DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
MUCHIPARA, BURDWAN.
Consumer Complaint No 132 of 2014
Date of filing: 24.7.2014 Date of disposal: 30.6.2015
Complainant: Uday Chand Mukherjee, S/o. Late Shib Shankar Mukherjee, resident of Chotonilpur, Jorapukur East, Post Office: Sripally, Police Station & District: Burdwan, PIN – 713 103, W.B.
-V E R S U S-
Opposite Party: 1. The Oriental Insurance Company Limited, having its Registered Office at: A-25/27, Asaf Ali Road, New Delhi, PIN – 110 002, service through its Chairman.
2. The Oriental Insurance Company Limited, having its Branch Office at: B.C.A. Building, Court Compound, PO, PS. & District: Burdwan, PIN – 713 101, service through its Branch Manager.
3. Medi Assist India Pvt. Ltd., having its office at 53A, Rafi Ahmed Kidwai Road, Opposite of Hotel Gulshan (near Rippon Street), Kolkata – 700 016. Service through its Manager.
Present: Hon’ble President: Sri Asoke Kumar Mandal
Hon’ble Member: Smt. Silpi Majumder
Appeared for the Complainant: Ld. Advocate, Subrata Mukherjee.
Appeared for the Opposite Party No. 1 & 2: Ld. Advocate, Saurabh Dey.
Appeared for the Opposite Party No. 3: None.
J U D G E M E N T
This complaint is filed by the Complainant u/S. 12 of the Consumer Protection Act, 1986, alleging deficiency in service as well as unfair trade practice against the OPs as the OPs did not decide the insurance claim in respect of the insurance policy till filing of this complaint.
The brief fact of the case of the Complainant is that the Complainant and his daughter were insured under a mediclaim policy, obtained on 23.7.2013 from the OP-2 for the period from 05.8.2012 to midnight 04.8.2014. The Complainant paid due premium of Rs.3, 320=00 in connection of the said policy to the OP-1. During validity of the policy the daughter of the Complainant became seriously ill on 26.12.2013 and without any delay the Complainant brought her daughter to Dr. A.K. Dey, an Ex-RMO of BMCH on 26.12.2013, who after thorough checking advised for blood test of her daughter as early as possible. The Complainant brought the report of the blood test to the doctor on 27.12.2013 and after observing the same advised for urgent admission in any Hospital or Nursing Home. Immediately the Complainant went at the Apollo Hospital, Chennai on 27.12.2013 and admitted her daughter at the said Hospital on 28.12.2013 for medical treatment. The doctors of the said Hospital treated the patient and diagnosed that the daughter of the Complainant was suffering from ‘Idiopathic Thrombocytopenic Purpura’. The Complainant had to incur the entire treatment cost from his own pocket. During admission of her daughter the Complainant intimated the fact to the OP-3 on 29.12.2013 and requested them to take necessary action over the matter as early as possible and forwarded the copy of the intimation letter to the OP-2. After getting discharge from the Hospital on 02.01.2014 the Complainant lodged mediclaim before the OPs after observing all formalities on 10.01.2014 and requested the OPs to settle the claim as early as possible. The Complainant sent a letter to the OP-2 on 15.01.2014 requesting to settle the claim of the medical expenses towards the treatment of her daughter against the policy, but the OPs have neither made any response nor settled the claim till filing of this complaint, which according to the Complainant is an example of deficiency in service as well as unfair trade practice on the parts of the OPs. Thereafter one reminder was issued by the Complainant on 17.02.2014, but to effect. On 24.02.2014 the Complainant again sent a letter to the OP-3 along with a medical certificate issued by Dr. A.K.De dated 21.02.2014 and a cancelled blank cheque as per their requirement and further requested to settle the claim, but no result had been yielded. Therefore finding no other alternative the Complainant has filed this complaint before the Ld. Forum praying for direction upon the OPs to make payment to him a sum of Rs.61,219/- towards medical expenses incurred by him for her insured daughter, Rs.25,000/- as compensation due to mental pain, agony and harassment and litigation cost of Rs.10,000=00.
The petition of complaint has been contested by the OP-1 and 2 by filing conjoint written version wherein it is stated that the Complainant obtained an insurance policy from them in which he and his daughter were under coverage. The policy was issued subject to some conditions, clauses, warranties and endorsements. It was mentioned in the said policy that payment shall be made for Hospitalization Expenses for Medical/Surgical Treatment at any Nursing Home/Hospital in India as an In-Patient as defined in the policy. It is specifically stated in the policy that ‘We at Oriental continuously strive to ensure that you get the best possible treatment from our Network Hospitals. Please contact your TPA or any of the Oriental Officials for our preferred Hospitals in your area before going for a treatment. This will help us to serve you in the best possible manner.’ The OPs have stated that the OP-3 is authorized to offer service for the mediclaim policy issued to the issued and his beneficiary and the Op-3 is an IRDA licensed TPA of Health Insurance Policies. For the purpose of claim settlement the bills and other related documents should be directly sent to any of the opted centre of Medi Assist and in the instant case the OP-3 is the Medi Assist. The Complainant had filed the claim form before the OP-3 along with relevant papers and documents regarding the treatment of her daughter at Apollo Hospital, Chennai for getting the reimbursement the treatment cost incurred by him. The Complainant submitted bill for Rs.61, 219=00, incurred by him at the Apollo Hospital for the period from 28.12.2013 to 02.01.2014. The insured, Sagari Mukherjee was diagnosed as Idiopathic Thrombo Cytopenic Purpura. The OP-3 had duly received the claim form and on scrutiny of the documents submitted by the policy holder required the following documents/information for further processing the claim and the OP-3 requested the policy holder to submit the following documents-
. Delay Condonation letter by Insurance Company.
. Cancelled cheque/Bank details with IFSC Code.
. Duration of Purpura certified by treating doctor.
. Reason of delay submission by the insured.
The OP-3 had assured vide its letter dated 25.01.2014 to the Complainant that on receipt of the above stated information/documents, the claim shall be processed expeditiously and also informed that the abovementioned documents are required for processing the claim and the same to be furnished within 10 days from the date of receipt of the letter dated 25.01.2014. Therefore it was the responsibility of the Complainant to send down the required documents to the OP-3 for settlement of his claim, but the OP-3 did not receive those vital information i.e. Duration of Purpura certified by the treating doctor. Though the certificate of Dr. A.K.De being the first consultation doctor dated 21.02.2014was submitted by the Complainant, but the said certificate did not disclose the history of the ailment of Sagari Mukherjee i.e. from what period to what period she was suffering from Purpura. During processing of the claim the OP-3 noticed the absence of the said document. It is very much essential to know the duration of the said ailment from which his daughter was suffering from. Inspite of repeated reminders for providing the said necessary and vital document, the Complainant had failed to comply with the same. For this reason his claim remained as unprocessed and ultimately closed. If the Complainant will submit the said document, the OP-2 will decide the claim on merit as per terms and conditions of the policy. Due to failure to submit the required document by the Complainant, the OPs cannot be held liable for making payment of any amount towards compensation, as there was no deficiency in service and unfair trade practice on their parts. As the claim of the Complainant as prayed for is not tenable and misconceived, prayers have been made by the OP-1 and 2 for dismissal of the complaint with cost.
Inspite of receipt of valid notice from this Ld. Forum the OP-3 did not turn to contest the complaint either orally or by filing written version, so we took up the hearing of this complaint ex parte against the OP-3.
The Complainant has filed evidence on affidavit along with several documents in favour of his contention. The Op-1 and 2 have filed written notes of arguments alon with a Xerox copy of the definition of the ailment from which the daughter of the Complainant was suffering from and those OPs have filed some papers and documents in support of their argument.
We have carefully peruse the entire record, documents filed by the contesting parties and heard arguments as advanced by the Ld. Counsel for the Complainant and the OP-1 and 2 at length. It is seen by us there are some admitted facts in the case in hand i.e. the Complainant obtained one medi-claim insurance policy from the Insurance Company on 23.07.2013, the Complainant and his daughter Sagari Mukherjee were under the coverage of the said policy, the same was valid for the period from 05.08.2013 to 04.08.2014, due premium amount of Rs.3,320/- was paid, within the validity of the said policy the daughter of the Complainant being an insured became seriously ill on 26.12.2013, met with the Dr. A.K. De on 26.12.2013, advise was given for blood test, blood report was perused by Dr. A.K. De on 27.12.2013, advise was given by the doctor for getting admission on urgent basis at any Hospital or Nursing Home, without any delay Sagari Mukherjee got admission at the Apollo Hospital, Chennai on 28.12.2013, doctors of the said hospital diagnosed her ailment as Idiopathic Thrombo Cytopenic Purpura, The complaint had incurred medical expenses to the tune of Rs.61, 219=00 from his own pocket, after admission at the said hospital the OP-3 was intimated by the Complainant on 29.12.2013, same intimation was given to the OP-2 on the same day, the daughter got discharge from the hospital on 02.01.2014, the Complainant lodged the claim form along with relevant papers and documents with the OP-3 on 10.01.2014, several letters and reminders dated 15.01.2014 and 17.02.2014 was issued by the Complainant to the OP-3 requesting for settlement of the claim, no fruitful result yielded till filing of this complaint, on 25.01.2014 the OP-3 by issuing a letter had sought for some documents, the Complainant had tried his best to comply with the said direction and sent a letter to the OP-3 on 24.02.2014 along with the medical certificate issued by Dr.A.K. De dated 21.02.2014 and a cancelled blank cheque. The allegation of the Complainant is that till filing of this complaint the OPs did not bother to settle the claim inspite of compliance with the direction of the OP-3. According to the Complainant such inaction is an example of deficiency in service and unfair trade practice on behalf of the OPs and this complaint has been initiated by him praying for certain relief along with reimbursement of the medical expenses as incurred by him. The contention of the OP-1 and 2 is that as the Complainant had failed to comply with the direction of the Op-3 to the extent the duration of Purpura certified by the treating doctor, the claim could not be processed and it is further submitted that they are ready to decide the claim subject to getting of the said document and in view of the terms and the conditions of the policy.
Now we are to adjudicate as to whether the documents and papers submitted by the Complainant relation to the treatment of her daughter was insufficient and improper or not and whether the Complainant had failed to comply with the direction of the OP-3 or not.
It is noticed by us that on 26.12.2013 the Complainant visited Dr. A.K. De due to illness of his daughter and in the prescription dated 26.12.2013 it was written on its left side as ‘Redish black….’and the patient Sagari Mukherjee was advised for blood test. Accordingly blood test done and upon perusal of the test report the patient was advised for getting admission at any medical center on urgent basis. The patient got admission at the Apollo Hospital. Chennai where treatment was given, several tests/repeated tests done and she got discharge on 02.01.2014. The treating doctors of the Apollo Hospital diagnosed her illness as Idiopathic Thrombocytopenic Purpura. Under the heading of the chief complaints of the discharge summary it is written that ‘this 24 year old lady, with no known comorbities, presented with complaints of rashes over the lips, oral mucosa and over the upper limbs since 3 days. She evaluated elsewhere and found to have severe thrombocytopenia, came here for further management. No history of fever, previous allergies, epistaxis or bloody stools’. Advices were given by the doctors at the time of discharge and during discharge the patient was declared as stable Haemodynamically. Admittedly after lodgment of the claim form along with relevant medical papers of the patient the OP-3 had sought for a document mentioning duration of Purpura certified by treating doctor i.e. from what period to what period the patient Sagari Mukherjee was suffering such ailment. In response to the letter dated 25.01.2014 the Complainant send down a certificate from Dr. A.K.De, who treated the patient at first on 26.12.2013. In the said certificate it is written by Dr. De as follows—
‘This is to certify that Sagari Mukherjee, aged 23 years (+), was clinically examined by me on 26.12.2013, who presented with Purpuric spots on her body and was advised blood examination, which revealed severe Thrombocytopania (Platelet count 15000/cu) and diagnosed as a case of Idiopathic thrombocytopenic Purpura, for which she was advised urgent admission in Hospital or Nursing Home on 27.12.2013.’
It is seen by us on 26.12.2013 when the patient visited Dr. De for the first time the doctor suspected the said disease because without perusing the blood report it was no possible for him to come to affirm conclusion that the patient Sagari Mukherjee was suffering from the said ailment. As the certificate of Dr. De did not satisfy the OP-3 the claim of the Complainant has not been decided till of this complaint. Being dissatisfied with the certificate of Dr. De, the OP-3 had further intimated the Complainant to provide the certificate stating the duration of Purpura, but as the Complainant did not possess any more certificate except the earlier one, he did not bother to response of the said intimation and being aggrieved and dissatisfied with such action of the OPs this complaint is initiated by the Complainant. During argument the Ld. Counsel for the OP-1 and 2 has submitted that until and unless the required document is placed by the Complainant, the claim cannot be processed and till they are agree to decide the claim subject to provide the said document along with terms and conditions of the policy. It is further submitted by the Ld. Counsel for the OP-1 and 2 as the instant claim is earlier one, the said document is necessary as the Complainant and his daughter obtained the mediclaim policy only on 05.08.2013 and fell ill on 26.12.2013. We have noticed that this policy is not a new one as there is mentioning of the number of the previous policy in the instant policy certificate. Therefore in our view this policy cannot be termed as a new policy, it is continuing one. The Insurance Company wants to know from what period the patient was suffering from. In this respect we are to say that as the patient for the first time visited Dr. De for her ailment on 26.12.2013, therefore it can safely be said on and from 26.12.2013 she was suffering from such ailment. Moreover in the discharge certificate it is also written that she was suffering from such disease for three days prior to coming at the Apollo Hospital. So in our view there is no such ambiguity in the certificate of Dr. De as well as the discharge certificate of the Apollo Hospital for coming to the conclusion as to from what period the patient was suffering from. During hearing the Ld. Counsel for the OP-1 and 2 has stated by filing the Xerox copy of the definition of the disease from which the patient was suffering from. It is written therein that ‘Idiopathic thrombocytopenic purpura (ITP), also known as primary immune thrombocytopenia, primary immune thrombocytopenic purpura or autoimmune thrombocytopenic purpura, is defined as isolated low platelet count (thrombocytopenia) with normal bone marrow and the absence of other causes of thrombocytopenia. It causes a characteristic purpuric rash and an increased tendency to bleed. Two distinct clinical syndromes manifest as an acute condition in children and a chronic condition in adults. The acute from often follows an infection and has a spontaneous resolution within 2 months. Chronic idiopathic thrombocytopenic purpura persist longer than 6 months with a specific cause being unknown.’
Ld. Counsel for the OP-1 and 2 has put emphasis on the words ‘Chronic’ and ‘Adult’. According to the OPs as the patient is an adult one, the said disease certainly was chronic and the same was persisted longer than six months. But the certificate of the concerned doctor does not reveal the period; claim could not be processed and decided. In respect of such argument we are to say that whether the disease was persisted in her body, that is not so important, it is more important that when she got knowledge about existence of such disease or ailment. The documentary evidence proves that on 26.12.2013 the Complainant and his daughter got knowledge about the existence of the disease from which she was suffering from. Therefore we have no doubt that 26.12.2013 is the date of her knowledge.
Upon considering the papers and documents and hearing the submission we are of the opinion that the OPs have unnecessarily harassed the Complainant for a prolonged period without deciding the claim. Being dissatisfied with such action the Complainant had to rush before the court of Law for redressal of his genuine grievance and incurred some expenditure. For this reason in our view the Complainant is entitled to get compensation and litigation cost from the OP-1 and 2. As per IRDA guideline every claim should be decided within one month from the date of receipt of the claim form along with relevant document. In the instant case claim form was lodged by the Complainant on 10.01.2014 and this complaint was filed before this Ld. Forum on 24.07.2014 and admittedly till that date the claim had not been decided by the Insurance Company i.e. Claim had neither been settled nor repudiated. Such action can easily be termed as deficiency in service on the part of the Insurance Company. Be it mentioned that the Complainant has successfully corroborated his insurance claim against the mediclaim policy by adducing sufficient and cogent documents with detailed break-up.
Going by the foregoing discussion, hence, it is
O r d e r e d
that the complaint be allowed on contest with cost against the OP-1and 2 and dismissed ex parte against the OP-3 without any cost. The OP-1 and 2 are directed either jointly or severally for making payment to the tune of Rs. 61, 219=00 (Rs. Sixty one thousand two hundred and nineteen) only to the Complainant towards the medical expenses of her daughter as incurred by him against the policy within a period of 45 (forty five) days from the date of passing of this final order, in default, the abovementioned amount shall carry penal interest @9% p.a. for the default period. The OP-1 and 2 are further directed to pay to the Complainant either jointly or severally a sum of Rs.4, 000=00 (Rs. Four thousand) only towards compensation due to harassment, mental pain and agony and Rs. 1,000=00 (Rs. One hundred) only as litigation cost within 45 (forty five) days from the date of this final order, failing which the Complainant will be at liberty to put the entire decree into execution as per provisions of Law.
Let a plain copy of this judgment be supplied to the parties free of charge.
(Asoke Kumar Mandal)
Dictated and corrected by me. President
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
