Debasis Bhattacharya:- PRESIDING MEMBER

 The instant case filed under section 12 of the Consumer Protection Act 1986 arises out of the grievances of the complainant with regard to repudiation of claim against a policy under the title ‘Jeevan Arogya’ of Life Insurance Corporation of India (hereinafter referred to as OP LICI in general as OP 1 i.e. Divisional Manager of Howrah Divisional Office of LICI and OP 2 i.e. Branch Manager of Tarakeswar Branch of LICI, belong to the same organization) held by her during the material period.

The brief facts of the case is that a policy under the name ‘Jeevan Arogya’ was incepted in favour of the complainant by the OP in the year 2013 which reportedly covered the risk of the health of the complainant.

The complainant claims to have paid all the due premiums in regular manner.

However during the continuance of the policy, the complainant having been indisposed took admission in a nursing home in Kolkata on 15.08.2019 at 11-15 A.M., following the advice of the treating Doctor. On completion of the required treatment the nursing home authority discharged her on 16.08.2019. Here, the complainant claims that she was discharged at 11-25 hrs from the nursing home. It is further claimed that the cost of treatment which was to the extent of Rs.48,761/- was incurred by the complainant.

On being discharged, the complainant lodged the necessary claim for reimbursement of the treatment expenses before the Opposite Parties on 11.09.2019 by submitting the relevant claim form and other required documents and the claim was registered accordingly by the Opposite Parties. The complainant claims to have intimated the issue regarding hospitalization to the OP 3 i.e. the TPA at the time of admission itself.
Subsequently, the complainant received a letter dtd.19.09.2019 from the OP 1 in which it was conveyed that the claim was repudiated on the ground that duration of stay in hospital was less than 24 hours.

In reply to the further communication dtd.01.10.2019 made by the complainant seeking clarification in the matter of duration of stay in hospital, the OP Insurance Company informed in their letter dtd.10.10.2019 that in the final bill the time of discharge is shown as 9-40 AM.

The complainant on the other hand argues that it is evident from the discharge certificate that the husband of the complainant while taking back his wife from the nursing home, put his signature in the discharge summary showing date and time as 16.08.2019 at 11:25 AM.

Considering the repudiation of the claim as deficiency in service and unfair trade practice the complainant filed the complaint petition seeking direction upon the opposite parties to pay a sum of Rs.48,761/- towards treatment expenses along with interest @10% p.a. from 19.09.2019 to the date of realization of the sum of Rs.48,761/-, Rs.1,00,000/- as compensation for mental pain, agony and harassment and to pay Rs.20,000/- towards cost of litigation.

The complainant along with his petition has submitted copies of the relevant documents related to the policy viz. premium receipts, medical reports, discharge summary, Bill Status Report, final bill and break-up thereof, tax invoice in respect of purchase of medical requisites and the policy advice itself along with terms and conditions, legal notice dispatched to the OP etc.

Evidence on affidavit filed by the complainant is almost a replica of the complainant petition.

The opposite parties 1 and 2, belonging to the same organization contested the case by filing elaborate rebuttals in their written version, evidence on affidavit and brief notes of argument denying therein most of the allegations leveled against them.

    In view of the above discussion and on examination of available records, it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(1)(d) of the Consumer Protection Act 1986 are concerned.

One of the opposite parties, at the time of institution of the complaint had a branch office within the district of Hooghly. The claim preferred by the complainant does not exceed the limit of Rs.20,00,000/- Thus this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.

The OP clarifies in their written version and evidence on affidavit that it is true that the complainant patient was admitted into the nursing home on15.08.2019 at 11-15 A.M but she was discharged next day at 9-40 A.M. so far as the final bill issued by the nursing home was concerned. Thus the hospitalization period was technically less than 24 hours.

In this connection OP 1 refers to the conditions and privileges as laid down under clause 2(iv) of the benefit column of the terms and conditions of the policy.

OP 1 further points out that in the instant case the surgery performed comes under other surgical benefit category and as per terms and conditions of the policy to become eligible for benefit under this category minimum hospitalization period must be more than 24 hours. OP Insurance Company claims that as the complainant did not fulfill the terms and conditions to avail the benefit of reimbursement of hospital expenses so the claim was repudiated by them lawfully.  

Materials on records are perused.

Now the focus lies on the sole issue that whether the hospitalization period was 24 hours or not.

In this case, the respective Nursing Home is the appropriate authority to certify the appropriate time of discharge.

It is true that in the discharge summary the time of discharge is not mentioned but in the final bill and the break up thereof, the time of discharge is specifically mentioned as 9-40 A.M. of 16.08.2019. Thus the Nursing Home authority in one way or the other certifies the actual time of discharge. There is no indication that the Nursing Home authority had any mala fide intention or material interest in mentioning the actual time of discharge in the final bill. This Commission has to rely upon the documents issued by the Nursing Home authority.

The complainant in the brief notes of argument claims that after completion of treatment, though the nursing home authority raised the final bill at 9-40 A.M. on 16.08.2019 but they kept the patient before them under observation till 11-25 A.M. However no corroborating evidence in support of the claim could be produced.

National Accreditation Board for Hospitals (NABH) is a body that accredits hospitals and healthcare providers in India.

NABH defines discharge as a process by which a patient is shifted out from the hospital with all concerned medical summaries ensuring stability. The discharge process is deemed to have started when the consultant formally approves discharge and ends with the patient leaving the ‘clinical unit’.

Mentioning time as 11-25 A.M., in the discharge summary by the husband of the complainant, while signing the same, does not necessarily and conclusively establish that the complainant was discharged at 11-25 A.M. The opening sentence of the declaration is ‘I am taking my relative home after discharge’. The same indicates that the patient left the clinical unit prior to signing the declaration.

Considering the facts and circumstances of the case this District Commission is of the view that there was neither any unfair trade practice nor any deficiency of service on the OP LICI’s part and unfortunately in terms of the stipulated terms and conditions of the policy the complainant cannot be entitled to reimbursement of the treatment expenses. 

Hence, it is

                                        ORDERED

that the complaint case no.03/2020 cannot be allowed on contest  and the same stands dismissed with no order as to costs.

 Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgements/sent by ordinary post for information and necessary action.