IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MURSHIDABAD AT BERHAMPORE.
CASE No.CC 10/2016 .
Date of Filing: 19.01.2016. Date of Final Order: 30.05.2017.
Complainant: Sumita Phani , W/O Surajit Kumar Phani, Vill. Chuanpur (near Maya Filling Station)
P.O. Berhampore, Dist. Murshidabad. Pin 742101.
-Vs-
Opposite Party: 1. Chief Administrator Officer, Heritage Health Services Pvt. Ltd,
Nicco House (5th floor), 2, Hare Street, Kolkata 700 001.
2. Branch Manager, United India Insurance Co. Ltd, 3/20/A, K.K. Banerjee Road,
P.O. Berhampore, Dist. Murshidabad. Pin 742101.
Present: Sri Anupam Bhattacharyya …………………. President.
Sri Samaresh Kumar Mitra ……………………..Member.
FINAL ORDER
Sri Anupam Bhattacharyya-Presiding Member.
The instant complaint has been filed by the complainant u/s 12 of C. P. Act, 1986 praying for payment of Rs.1, 26,649/- towards medical expenses against medi claim and compensation of Rs.1 lakh and Rs.20, 000/- towards litigation cost.
The complainant’s case, in brief, is that the complainant purchased “Medical Health Insurance Policy” from OP No.2 for the period from 1.7.15 to 30.6.16 since 2008 at a straight with a premium of Rs.8200/- . The complainant fell ill and got admitted on 24.10.15 in Artemis Hospital, Sector 51, Gurgaon, Haryana and got treatment as an in-patient there up to 29.10.15 where he had to undergo an emergency major open surgery of the abdomen in that hospital. The complainant claimed cashless medical treatment facility from the Insurance Company through its agent and received a sum of Rs.56250/- . After discharge the complainant submitted a bill for Rs.128439/- for cost of treatment where OPs paid only Rs.1070/- and repudiated the claim by a letter dt. 24.11.15. The OP Nos. 1&2 have negligently and willfully deprived this complainant from his bona fide claim. Hence, the instant complaint case.
The written version filed by the OP, in brief, is that the complainant underwent a “ventral Hernia” as per individual policy of Health Insurance Policy –Gold and Terms and conditions this surgery is restricted up to 25% of the sum insured for during hospitalization period. As per clause No. 1:2:1 of the policy Rs.56250 (25% , S-1) has been paid by the OP as cashless Bill to Artemis Health Institute . Further a sum of Rs.1070 was paid with full and final settlement and the same was taken without raising any objection and for that there is no deficiency in service. For wrongful gain the complainant has filed the instant complaint and for that the complaint is liable to be rejected. Hence, the instant written version.
Considering the pleadings of both parties the following points have been raised for the disposal of the case.
Points for Decision.
- Whether the complaint is maintainable in its present form and in Law?
- Whether the complaint is bad for defect of parties?
- Whether the complainant has locus standi to file the present complaint?
- Whether the complaint is barred by law of limitation?
- Whether the complainant is entitled to get the relief as prayed for?
- To what other relief/reliefs the complainant is entitled to get?
Decision with Reasons.
Point Nos. 1 to 6.
All the points are taken up together for the sake of convenience.
The instant complaint is for payment of Rs.1, 26,649/- towards medical expenses against medi claim and compensation of Rs.1 lakh and Rs.20, 000/- towards litigation cost.
The complainant’s main case is that the complainant had undergone emergency major open surgery of abdomen and claimed the cost of treatment for that operation on the basis of Insurance Policy for Rs.128439/- where the OP paid only Rs.56,250/- towards 25% of the sum insured and further paid Rs.1070/- as full and final settlement . But the complainant is entitled to get 70% of the sum insured being the impugned hernia operation was major surgery as per said MOU under Cl.1:2:1
On the other hand the OP Insurance Company’s case is that the impugned operation of the complainant was simple hernia operation and as per Cl 1:2:1 of the impugned Policy, the complainant is only entitled to get 25% of the sum assured.
Thus, the dispute is whether the impugned Hernia Operation is simple hernia operation or major surgical operation.
To establish the complainant’s case as to major surgery the complainant has adduced evidence on affidavit along with relevant documents in support of her case including the letter dt. 04.11.2015 written by the complainant to the OP along with the comment of Dr. Mayank M. Madan who held the impugned operation of the complainant.
At the same time challenging the complainant’s case, OP has adduced relevant documents including the report of the medical officer held at the instance of the OP Insurance Co in respect of the disputed Operation held by Dr. Mayank M.Madan.
Admittedly, the complainant has Health Insurance Policy-Gold with OP No.1.
It is also admitted that the terms of the said Insurance Policy as per Cl 1:2:1 is that in case of hernia operation the complainant/ policy holder will get actual expenses incurred or 25% of the sum assured whichever is less and in case of major surgeries the complaint policy holder will get actual expenses incurred or 70% of the sum assured whichever is less.
In this case the dispute is that the impugned operation is a simple hernia operation and not major surgery and for that the complainant is not entitled to get 70% of the sum assured. The complainant is entitled to get 25% of the sum assured only.
Where, the OP has admittedly paid more than 25% of the assured sum to the complainant on two occasions on first occasion the OP Insurance Company paid first Rs.56250/- for 25% of the assured sum and lastly paid Rs.1070/- as settled amount.
The Ld. Lawyer for the OP-Insurance Co. has advanced argument raising strong objection against the claim of the complainant for 70% of the assured sum on the g round of major surgery as per terms of the policy relying upon the comment of the particular doctor Dr. Mayank M. Madan in respect of the operation suffering from obstructed ventral Hernia, which was an emergency and sy-Ex ploratomy with hernia.
He has advanced argument with the plea that Dr. Mayank M. Madan has not whispered any word as to major surgery categorically in his comment in the letter of complainant dt. 4.11.15 addressed to OP No.1.
Also, he has advanced argument relying upon the report of the doctor who investigated the matter from the end of OpNo.1 that the impugned operation is not a major surgery.
He has further argued that the comment of Dr. Mayank M. Madan in the letter dt. 04.11.15 written by complainant to Op No.1 does not tally in toto with the discharge summary of Gurgaon Medical Report of Artemis Medicare Services Ltd. , Gurgaon where operation of the complainant was held.
We are not in the agreement with the argument advanced by the ld. lawyer for the OP Insurance Co. to that effect.
Rather, we find that the diagnosis was ventral hernia with obstruction as per Medical report which corroborates in toto with the comment of Dr. Mayank M. Madan and also fall with the procedure as to Exploratory laparotomy with hernia sac excision and reduction of contents with meshplasty done on 25.10.15.
It is clear from the Discharge Summary of the nursing Home that the complainant was admitted on 24.10.15 and operated on 25.10.15 and discharged on 29.10.15.
The Ld. lawyer for the OP Insurance Co. has further advanced argument that beyond 25% the OP has paid Rs.1070/- with full satisfaction.
But, no such document has come before this Forum that the complainant has received Rs.1070/- with full satisfaction.
Further, from the medical remarks derived from net submitted by the Ld. Lawyer for the complainant it appears that major surgery-include open surgery, laparoscopic surgery and microsurgery. Other major surgical procedures may include organ transplant surgery, keyhole surgery or some types of emergency surgery.
In this case there is clear comment of the doctor who held operation of the complainant that there was an emergency and Sy-Exploratary with hernia sac excision and meshplasty was done.
Considering the above discussions as a whole we can safely conclude that the impugned operation was a major surgery and as per Clear 1.2:1 of the policy the complainant is entitled to get 70% of the sum assured.
Admittedly, the assured sum of the impugned policy is Rs.2, 25,000/- and this instant 70% of the same is Rs.1, 57,500/- .
It is also admitted that the complainant has already got Rs.(56250/- + 1070/-) = Rs. 57320/- towards cost of treatment as per policy and thus, the complainant is entitled to get Rs.(1,57500 – 57320/-) = Rs.1,00,180/- in respect of 70% of sum assured as per Cl 1.2.1 of the policy.
Regarding compensation we find that complainant lastly settled at Rs.1070/- on 24.11.15 and for that we are of view that the complainant is entitled to get interest @7% p.a on Rs.100180/- since 25.11.2015 till realization towards compensation.
Considering the above discussions as a whole we find that all the points are disposed in part in favour of the complaint and as such the complainant will get rs.100180/- plus interest @ 7% p.a. on Rs.100180/- since 25.11.2015 till date of realization towards compensation.
Hence,
Ordered
that the Consumer Complaint No. 10/2016 be and the same is hereby allowed on contest but in part. There will be no order as to cost.
The complainant is entitled to get Rs.100180/- with interest @7% p.a. from 15.11.2015 till the date of realization.
The OP No.2 /Branch Manager United India Insurance Co. Ltd, is directed to pay Rs. 100180 with interest @7% p.a. from 15.11.2015 till the date of realization to complainant within 60 days from the date of this order, failing which the OP No.2 is to pay Rs.50/- per day’s delay as fine and the amount so accumulated shall be deposited in Consumer Legal Aid Account.
Let a plain copy of this order be made available and be supplied free of cost, to each of the parties on contest in person, Ld. Advocate/Agent on record, by hand under proper acknowledgment / be sent forthwith under ordinary post to the concerned parties as per rules, for information and necessary action.
