DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA :  AGARTALA

 

 

CASE   NO:   CC- 191  of  2022

 

Sri Anindita Datta,

W/O- Sri Sushobhan Sengupta,

Shyamalima Housing Complex, 

Near ILS Hospital, P.O. Kunjaban-799006, 

P.S. New Capital Complex, 

District-West Tripura. ..…...…...Complainant.

 

 

-VERSUS-

 

1. Care Health Insurance Ltd.,

Agartala Office,

  Represented by its Manager,

RMS Chowmuhani, 

GRS Tower, P.O. Agartala-799001,

P.S. West Agartala.

District- west Tripura.

 

2. Care Health Insurance Ltd.

5th Floor, 19, Chawla House, 

Hehru Palace, New Delhi- 110019. 

 

 3. ILS Hospital, Agartala. 

Capital Complex Extension,

P.O. New Secretariat – 799010, 

P.S. New Capital Complex, 

District- West Tripura,

Represented by its 

Managing Director. …..….....Opposite Parties.

 

 

 

 

 

    __________PRESENT__________

 

 SRI GOUTAM DEBNATH

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

DR (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

  WEST TRIPURA, AGARTALA.

 

SRI SAMIR GUPTA

MEMBER,

  DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA. 

 

 

C O U N S E L

 

For the Complainant : Sri Abhijit Sengupta,

  Learned Advocate. 

 

For the O.Ps : Sri Utpal Das, 

  Sri Sampad Choudhury,

  Learned Advocates.

 

 

ORDER   DELIVERED  ON:  20/02/2023.

 

F I N A L    O R D E R

1. This complainant has been lodged by Smt. Anindita Datta alleging inter alia that she along with her husband Sushobhan Sengupta purchased a Health Insurance Policy 2 years prior to her ailment. The policy was renewed from 13.03.2022 to 12.03.2023 covering the date of ailments and hospitalization of the complainant. The nature of the policy was cashless facilities. On 08.02.2022 the complainant fell ill and was admitted in ILS Hospital, Agartala with multiple episodes of vomiting with bloating sensation generalized weakness, this was the diagnosis of the hospital in fact. The complainant was discharged from the hospital on 11.02.2022 with diagnosis ''Mild Hepatosplenomegaly'' with grade -1 fatty liver changes''. 

2. On 11.02.2022, the date of discharge, the O.P. Insurance company informed the hospital authority denying payment on the ground that the complainant had been suffering from ''Acute Appendicitis'' and ''reasons for admission in the hospital of the complainant was not justified''. 

Hence, this complainant alleging deficiency in service and claiming reliefs of Rs.44,886/- that is medical expenses incurred; Rs.50,000/- as compensation for deficiency in service; interest @ 10% P.A from 11.02.2022 till the date of actual payment and Rs. 50,000/-  as cost of the proceeding. 

Initially the case proceeded exparte against the O.Ps vide order dated 12.08.2022 subsequently the exparte order was vacated vide order dated 14.09.2022.

3. In the written statement the stand taken by the O.Ps is mainly in Para- 16 that ''All the body vital are within normal range hence, she could have been easily managed on OPD basis''.

The O.Ps taken the stand of permanent exclusion clause as follows:

a) Expenses related to any admission primarily for diagnostics and evaluation purpose only are excluded 

(b) Any diagnostics expenses which are not related or not incidental to the current diagnosis and treatment are excluded.  

4. In the backdrop of divergent stands and arguments including the papers submitted mainly by the complainant, the following points emerge for discussion and decision.

(i) Whether the rejection of claim by the O.Ps fall within the ambit of exclusion clause of the policy of insurance? 

(ii) Whether the rejection of claim on the ground of'' Acute Appendicitis'' and ''Admission not justified'' are based of medical records and consequently there has been deficiency in service on the part of the O.Ps?

DECISIONS AND REASONS FOR DECISION:-

5. We have meticulously perused the medical documents, the papers of ILS Hospital, Agartala. We find that the patient was diagnosed finally as ''Acute onset vomiting'' and the course of treatment was USG W/A revealed ''mild hepatosplenomegaly''. Patient was treated conservatively low BP with proper IVF and other supportive medications under strict vital monitoring.

 

6. The O.Ps have submitted one paper addressed to the authority of ILS Hospital dated 11th February, 2022 wherein the O.Ps provisionally diagnosed the patient as ''Acute Appendicitis'' and also mentioned that ''the  admission was not justified.'' 

7. The O.Ps have not justified their stand by submitting any scrap of paper issued by the Hospital authority.

8. We have perused the terms and conditions of the policy of Insurance particularly condition no. 1.28 wherein it is specifically mentioned hospitalization means for a minimum period of 24 hours except in some cases where it can be less than 24 hours.

9. What necessarily follows from the discussion above, we find no reason for the O.Ps to take some unjustified stand and refuse payment. Meaning thereby this unnecessarily stand of the O.Ps is a huge deficiency in service and shall not encourage the people at large to take medical Insurance. Consequently both the points are decided in affirmative in favour of the complainant.

10. In the result, it is ordered that the O.Ps shall pay to the complainant the medical expenses of Rs.44,886/- with interest @ 7.5% P.A. from 11.02.2022 that is the date of discharge from the hospital till the date of actual payment. However, the O.Ps shall pay Rs.10,000/-  as compensation and litigation cost to the complainant within 30 days from today otherwise this amount of Rs.10,000/- shall also bear interest @ 7.5% P.A. from the date of filing this complaint i.e., 06.06.2022 till the date of actual payment. 

  The case stands disposed off. 

Supply a copy of this Final Order free of cost to the complainant and the Opposite party.

 

Announced.

 

 

 

SRI  GOUTAM DEBNATH

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA

 

 

 

 

DR (SMT)  BINDU  PAL

MEMBER, 

DISTRICT CONSUMER DISPUTES 

REDRESSAL COMMISSION, 

WEST TRIPURA,AGARTALA

 

SRI SAMIR  GUPTA

MEMBER,

 DISTRICT CONSUMER DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,AGARTALA.