This case has been arising out of the complaint filed by the complainant against the O.Ps named above u/s. 12 of the Consumer Protection Act, 1986.
According to the complainant he himself and his wife was covered on insurance policy Vide No. 2856/00215015/000/03 under the O.Ps and the said policy was valid from August, 2020 - 2021 and that policy was covered himself and his wife Ambia Begum and his minor son Ahil Akhtar and sum assured of the policy was 2,00,000/-. That on 09/10/2020 the wife of the compllainant Ambia Begam became seriously ill due to pneumonia and the doctor advised her to take admission at Maa Seva Nursing Home, Alipurduar for her medical treatment. After recovery of the diseased, she was released from the said nursing home on 12/10/2020 but the next date i.e. on 13/10/2020 she again became seriously ill and again she was admitted at the said nursing home as per advice of the doctor but on the next date i.e. on 14/10/2020 her health condition became critical and deteriorate and then the attending doctor refer her to any higher institution with I.C.U. facilities. Considering the health condition of his wife and according to the advice of the doctor the complainant took her wife at Nivedita Nursing Home and Polyclinic Pvt. Ltd. at Siliguri for her treatment. She was admitted at the said nursing home on 14/10/2020 and she was treated as indore patient and on 21/10/2020 she was discharged from medical ward. After discharge from medical ward as per advice from the doctor she was admitted in the quarantine ward for three days the complainant spent huge amount of money for the treatment of his wife at Maa Seva Nursing Home, Alipurduar and also at Nivedita Nursing Home and Polyclinic Pvt. Ltd. at Siliguri. After release from nursing home the complainant being husband of the patient claim the insurance amount as per provision of the O.Ps within time and he sent all original papers, bills to the O.Ps company’s through blue dart courier service on 12/11/2020. After receiving all the documents the O.Ps stated that according to the MOHFW guidelines the patient was not requires to treat at hospital and she can stayed at quarantine in her room and for that reason they refused to pay the insurance claim of the complainant. The wife of the complainant was suffering from acute pneumonia as per advice of the doctor she was admitted at first Maa Seva Nursing Home, Alipurduar and also as per advice of the doctor she was referred to Nivedita Nursing Home and Polyclinic Pvt. Ltd. at Siliguri. The complainant has filed claim petition within time and according to the terms and condition to the O.Ps, the complainant on several occasion contact with the O.Ps but they refused to pay the same thereafter, the complainant sent a legal notice to the O.Ps by a registered post for sum of claim amounting to Rs. 1,96,859/- but the O.Ps have refused to pay the same. Ultimately, the complainant has filed this case and praying for the insured claim amount and also claim Rs. 1,00,000/- for his harassment and mental agony and another claim Rs. 10,000/- for litigation cost.
The O.Ps has filed the written version. They have denied all the allegations made by the complainant. According to the O.Ps that the patient was suffering from Covid-19 as per guidelines of MOHFW, she was not required for hospitalization and her treatment can be done in home quarantine and as there was no requirement for hospitalization of the patient and the complainant is not entitled to get any claim.
We have perused the materials on record meticulously. Considering the above pleadings the following issues are necessarily come out to consideration to reach just decision of the case.
POINTS FOR CONSIDERATION
- Is the complainant a consumer u/s.12 (1)(d)(ii) of Consumer Protection Act, 1986 ?
- Has this Forum jurisdiction to entertain the instant case?
- Have the O.Ps any deficiency in service as alleged by the complainant?
- Is the complainant entitled to get any relief/reliefs as he prayed for?
DECISION WITH REASON
Considering the nature and character of the case all the points are taken up together for consideration for the sake of brevity and convenience.
Point Nos. 1 and 2:- In this case the complainant is the insured under the O.Ps and the said insurance covered the complainant himself, his wife and his son. It was the health insurance under sum assured of Rs. 2,00,000/-, it was valid from 11/08/2020 to 10/08/2021 Annexure - A is the document proved the same. According to the provision of C.P. Act the complainant has paid the premium of Rs. 3,487/- and the O.Ps have issued the policy in the name of the complainant and others. The complainant and his wife is a valid consume as per law and the complainant has filed this case only because his wife became ill and hospitalized and the complainant paid huge money from the treatment of his wife then he has claimed from the O.Ps for his said expenses and the O.Ps refused to pay the said claim amount. So, according to the provision of law this case has filed by the complainant to get the claim amount as well as the compensation for his harassment and the case is valid and well maintainable. The complainant residing within the jurisdiction of this Commission and according to the amendment of C.P. Act the complainant has right to file the case where he resides and for that this Commission has jurisdiction to try the same.
Point Nos. 3 and 4:- According to the complainant his wife who is also insured became ill on 09/10/2021 and she was suffering from pneumonia. She went to the doctor Annexure - C is the document to prove that. On 09/10/2020 the wife of the complainant went to the doctor Partho Pratim Das, Alipurduar who treated her and prescribed some medicines and also adviced to admit her in the nursing home. According to the advice of doctor the wife of the complainant was admitted the Maa Seva Nursing Home at Alipurduar where she was admitted on 09/10/2020 till discharge on 12/10/2020 Annexure – D the document to prove the same. Annexure - E proves that on 13/10/2020 at 10:30 P.M. she again admitted at Maa Seva Nursing Home at Alipurduar and on 14/10/2020 at 10:40 A.M. she was referred to any higher institution with I.C.U. facility. It also appears from Annexure - F and F1 that on 14/10/2020 the patient treated as Siliguri by doctor C.P. Sharma who was attached to Nivedita Nursing Home and Polyclinic Pvt. Ltd. at Siliguri. and he was admitted there as per advice of the doctor from 14/10/2020 and discharge on 21/10/2020 and after discharge she was referred to quarantine ward of that nursing home under the supervision of Dr. C.P. Sharma and her team, Annexure - D is the document to prove the same. From all these Annexure have referred above we find that the wife of the complainant was admitted to the hospital either at Alipurduar or at Siliguri according to the advice of the doctor and she was treated there by the doctor and the complainant had to pay huge amount in both the nursing home as well as medicines and other tests and it also appears from all the Annexure that all these documents in claim of the bills were submitted to the O.Ps. The complainant is a laymen regarding medical science and diseases. It was quite obvious that the guidelines of MOHFW is not well within the knowledge of the complainant and his wife. It also appears that wife of the complainant herself did not take admission in the nursing home at her own sweet will, she was admitted on the basis of the advice of the doctor and she was referred to higher institution by the doctor not by the complainant himself. The main contention of the O.Ps are that as per guidelines of MOHFW the treatment can be done at the home quarantine but it is not possible to know this guidelines by a general public like this complainant and his wife. The doctor did not advice the wife of the complainant to stay at home quarantine. The O.Ps have filed the copy of this Clinical Management Protocol of Covid-19 issued by MOHFW but in nowhere in that said guideline it is mentioned that the Covid patient is not entitled to get any benefit from insurance claim. It is also not mentioned in the said guidelines regarding a treatment of a pneumonia patient. The treatment of the wife of the complainant in nursing home both in Alipurduar and Siliguri was done by the advice of the doctor and she was admitted there. The bill of the nursing home as well as the medicine paid by the complainant for treatment of his wife as the complainant and his wife was covered by health insurance under the O.Ps so the wife of the complainant is entitled to get insurance claim from the O.Ps and the O.Ps can not avoid to pay the said amount taking the plea that her treatment was not required to be done at nursing home. It is the doctor who can say where her treatment as pneumonia patient was was required to be done at home quarantine or at nursing home. But here we find that both the doctors advice to admit in the nursing home not only at Alipurduar and also at Siliguri and the patient was admitted in the hospital on 09/10/2020 to 12/10/2020 then 13/10/2020 to 14/10/2020 at Alipurduar and then 14/10/2020 to 21/10/2020 at Siliguri Nivedita Nursing Home and Polyclinic Pvt. Ltd. and thereafter, at the quarantine at that nursing home till 23/10/2020. The complainant has filed all his documents regarding the payment of the nursing home as well as the purchased of medicines, Annexure – G - J (collectively) from which it appears that the total claim amount of Rs. 1, 96,859/-. The insurance company have refused to pay the said claim amount only on a flimsy ground and from the documents i.e. MOHFW we find that in case of a pneumonia there is no whisper. The doctor is the best person to say that the Covid patient is required to admit in the nursing home or not according to the condition of the patient. Here in this case we find that both the doctors from Alipurduar and Siliguri adviced the patient to admit in their nursing home as she was suffering from acute pneumonia. And after discharge from Siliguri nursing home the complainant came to know that her wife was suffering from Covid-19 as the doctor advice her wife for quarantine in that nursing home. The O.Ps intentionally avoid to pay the claim amount knowing it fully well that he has to pay the same according to the condition to the policy. The O.Ps companies tried to harass the complainant and misguided him for not making any payment. We find that there is deficiency in service from the side of the O.Ps for refusing the claim amount as well as they had harassed the complainant for which he and his family has been suffering from mental agony and sufferings. The complainant is entitled to get the claim amount of Rs. 1,96,859/- along with interest @ 6% per annum from the date of the claim to till the realization of that amount, the complainant is also entitled to get the compensation for harassment, mental agony and sufferings for himself and family members amounting to Rs. 75,000/-. The complainant is also entitled to get Rs. 5,000/- as litigation costs. The O.Ps are bound to make payment on the basis of the above order passed in this case.
Thus all the points are disposed of accordingly.
Hence, for ends of justice; it is;-
ORDERED
that the instant case be and same is allowed on contest against the O.Ps. The complainant do get the award of Rs. 1,96,859/- for insurance claim with 6% interest Per Annum from 12/11/2020 to till the payment of that amount is made and he also do get an award amounting to Rs. 75,000/- as compensation for his mental agony and sufferings and also Rs. 5,000/- as his litigation costs; total decreetal amount of Rs. 2,76,859/- (Two Lakh Seventy Six Thousands Eight Hundred Fifty Nine Rupees) excluding interest. The O.Ps are hereby directed to pay the decreetal amount along with the interest upon the insurance amount as stated above till the payment is made to the complainant. The O.Ps are directed to the pay the said award to the complainant within 30 days from this day, failing which legal action will be taken against him.
Let a copy of this final order be sent to the concerned parties through registered post with A/D or by hand forthwith for information and necessary action.
Dictated & Corrected by me
