside the hospital. After considering the entire materials, it is found that there was no need to admit to the hospital and such sort of treatment can be made invariably after making x-ray, MRI outside hospital and it can be treated by any general doctor and truth is that during the stay no doctor specialist ortho or surgeon examined him or treated him and from the report, it is clear that it is completely a conservative treatment but it should be kept in our mind that during his stay in the hospital from 14.11.2013 to 20.11.2013 there was no question of any complaint of heart pain etc. Considering that fact it is clear that all those treatments were related to conservative treatment and that is admitted by the hospital authority.
As per terms and conditions of the Mediclaim policy it is fact that pre-existing disease covered by the said policy. But fact remains that such sort of treatment can be made conservatively placing him in his house. But he availed of nursing home or the private hospital CMRI no doubt it is not the fault of the complainant. But as per advice of the doctor, he was admitted and doctor after diagnosis found that he has been suffering from pre-existing disease for which only directed the complainant for contacting orthopedic surgeon and other surgeon. Anyhow such a treatment can be made conservatively and doctor has also opined that doctor at hospital gave conservative treatment.
So, considering that fact and also considering the terms and conditions of the policy, complainant is not entitled to get such relief as same comes under the purview of the Exclusion Clause 4.1.4. Truth is that parties are strictly governed by the policy condition and no exception and relaxation can be made on the ground of equity as already observed by National Commission reported in 2013 4 (CPR) 165. So, we are convinced that defence of the ops is otherwise as per contract and relying upon the entire medical certificate, discharging certificate etc., op repudiated the claim. In this particular case we have gathered that the complainant as his own was not admitted. So, for the fault of the doctor or continuing the business by the op hospital authority complainant cannot be deprived from getting such benefit what he is entitled to as per contract for conservative treatment also and if conservative treatment would be made, in that case invariably MRI, X-ray and for purchasing other medicines, he was entitled to get some fund. But only for admission in the hospital as per advice of the doctor, he is not getting the same.
But truth is that the medical certificate proves that it is completely conservative treatment. So, considering that fact deducting all other amounts and after calculation, we find that at least complainant is entitled to Rs. 20,000/- for his conservative treatment and for X-ray, MRI and for doctor’s visit etc and taking into the above fact into consideration as per contract we feel that it would be just and proper and for the end of justice, necessary order should be passed directing the op to pay a sum of Rs. 20,000/- as final settlement of the claim treating that repudiation as cancelled and it shall be paid by the op within one month from the date of this order and accordingly dispute is decided finally along with cost.
Thus the complaint succeeds in part.
Hence, it is
ORDERED
That the complaint be and the same is allowed on contest in part with a cost of Rs. 2,000/- against the op.
Op is hereby directed to pay a sum of Rs. 20,000/- as compensation-cum-final settlement account of the deposited medicalim treating the repudiation as cancelled and op is hereby directed to pay the same along with litigation cost that is total Rs. 22,000/- top the complainant within one month from the date of this order failing which op shall have to pay punitive damages at the rate Rs. 100/- per day till full satisfaction of the decree and if punitive damage is collected, it shall be deposited to this Forum.
Op is also directed to comply the order very strictly and for disobeyance of the Forum’s order, the penal action shall be started against them and for which they shall be paid further penalty and fine.
