This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted he is the beneficiary of the Group Mediclaim Insurance Policy named as ‘Health and Wellness’ being No.OG-13-2401-8403-00000006 valid up to 31-03-2013 and that policy was practically purchased by their employer United Bank, Head Office and complainant was in the service and even after retirement, the said policy continued to be in-operation as per the terms and condition executed in between the ex-employer and the OP and complainant was provided his insurance policy by the OP through the said bank during the service period of the complainant.

          Complainant has further submitted that he went to his sister’s house at Siliguri where he fell ill and was examined by Dr. Sankha Sen, Siliguri examined the complainant was advised to take medicines to stop flow of bleeding and also advised for hospitalization considering seriousness of his sickness.  Thereafter, complainant returned to Kolkata and consulted the local doctor, Dr. K. M. Das(M.D.) as complainant was again fell ill on 19-11-2012 and as per advice of the doctor ultimately he was admitted to CMRI on 21-011-2011 wherefrom he was discharge on 27-11-2012 after treatment.

          During treatment period in the said hospital complainant incurred a total expenditure of Rs.29,407/- including cost of medicine, doctor’s fees, clinical test etc. and complainant submitted bill for reimbursement along with claim form to the OP on 11-12-2012 but OP repudiated the claim on the ground that the treatment was conservative in nature and at the same time the diagnostic matters ought to have been made without admission and practically the discharge certificate reveals that no treatment was made but only different types of tests were done and admittedly there is a history of chain smoking by the complainant and for which his lung were found affected for which it was bleeding from his nose and showing clauses of the contract the claim was repudiated but complainant has alleged that such sort of observation of the OP is completely against any medical opinion because complainant was admitted with a history of oozing blood from nostrils.  So, invariably there was sufficient ground for his admission and as per doctor advice he was admitted and what would be procedure of the treatment that is up to the doctor not upon the complainant so the entire repudiation is illegal and invalid and for which complainant is entitled to disbursement of the entire mediclaim amount.

          On the other hand, OP simply have submitted that the discharge certificate treatment was conservative in nature then as per Clause in respect of conservative treatment no bill can be reimbursed and there is no question of deficiency and apparently the admission was related only different tests during five days.  So, complainant was admitted only for different type of tests and check up and not for any treatment and at the same time his discharge certificate reveals no treatment was started during that period for which the treatment was conservative in nature and for which they repudiated the claim.  In the above circumstances there is no deficiency on the part of the OP for which it shall be dismissed.

Decision with Reasons

On careful study of the complaint and also the written version including the discharge certificate as submitted by the complainant in respect of his treatment at the CMRI we have gathered that no doubt during 5 day’s stay at CMRI practically different type of investigations, tests were done but practically no treatment was started because after considering discharge certificate it appears that the patient was admitted only for the purpose of health checking for which there is no scope for any treatment because no positive disease was detected but ultimately the doctor diagnosed that the blood was oozing from the nostril due to his continuous smoking habit and for which the lung has been affected and doctor advised him nothing but to stop smoking and as because he is a  patient of hyper-tension some preventive drugs to lower down the degree of hyper-tension was given and the medicine as prescribed after discharge was all general medicine which are generally used for the person who are suffering from hyper-tension and who are chain smoker and if we justify the medical report then we can say that this admission was made by the doctor only to give a relief to the medical policy holder and if for any other reason complainant used to all test and x-ray etc. in that case chance of getting medical claim benefit shall be nowhere for which it has become a common practice of medical policy holder to pray to doctor for admission on the ground otherwise he shall not get any benefit.  We have no doubt covered that type of instance.

          But fact remains blood was oozing from his nose that was caused for admission then invariably a person aged about 63 must be admitted to hospital to ascertain for what reason blood has been oozing from the nostril continuously and in that case detection is highly required and it may be due to high blood pressure or due to different type of infection within the nostril or trachea in case of a chain smoker and generally such sort of infection caused the nostril covering throat and other parts and which is also sometime up to lung and in this case same instance happened and after thorough inspection and investigation it was found.  So, the admission was done rightly but considering the entire fact it is clear that he was treated by doctor not by himself if any doctor opines or advices any patient to be admitted at once then it is not the choice of the patient to be admitted but he must have to take admission as per advice of the doctor because doctor knows how and what manner a patient shall be treated.  Anyhow that factor has not been considered by the OP and the OPs are always bound by the terms and condition of the policy and may be there are some technicalities for which in all the mediclaim cases it may not be possible for the mediclaim holder to place before the authority all the documents and materials as per requirement of the policy condition but it is principle of law that technicalities shall be avoided when the mediclaim policies are for social protection.

          So, considering all the above facts and also considering the bill including policy conditions we find that the complainant submitted a bill of Rs.29,460/- but after considering the details of the bill and heads of account, pharmacy charges, doctor charges, service charges and x-ray and other testing chares(pathology) and also the bed charges we have gathered that as per terms and condition of the policy complainant shall have to get 25% of the total doctor charges, 50% of the pharmacy charges and 50% of the pathology tests and x-ray charges but anyhow no service charges can be granted as per terms.  So, considering that fact it is clear that after assessment the complainant is entitled to only Rs.15,000/- and no doubt we are releasing as final settlement of the claim considering the social aspect and taking a social approach when he has paid some premium in the group mediclaim policy through his employer but anyhow the complainant is entitled to any compensation in view of the fact his discharge summary is somehow or otherwise against the complainant.  But even then considering the certain cause of admission for determination and detection of the cause by bleeding from nose he was admitted and several tests were done and rightly it was diagnosed that it was bleeding from the nostril due to some ulcereous cause and for which soframycin is being used daily within nostril and that was caused due to chain smoking habit of the complainant and complainant was asked to stop smoking and it is also proved that he had his blood pressure so he was admitted and so he was advised to take medicine in his nostril and other doses to come down the degree of the hyper-tension.  

In the light of the above observation we are convinced to hold that ground for rejection was there for terms and conditions as applied but mediclaim policy are generally purchased for the purpose of getting some relief if the relief is not granted then what is the necessity to purchase mediclaim policy.

In the result, the case succeeds.

Hence,

Ordered

That the case be and the same is allowed on contest but without any cost against the OP.

          OP is directed to release and pay a sum of Rs.15,000/- treating his claim as finally settled and the repudiation if any is made that is treated as invalid and the payment shall be made within one month from the date of this order by the OP by issuing such cheque and without any harassment and if OP fails to comply the order within the stipulated time in that case the OP shall have to pay punitive damages of @Rs.300/- per day till full satisfaction of the decree and if reluctant attitude of the OP is also found in that case penal proceeding u/s.27 of the C.P. Act shall be started against them and for which they shall be penalized further.