Ld. Advocate(s)
For Complainant: Makbul Rahaman
For OP/OPs :Rajkumar Mandal
Date of filing of the case :21.08.2018
Date of Disposal of the case :21.03.2024
Final Order / Judgment dtd.21.03.2024
The basic fact of the case of the complainant is that the complainant Subhash Chandra Sarkar purchased a mediclaim policy (Varistha Mediclaim) on 29.12.2011, for the period 29.12.2011 to 28.12.2012 vide policy no.154001/48/11/8565000066 of National Insurance Company (NIC). Subsequently, it was renewed on 29.12.2012. Later it was further renewed on 29.12.2013 to 28.12.2014 and further renewed upto 28.12.2015. Again it was renewed on 29.12.2016 to 18.12.2017. The first premium on 29.12.2011. During the continuation of the said policy holder Subhash Chandra Sarkar felt chest pain and was medically treated at NH R.N. Tagore Hospital, Mukundapur, Kolkata on 24.11.2017 and discharged on 28.11.2017 and incurred medical expenses for Rs.43,766/-. Subsequently, the complainant sent the medical bill to OP No.1. But the OP NO.1 repudiated the claim on the ground stated in the petition. The said repudiation of the claim by the OP No.1 company M/S National Insurance Company Limited , Krishnagar is arbitrary and whimsically . So, the present case is filed . The cause of action for the present case arose on and from 20.12.2017 and subsequent dates till the filing of this case. The complainant prayed for an award for Rs.43,766/- together with interest @10% on and from 20.12.2017, Rs.20,000/- towards loss and damages, harassment and mental agony.
The OP No.1 contested the case denying each and every allegation by filing W/V on the ground that the present case is not maintainable and barred by special law of limitation. The positive defence case of the OP No.1 is that the complainant purchased Varistha Mediclaim Policy for the period 29.12.2016 to 28.12.2017 subject to terms and conditions. The complainant filed a claim to the OP No.1 National Insurance Company (NIC) Limited for the aforesaid bills. There is a provision in the policy in clause 4.15 for hospitalisation for the purpose of diagnosis and evaluation. The OP No.1 National Insurance Company (NIC) repudiated the claim on the ground that the expenses incurred at hospital is primarily diagnostic and X-ray and laboratory examination or other diagnostic studies which are not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any element of sickness or injury for which confinement is required at a hospital. The said claim is against the conditions of the policy. There was no deficiency in service by the OP. The OP No.1 National Insurance Company claimed that the case is liable to be dismissed with cost.
The respective pleadings of the parties and the question involved in the case demand for ascertainment of the following points for consideration.
Points for Determination
Point No.1.
Whether the present case is maintainable in its present form and prayer.
Point No.2.
Whether the complainant is entitled to get the relief as prayed for.
Point No.3.
To what other relief if any the complainant is entitled to get.
Decision with Reasons
Point No.1.
This point relates to ascertainment of maintainability of the case. The OP raised one question that the present complaint is barred by special law of limitation.
The complainant seems to have stated in the complaint that the cause of action for the present case arose on and from 20.12.2017 which is the date of repudiation of the claim by the OP. The Ld. Senior Advocate for the OP in course of argument could not specify any particular provisions of law of limitation as to why this barred. The OP No.1 only resorted to clause 4.15 of the policy which means for hospitalisation for the purpose of diagnosis and evaluation.
The present case is filed on 21.08.2018. The cause of action claimed to have arisen on 20.12.2017. So, the present case is filed within the statutory limitation period under the C.P. Act. The opposite party could not make out sufficient ground regarding objection as to the maintainability of the case or that it is barred by limitation.
Accordingly, point no.1 is decided positively with the finding that the case is not barred by limitation.
Point No.2&3.
Both the points are taken up together since these are closely interlinked with each other.
The complainant Subhash Chandra Sarkar in order to substantiate the case adduced evidence in the form of affidavit in chief and documentary evidence.
The complainant took the following documents in course of trial of this case.
Annexure-1 is the Insurance Policy in the name of Tapas Kumar Sarkar under National Insurance Company (NIC) benefit policy no. 154001/48/11/8565000066.
Annexure-2 is the 2nd policy certificate of 2012-2013.
Annexure-3 is the third policy certificate with OP NO.1 for 2013-2014.
Annexure-4 is the policy certificate with OP No.1 for the period 2014-2015.
Annexure-5 is the another policy certificate with OP No.1 for the period 2015-2016.
Annexure-6 is the policy certificate for the period 2016-2017.
Annexure-7 is the copy of prescription of Dr. J. K. Roy, Surgeon J.N.M Hospital, Kalyani.
Annexure-8 is the copy of discharge and the summary of N.H R.N. Tagore Hospital.
Annexure-9 is the copy of bill of N.H R.N. Tagore Hospital.
Annexure-10 is the repudiation letter issued by N.I.C OP No.1 dated 20.12.2017.
After perusing all the documents and evidence in the case record it transpires that the complainant categorically stated in pleading and evidence that he purchased Varistha Mediclaim policy bearing no. 154001/48/11/8565000066 which was renewed time to time. There is no denial that the said policy stands in the name of the complainant which was renewed regularly.
The documents further reveal that the complainant was medically treated at N.H R.N. Tagore Hospital and incurred medical expenses for a sum of Rs.43,766/-. Annexure-7 and annexure-8 have closed relation with each other in as much as the complainant was initially medically treated by Dr. J.K. Roy finding chest pain. The said Dr. J.K. Roy is a heart specialist and cardiologist. In the said medical prescription Dr. J.K. Roy referred the patient to R.N. Tagore Hospital. Thereafter, he was again medically treated and subsequently, he was admitted to R.N Tagore Hospital, Kolkata on 24.11.2017. The doctor in the said hospital as per annexure-8 diagnosed for chronic obstructive pulmonary disease. The patient was admitted with shortness of breath on exertion urinary incontinence .
So, the medical report of R. N Tagore Hospital disclosed of about particular disease for which he was admitted and after 4 days he was discharged with advice for rest for two weeks.
Ld. Senior Advocate for the OP repeatedly argued that there was no sufficient ground for his admission and there is no specific disease for which the complainant can claim the medical benefit.
The OP claimed that the patient was admitted for clinical examination and Ld. Senior Defence Counsel argued that the complainant is not entitled to get the claim as he was admitted for clinical examination.
Ld. Advocate for the complainant counter argued that he was admitted on the basis of the advice of a cardiologist. The main point of defence taken by the OP is that as per clause 4.15 the complainant is not entitled to get the claim. Although, the OP did not file the original policy conditions containing clause 4.15. However, as per said clause 4.15, hospitalisations for the purpose of diagnosis and evaluation . The documents filed by the complainant clearly proved that the complainant was admitted. The doctor of R.N. Tagore Hospital diagnosed as shortness of breath of the complainant. So, the clause 4.15 does not refrain the complainant to raise the mediclaim for the purpose of his treatment. The opposite party cross-examined the complainant question no.3 and 4 could not discard the specific evidence of the complainant. Question no.1 relates to terms and conditions of the policy against which the complainant answered ‘yes’.
The complainant in cross-examination denied that the admission and hospitalisation were done only for observation, investigation and evaluation. So denial in cross-examination has a special effect and as such the defence claim under 4.15 could not be established.
The complainant also answered in cross-examination in question no.6 and 7 that the repudiation was not fair and proper and it was illegally and wrongly repudiated. The complainant also cross-examined OP NO.1 wherein the OP No.1 answered in most of the questions that the claim was repudiated on the basis of clause 4.15. It is evident from the documents proved by the complainant especially annexure-7 and 8 that the complainant being 70 years old hypertension patient was admitted with history of shortness of single breath on exertion and urinary incontinence. Different doctors examined the patient at R.N. Tagore Hospital and thereafter, the patient was discharged after 4 days. They advised for rest for two weeks.
Ld. Senior Defence Counsel also questioned as to what documents the complainant proved for his treatment.
Annexure-7, 8 and 9 are very relevant documents to prove the claim of the complainant. The OP could not discard those specific documentary evidence of the complainant.
So, having assessed the entire evidence of the complainant on the basis of the pleadings of the parties clearly justified the claim of the complainant. The said documentary evidence are sufficient to discard the defence case and the improper repudiation of the claim of the complainant.
In the backdrop of the aforesaid assessment of evidence and observation made hereinabove the Commission comes to the finding that the complainant successfully proved the case. The OP improperly repudiated the claim of the complainant. The said demeanour on the part of the OPs tantamounts to deficiency in service which should be compensated in terms of money.
Accordingly, the Point no.2 & 3 are answered in affirmative and decided in favour of the complainant.
In the result complaint case succeeds on contest with cost.
Hence,
It is
Ordered
that the complaint case no.CC/138/2018 be and the same is allowed on contest against OP No.1 and ex-parte against OP No.2 with cost of Rs.4,000/- (Rupees four thousand). The complainant Subhash Chandra Sarkar do get an award for a sum of Rs.43,766/- (Rupees forty three thousand seven hundred sixty six) together with interest @10% p.a from the date of claim against the OP No.1, Rs.10,000/- (Rupees ten thousand) towards deficiency in service, harassment and mental agony and Rs.4,000/- (Rupees four thousand) towards litigation cost. The OPs are jointly and severally liable for payment of the said award money. The OPs are directed to pay Rs.57,766/- (Rupees fifty seven thousand seven hundred sixty six) to the complainant within 30 days from the date of passing the final order failing which the entire award money shall carry an interest @8% p.a from the date of passing the final order till the date of its realisation.
All Interim Applications (I.A) stand disposed of accordingly.
D.A to note in the trial register.
The case is accordingly disposed of.
Let a copy of this final order be supplied to both the parties at free of costs.
Dictated & corrected by me
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PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,) ................ ..........................................
PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,)
I concur,
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MEMBER
(NIROD BARAN ROY CHOWDHURY)
