Judgment & Order dt. 03.05.2017
Repudiation of claim of Complainant by OP Nos.1 & 2, i.e., National Insurance Company has galvanized the complainant to come up before this Forum with the filing of the instant case, praying for issuing a direction upon OP Nos.1 & 2 to pay a sum of Rs.35,803/- as reimbursement for the cost incurred by the complainant for her treatment. The facts of the case may be epitomized as follows.
The Complainant is a holder of BOI Swasthya Bima Policy of OP Nos.1 & 2 i.e., National Insurance Company which was launched in collaboration with OP Nos. 3 & 4. The Policy was in force from 27/04/2015 to 26/04/2016. On 10/04/2016, the complainant felt severe abdominal pain for which she was treated by different doctors at Balurghat without having no positive result. So, she rushed to Kolkata for better treatment and was attended to by Dr. Ranjit Chakraborti on 18/04/2016. Thereafter, she was admitted to Woodland Super Speciality Hospital at Kolkata under advice of Dr. Ranjit Chakraborti on 19/04/2016. On 21/04/2016 she was discharged from the said Hospital after Medical check-up and treatment. A sum of Rs.35,803/- was incurred by her as cost of treatment in the said hospital. Claim for reimbursement was submitted on 03/05/2016. But, this claim of the complainant was repudiated by OP Nos.1 & 2 on the ground that the hospitalization of the complainant was not for treatment but for medical investigation and check-up only. So, the instant case is filed by the complainant praying for issuing a direction to the Op Nos.1 & 2 to pay Rs.35,803/- as bona fide expense and Rs.5,000/- as compensation for mental and physical harassment. Hence, this case.
The Complaint is resisted by OP Nos.1 & 2 on the ground that the complainant is not entitled to get the reimbursement as prayed for, because she was admitted to the hospital not for any medical treatment but for body check-up and for diagnostic purpose. Bima Policy does not include diagnostic treatment. Repudiation of claim of the complainant was done lawfully and there was no deficiency in service as alleged. So, to them, the complaint should be dismissed in limini. OP No. 4 has not filed any written version to contest herein and therefore the case is proceeded exparte against him. OP No. 3 has filed written version of statement supporting the case of the complainant.
Upon the averments of the parties, the following issues are formulated for proper adjudication of the matter in dispute.
Issues
- Does the Complainant fall within the exclusion clause, i.e, clause 4 of the insurance agreement?
- Are the OP Nos.1 & 2 guilty of deficiency in service as alleged?
- Is the Complainant entitled to get relief as prayed for ?
Evidence of the Parties
The Complainant has filed affidavit-in-chief and has also got herself examined as PW-1. The documents admitted in evidence are marked as Ext. No.1, 2 series, 3, 4, 5, 6, 7, 8 series, 9,10,11,12 series and, last of all, Ext.13 as detailed in the list of documents kept in the record. On the other hand, the standard agreement of Bima Policy is filed by OP Nos. 1 & 2and the same is marked as Ext. No. A also detailed in the list of documents kept in the record.
Decision with Reasons
ISSUE NO: 1
It is contended on behalf of the contesting OPs that the complainant’s case is covered under exclusion clause of the agreement in as much as the complainant was admitted to the hospital for diagnostic purpose only. She was not admitted to the hospital for treatment of any kind of disease. According to them, Clause 4.13 of the agreement excludes hospitalization for the purpose of mere diagnostic treatment. Ld. Lawyer appearing for the complainant has submitted that the complainant was admitted to the hospital on the advice of Dr. Ranjit Chakraborti and she was not only subjected to Body check-up but to medical treatment for abdominal pain she was suffering from that time. So, according to him, the insurance co. has acted arbitrarily in repudiating the lawful claim of the complainant.
Heard the submissions of both sides. Perused the materials on record. Considered all these.
The complainant is admittedly an insured person. Her policy is also admittedly in force. The fact of her being admitted to the aforesaid hospital is not also disputed. The only question a-begging an answer is whether the complainant comes within the mischief of exclusion clause 4.13 of the agreement reached between the parties. Clause 2 is the operative clause of the agreement and it lays down that if during the continuance of policy, if the holder thereof is admitted to any nursing home or hospital as an in-patient on the advice of a duly qualified medical practitioner for treatment of any illness of disease, the company shall pay to the hospital or reimburse the insured the expenses to the limit of the sum insured, provided the expenses are included in the “Coverage” clause of the agreement. Clause 2.11.1 provides for cost of health check-up of the Policy Holder. Clause 3.15 defines “In-patient” as an insured person who is admitted in hospital upon the written advice of a duly qualified medical practitioner for more than 24 continuous hours for the treatment of covered disease/injury during the policy period.
In view of the above provisions, it is found that the complainant is an in-patient, because she was admitted to the said hospital with pain in lower abdomen on the advice of Dr. Chakraborti, vide Ext.6,i.e, the certificate issued by Dr. R. Chakraborti. There is no reason to disbelieve the certificate of the Dr. Chakraborti.
Now to see whether the complainant falls in the jaws of the mischief clause, particularly clause 4.13 of the insurance agreement. Clause 4.13 reads as follows:
4.13 Hospitalization for the purpose of Diagnosis and evaluation, irrelevant investigations charges.......All expenses incurred at hospital primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital.
The above provision of agreement of insurance makes it abundantly clear that the expenses incurred by the insured for his or her treatment and diagnosis in the hospital are excluded, if the diagnostic studies are not consistent with or incidental to the diagnosis and treatment of the ailment the insured has been suffering from. It is contended on behalf of the contesting OPs that the investigation done by the complainant are not consistent with the abdominal pain the complainant suffered from. The complainant has deposed that she was treated by Dr. R. Chakraborti in woodland hospital at Kolkata and for that purpose she was admitted therein from 19/04/2016 to 21/04/2016. Ext.12 is the detailed bill filled by the complainant. It establishes that the complainant was treated in that hospital during the aforesaid period by the doctors including Dr. R. Chakraborti. Ext.5 is discharge summary. It also establishes that the insured was admitted to the said hospital with pain lower abdomen. Medication advice on discharge runs thus:
Tab. NEXITO(10mg) ½ tab. at bed time
after food for 10 days.
Tab. LONAZEP MD(0.25mg) tab.SOS.
Continue Tab. ONNEZESTand Tab. TIBOLONE
as before.
The above medication advice only goes to prove that the complainant was admitted to the said hospital for diagnosis as well as treatment. 10-days’ medicines were prescribed to the complainant. Not only this, she was advised some follow up actions. From all these, it can be held that the complainant has been able to primarily discharge the burden of proof that she was admitted to the hospital for diagnosis and treatment of her abdominal pain and other disease which was after-effect of menopause. The OPs dispute the necessity of the diagnostic tests done by the complainant. The onus to prove this fact lies upon the contesting OPs and they will have to discharge it with cogent evidence. We are laymen and we cannot say whether the tests done by the complainant are unnecessary or not for the purpose of her treatment of abdominal pain. No evidence much less any cogent evidence is adduced by the Ops. They could have produced a doctor to establish their contention. Be that as it may, we do hold that the Ops’ contention as referred to above is apocryphal and that the complainant does not attract the mischief of exclusion clause of the agreement.
Ld. Lawyer for the Ops has contended that the condition of the agreement has not been followed by the complainant. According to him, the intimation regarding admission is not given to them before 72 hours as required under the terms of agreement and, therefore, the complainant is not entitled to get reimbursement as prayed for. This contention also appears to be without any substance. Clause 5.6.1 of the agreement lays down that in case of emergency hospitalization, the TPA must be informed within 24 hours of the insured person’s admission to the hospital. In the instant case, intimation of admission was given to the TPA, i.e Op No.4 on the very day of admission to the hospital. The admission of the complainant to the said hospital was not pre-planned and she had to get herself admitted to hospital on emergent basis on the advice of Dr. R. Chakraborti. So it is found that the condition of the agreement is sufficiently complied with by the complainant.
Hence, this issue is answered in favour of the complainant.
ISSUE NO: 2
The claim of the complainant is refused by the OP Nos. 1 & 2 on the ground that she was not admitted to the hospital for medical treatment. But, the complainant has been successful to establish by cogent evidence that she was admitted to the hospital not only for diagnostic test but also for medical treatment. The terms of the agreement stand fully complied with by her and she does not fall within the mischief of exclusion clause of the insurance agreement. She is entitled to get reimbursement from the contesting OPs for her treatment, but those OPs have deliberately turned down her claim by adopting a subterfuge as discussed above. So, the OP Nos. 1 & 2 are found guilty in deficiency in service towards the complainant.
There is still another aspect to be discussed regarding deficiency in service on the part of the contesting OPs. Clause 5.6.5 of the insurance agreement provides that the intimation regarding repudiation of claim shall be intimated within 30 days from the date of filing of final document or the receipt of investigation report. This provision of the agreement has been thrown to the wind by the OP Nos. 1 & 2. They did not discharge their duties in terms of the agreement by giving intimation of rejection of the claim within 30 days of the receipt of claim documents from the complainant. Such documents along with claim was submitted on 03/05/2016 and the repudiation of claim was intimated to the complainant on 07/09/2016, vide exhibit-3, i.e., about four months after submission of claim. This delay in giving such intimation to the complainant is contrary to the terms of the insurance agreement and as such a clear deficiency of service on the part of OP Nos. 1 & 2. Hence, this issue is answered against the OP Nos. 1 & 2.
ISSUE NO: 3
There is no reason to repudiate the claim of the complainant by the contesting OPs and it is found that such claim is turned down deliberately and whimsically for which the complainant has certainly been subjected to mental pain and agony. She is therefore entitled to compensation for mental pain and agony sustained by her along with the amount of reimbursement as claimed by her. The issue thus goes answered also in favour of the complainant.
In the result, the case succeeds.
Hence,
ORDERED
That the case be and the same is allowed on contest against the OP Nos. 1 & 2 with costs and OP No. 3 without costs. It is allowed exparte against the OP No. 4 also without costs. The costs of the proceeding is quantified at Rs. 5000/-.
The OP Nos. 1 & 2 are directed to make payment of Rs. 35,803/- only to the complainant as amount of reimbursement towards her medical treatment along with Rs. 5000/- as compensation for mental pain and agony and Rs. 2000/- as litigation costs within a month of this order, failing which the reimbursement amount and compensation amount will bear interest at the rate of 12% per annum till the date of full realization of the amount.
Let a copy of the order be supplied free of costs to the parties concerned.
