West Bengal

Paschim Midnapore

CC/112/2016

Sekhar Ghosh - Complainant(s)

Versus

Divisional Manager, United India Insurance Co.Ltd. - Opp.Party(s)

10 Apr 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

 Kapot Chattopadhyay, Member

and

Smt. Sagarika Sarkar, Member

   

Complaint Case No.112/2016

 

1)Sekhar Ghosh, S/o Late Subodh Ranjan Ghosh,

2)Jayanti Ghosh, W/o Sekhar Ghosh, both of  Patnabazar, P.O. Medinipur, P.S. Kotwali, District - Paschim Medinipur. …………..………..……Complainant.

                                                                              Vs.

1)Divisional Manager United India Insurance Co. Ltd., Divisional Office No. IV, 2, Brabourne Road, Govind Bhawan, Kolkata-700 001,

2)Branch Manager, United India Insurance Co. Ltd., Bat-tala Chak, P.O. Medinipur, P.S. Kotwali, Dist. Paschim Medinipur,

3)Vidal Health – TPA Pvt. Ltd., Chatterjee International Centre, 6^th Floor, Plat no. A/12, 33A, Jawaharlal Nehru Road, Kolkata-700071....……….….Opp. Parties.                                                    

                For the Complainant   : Mr. Subrata Das, Advocate.

              For the O.P.               : Mr. Pradut Kumar Ghosh, Advocate.

 

Decided on: -10/04/2017

                               

ORDER

                          Bibekananda Pramanik, President – Facts of the case, in brief, is that the present complaint case has been filed by the complainants namely Sekhar Ghosh and Jayanti Ghosh against the Divisional Manager, United India Insurance Ltd. and two others.  Complainants’ case is that the complainant No.1 was an employee of the UCO Bank and he retired from his service on 28/02/2011 from UCO Bank, Medinipur Branch.  Op nos.1&2 are the leading insurance co. having their branch office at Medinipur. O.P. no.1 obtained a Group Insurance Policy through the UCO Bank from the O.P.-Insurance Company in his name and the name of his wife, Jayanti Ghosh, the complainant no.2 after

Contd………………P/2

 

 

( 2 )

 depositing necessary premium of the policy and the O.P.-Insurance Company also insured card nos. KOL-UI-U0090-002-0002774-A &KOL-UI-U0090-002-0002774-B respectively in favour of the complainants through O.P. no.3- VIDAL Health – TPA Pvt. Ltd. and the period of coverage of that policy was from 2/04/2015- 1/04/2016.  Thereafter on 21/04/2015, complainant no.2 Jayanti Ghosh was admitted in Spondan Nursing Home due to Gastric problem and she was discharged on 22/04/2015 and the complainant had to pay Rs.9,000/- to Spondan Nursing Home.  Complainant no.2 was thereafter treated on 13/01/2016 at Thakurpukur Cancer Hospital at Kolkata and she was discharged on 14/01/2016 and the concerned doctor advised for operation.  She was therefore taken to Christian Medical College, Vellore for treatment in the 2^nd week of March, 2016 and she was admitted there on 12/03/2016 and was discharged on 19/05/2016.  Within this period, various examination was done by the board of doctors of that hospital and for such investigation, complainant no.1 incurred an expenditure of Rs.1,20,058/- for which he submitted a claim-form before the O.P. no.3 on 29/03/2016 along with all relevant documents.  By sending a letter dated 31/03/2016, the O.P. no.3 directed the complainant no.1 to submit particulars of Bank A/C and after submission of such documents, O.P.-  Insurance Company vide letters dated 12/05/2016 and 24/06/2016 illegally rejected the claim of the complainants.  It is stated that as per policy, the O.P.-Insurance Company is bound to pay medical re-imbursement of Rs.1,29,058/- to the complainants  but they illegally denied to pay the said amount, which tantamount  to deficiency in service on their part.  Hence the complaint, praying for directing the O.P. nos.1&2 to pay Rs.1,29,058/- and for compensation and cost. 

                  The opposite party nos.1&2 have contested this case by filling a joint written objection.

                  Denying and disputing the case of the complainants, it is the specific case of the opposite parties that nowhere in the discharge certificate, issued by the Spondon Advanced Medicare, it has been mentioned about the exact diagnosis or ailments of the patient for which bill of Rs.9000/- was repudiated by the O.P.-Insurance Company.  It is further submitted by the O.Ps that the complainant no.2 was admitted at C.M.C., Vellore almost a year after her initial hospitalization in April 2015.  The discharge summary of CMC contains history of abdominal pain.  Seven months back along with altered bowl habits, where her age has been mentioned 61 years but discharge certificate of Spondon Medicare shows that her age was 55 which is vital anomaly.   In the discharge summary of CMC, it has been stated that she was referred for further evaluation and various

Contd………………P/3

 

 

( 3 )

investigations and tests in order to evaluate to come to a decision about the next course of action and she was recommended for surgical management but no paper of her surgical operation has been furnished.  When such admission at CMC, Vellore was solely for evaluation purpose with no active line of treatment or no positive treatment was done there, so it stands excluded from the scope of coverage of the said Group Medical Policy as per clause 5.11 and thus the claim was rightly repudiated by the O.Ps and as such there is no deficiency in service on the part of the O.Ps.  O.Ps therefore claim dismissal of the complaint. 

                      O.P. no.3 was duly served with notice of this case but in spite of receipt of such notice, O.P. no.3 did not appear to contest this case and hence the case was ordered to be heard ex parte against O.P. no.3.

                      To prove their case, the complainants have examined one witness namely Sekher Ghosh as PW-1 and during his evidence, few documents were marked as Exhibit-1 to 23 respectively.  On the other hand, O.P. nos. 1&2 adduced no evidence although they were given opportunity to adduce  evidence.

                                                                 Points for decision

1)Is the case maintainable in it’s present form and prayer?

2)Are the complainants consumers under the C.P. Act?

3)Is there any deficiency in service on the part of the opposite parties?

4)Are the complainants entitled to get the reliefs, as sought for?    

                   

Decision with reasons

          For the sake of convenience and brevity, all the above points are taken up together for consideration.

          Maintainability of this case has not been questioned by the O.Ps. during hearing of this case.  It is also not denied and disputed that the complainants are the ‘consumers’ under the O.P. nos.1&2.  Admittedly, the complainants obtained a Medi Claim policy from the O.P. nos.1&2 and the O.P.-Insurance Company issued two cards no. no. .KOL-UI-U0090-002-000- 2774-A & KOL-UI-U0090-002-000- 2774-B through TPA-VIDAL HEALTH Pvt. Ltd. i.e the O.P. no.3 and the said policy had coverage with effect from 2/04/2015- 1/04/2016.  According to the complainants,  during that coverage period the complainant no.2 became ill due to gastric problem on 21/04/2015 and she was admitted in Spondan Nursing Home and there she spend Rs.9000/- for her medical test.   Further according to the complainants thereafter complainant no.2 was taken to Thakurpukur Cancer Hospital at Kolkata on 13/01/2016 and she was discharged on 14/01/2016 and the concerned

Contd………………P/4

 

( 4 )

doctor of the cancer hospital advised for operation.  Further according to the complainants as the matter was serious,  so complainant no.2 was taken to Christian Medical College, Vellore for treatment in the 2^nd week of March, 2016 and as per advise of the doctors, some investigations were done there for which the complainant had to incur an expenditure of Rs.1,20,058/-.  It is not denied and disputed that the complainants’ submitted claim form along with relevant documents and thereafter O.P.-Insurance Company vide their letters dated 12/05/2016 and 24/06/2016 rejected the claim of the petitioners.  In their w/o,  O.P.-Insurance Company has stated in paragraph-15 (d) that the hospitalization papers show that the petitioner no.2 was admitted at C.M.C. Vellore for evaluation and investigation purpose only.  All the tests carried out there were to analyse her condition and to rule out various other ailments.  According to the O.Ps., when such admission at Vellore was solely for evaluation purpose with no active line of treatment or no positive treatment was done there so  it stands excluded from the scope of coverage of the said Group Mediclaim policy as per clause 5.11 and thus the claim was rightly repudiated by the O.Ps and as such  there is no deficiency in service on the part of the O.Ps.,  as claimed by the complainants.  So according to the O.Ps. as the said admission at Vellore was solely for evaluation purpose with no active line of treatment, so the claim was rightly repudiated by the O.Ps.  Said repudiation letter has been marked as (exhibit-23) in this case.  From this letter, it appears that the repudiation of claim was done as per clause 5.11 of the policy.  Schedule for reimbursement of hospitalization expenses along with Appendix-1 has been marked as Exhibit-22 in this case and from this document we find that there are several clauses in respect of the said Mediclaim policy and those clauses end with clause 5.10 and there is no such clause as 05.11.  So it is not understood how the claim of the complainants was repudiated by the O.P.-Insurance Company as per clause 5.11 of the policy terms and conditions.  Be that as it may, we find that admittedly the complainant no.2 was admitted in Christian Medical College, Vellore and there some investments were done.  From exhibit-3, we find from the report of Endoscopic Ultrasound that it was recommended for surgical management.  From Exhibit-8 we find that the complainant no.2 was thereafter admitted in the Christian Medical College, Vellore for operation and for such operation, she had incurred a sum of Rs.1,60,515.21/-.  At that time of hearing of argument of this case, Ld. Lawyer for the complainants  submitted that the said medical expenses for such operation was duly paid thereafter by the O.P.-Insurance Company.  Ld. Lawyer for the O.P.-Insurance Company also admitted that the said claim of Rs.1,60,515.21.- for undergoing operation was duly reimbursed.  Since it appears that after such investigations at C.M.C., Vellore in the month

Contd………………P/5

 

 

( 5 )

 of March 2016, the complainant no.2 had to undergo an operation in the month of May, 2016, so it cannot be said that all such medical investigations at C.M.C., Vellore in the month of March 2016 was only for evaluation and investigation with no active line of treatment.  Therefore to our view, the O.Ps-Insurance Company was not justified in repudiating the claim of medical reimbursement under that policy of the complainants.  It appears from Exhibits- 13 and 21 that for such investigations at C.M.C., Vellore, the complainants had to incur a sum of Rs.1,21,123.73/-.  It also appears that the said treatment at C.M.C., Vellore was done during the period from 12/03/2016 to 19/03/2016 i.e. within the coverage period of Mediclaim Insurance Policy.  Admittedly, the complainants submitted claim within the stipulated period and therefore the repudiation of the said claim was not at all justified.  The complainants are therefore entitled to get the said sum of Rs.1,21,123.73/- as medical reimbursement under that medical insurance policy from the O.P. and we accordingly allow the petition of complaint in part.

                                                  Hence, it is,

                                                     Ordered,

                                that the complaint case no.112/2016  is hereby allowed in part on contest  with cost against O.P. nos. 1 & 2 and dismissed ex parte against O.P. no. 3 without cost.  O.P. nos. 1 & 2 are directed to pay Rs.1.21,123.73/- as medical reimbursement under the mediclaim policy in question to the complainants and also to pay Rs.5,000/- as compensation for deficiency in service and to pay a further sum of Rs.3,000/- as litigation cost.

All such payments shall be made within a month from this date of order.

                                  Let plain copy of this order be given to the parties free of cost.

          Dictated and Corrected by me

                   Sd/-B. Pramanik.      Sd/-K. K. Chattopadhayay     Sd/- S. Sarkar         Sd/-B. Pramanik. 

                         President                          Member                        Member                    President

                                                                                                                                   District Forum

                                                                                                                               Paschim Medinipur