Order-12.
Date-02/12/2015.
In this complaint Complainant Gopinath Pal by filing this complaint has submitted that on 17.04.2012 Mira Pal the wife of the complainant felt seriously ill with acute loser abdominal pain associated with chest pain with urinary frequency and dysuria and she was immediately brought to the chamber of Dr. Argho Roy where he examined and admitted her at Capital Nursing Home Pvt. Ltd. and after investigation and several testing it was detected that she was suffering from Urinary Tract Infection and after treatment she was discharged on 25.04.2012.
After treatment of the patient, complainant submitted the claim papers for Rs. 21,606.10 paisa on 22.05.2012 enclosing all documents, bills, cash memo to the op.But even then waiting by more than 45 days from the receipt of that he has not received any amount of the bill from the op.Thereafter a reminder was given to the Divisional Manager on 06.07.2012 of the op, but no reply was received.Thereafter reminder was given by op on 30.08.2012 and all other higher official including op but they did not pay it and for which for their negligent and deficient manner of service, complainant has filed this complaint for redressal.
On the other hand op nos. 1 & 2 by filing written statement submitted that the claim of the complainant was repudiated by the 3rd party administrator M/s. M.D. India by a letter dated 15.06.2012 and the complainant just mislead this Ld. Forum has tried to make out the case the he has not received any repudiation letter.Now the present complaint has been filed after 2 years from the date of repudiation of the claim and therefore the present complaint is barred by lay of limitation and at the time of filing of this complaint, no such application for condonation of delay u/s 24 for which the present complaint is not maintainable.No doubt ops admitted that complainant took health insurance policy from the op for the period from 01.04.2012 to 14.04.2013, but the said policy as per certain terms and conditions attached with the policy schedule and as per clause 4.10 of such policy conditions, expenses incurred primarily diagnostic purposes not followed by active treatment during hospitalization is not covered by the terms and conditions of the policy.
So, in the present case the discharge certificate filed by the complainant himself in respect of relevant admission of his wife in the Capital Nursing Home Pvt. Ltd. during the period from 17.04.2012 to 25.04.2012, it is clear that she was admitted that for the purpose of primary evaluation and diagnostic of her ailments though during entire period of such admission and no active line of treatment save and except conservative treatment was provided to her.Such diagnosis and conservative treatment could have been easily done without being admitted in the said nursing home and just to get the expenses reimbursed by the ops through the aforesaid health insurance policy of insurance she was admitted in the said Nursing Home during the relevant period and that too without being even advised by the treating doctor which is also a compulsory pre-requisite for being entitled to a claim and as per the terms and conditions of the policy of insurance for which the complainant’s claim was bonafidely repudiated and same was communicated to him by letter dated 15.06.2012 by TPA.Therefore the entire claim is false and fabricated.
Moreover it is submitted from the conjoint consideration of the discharge certificate as well as the bill issued by said nursing home, it is clear that though the complainant claimed Rs. 21,606.10 paisa for the relevant treatment of his wife but certain medicines were prescribed and medical tests were conducted during such admission period, which has no connection with the relevant ailment i.e. urinary tract infection.Rather some of the tests were conducted and some medicines were prescribed for old existing diabetic problem of wife of the complainant and naturally the expenses incurred for treatment of diabetic problems are not payable as it is in no way related with the urinary tract infection of the wife of the complainant.Beside that certain expenses incurred by the complainant were also not payable by virtue of terms and conditions of the policy of insurance.Therefore it is most respectfully submitted that even if the Ld. Forum ultimately comes to the conclusion that the claim of the complainant is at all payable in that case the liability of ops is limited to the extent of Rs. 15,597/- but not more than that.So, the present complaint should be dismissed.
Decision with reasons
On comparative study of the complaint and written version and also considering the policy condition it is found that as per clause 4.1 if a person suffer from Hypertension or Diabetes or both at the time of the policy, they shall be subject to following exclusion.
Truth is that complainant had their mediclaim policy valid from 01.04.2012 to 31.032.013.It is also admitted fact that complainant’s wife Smt. Mira Pal was admitted to Capital Nursing Home Pvt. Ltd. from 17.04.2012 to 25.04.2012, but on 17.04.2012 she was examined by Dr. Arogho Roy who prescribed from certain diagnostic and clinical tests.But Dr. A. Roy did not prescribe her for admission in the Nursing Home at any point of time.It is also a fact that complainant lodged a complaint before Insurance Ombudsman, Kolkata but that was rejected on 29.12.2014.But it is found from the discharge summary that Mira Pal ab old knowncase of diabetic lady was admitted and she was treated conservatively and she was discharged with following advices and final diagnosis was urinary tract infection.
But it is clear that during the period of stay only some tests were done and those were USG, ECG, Eco Cardiograph, blood for Lipid Profile, PP, Fasting, and Urine etc. which were clinically tested and X-ray was made.Such a treatment is generally made conservatively and doctor has also treated conservatively.But all the tests were done and it can be done at any laboratory.But Dr. A. Roy under whom she was admitted in the Capital Nursing Home did not ever prescribe for her admission to the said Nursing Home.
Then it is clear that only for the purpose of realization the costs of the tests, complainant’s wife was admitted.From the advice of doctor and medicine it is found that treatment was not held for urinary truck infection but treatment was for blood sugar, because the sugar Fasting level was 175 and PP was 127.So, it is clear that the patient was known patient of diabetic and for which the treatment was given.In view of the above findings we are of the view that practically conservative treatment can be taken in the house but it was taken by the complainant in the nursing home for only reimburse of the amount.
Whatever it may be after considering all the papers, it is clear that it is a new technique for claiming mediclaim.But considering the age of the complainant’s wife and also amount of the claim and other matter and also considering the ops’ Ld. Lawyer’s submission and for giving a natural justice to the complainant a sum of Rs. 15,597/- is granted in favour of the complainant treating the entire claim is finally disposed of and in this regard ops have no grievance.So, this complaint succeeds in part.
Hence, it is
Ordered,
That the complaint be and the same is allowed on contest without any cost against the ops.
Op nos. 1 & 2 the Insurance Company are hereby directed to handover an amount of Rs.15,597/- to the complainant within 45 days from the date of this order.But no other relief is granted in view of the above fact.Though as per law and equitable view cannot be taken in case of a contract of insurance when rights of application are strictly governed by the Insurance Policy and no exception and relaxation on the ground of equity is applicable.But even then on humanitarian ground it is granted.
Op nos. 1 & 2 are directed to comply the order within 45 days failing which penal action shall be started against them for which further penalty and fine u/s 25 read with Section 27 of C.P. Act 1986 shall be imposed.
