Orissa

Cuttak

CC/135/2018

Ramwater Agarwal - Complainant(s)

Versus

Divisional Manager,New India Assurance Co Ltd - Opp.Party(s)

J K Mohanty

24 Nov 2020

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL FORUM,CUTTACK.

C.C No.135/2018

Ramwatar Agarwal,

At:Manikghose Bazar,

P.S:Purighat,Dist:Cuttack.                                                   .… Complainant.

 

Vrs.

1.        Divisional Manager,

M/s. New India Assurance Co. Ltd.,

                Cuttack-DOI,Badambadi

Kathajodi Road,Cuttack.

 

2.     M/s. The Heritage Health Insurance T.P.A,

O.C.H.C. Compled,1^st Floor,

South Block,Near Ram Mandir,Janpath,

                  Bhubaneswar-751001,Dist:Khurda

 

Present:               Sri Dhruba Charan Barik,President.

Smt. Sarmistha Nath, Member (W).

 

Date of filing:     29.12.2018

Date of Order:  24.11.2020

 

For the complainant  :   Sri J.K.Mohanty,Adv. & Associates.

For the O.P.No.1 & 2 :   Sri R.M.Mohanty`,Adv. & Associates.

 

Smt. Sarmistha Nath,Member(W).

 

                The complainant being a consumer has filed this complaint before this Forum against the O.Ps for Redressal of his grievances U/S-12 of the Consumer Protection Act,1986(Act in short) in terms of his prayer made in the complaint petition alleging deficiency in service on the part of O.Ps.

1. The case of the complainant in brief is that the complainant is a consumer under the O.Ps insured himself with family under the universal Health insurance Policy(Hospitalization Benefit policy) bearing policy No.55030234161900000006 for the period with effect from 2.12.2016 to 1.12.2017.  The policy schedule is attached as Annexure-1.  The complainant has paid the premium of Rs.548/- on 30.11.16 in cash in the branch office of O.P.1 and has obtained the receipt.  The receipt is attached as Annexure-2.  On 2.8.17 the complainant fell ill and was admitted to S.C.B.Medical College and Hospital,Cuttack bearing registration no.11989 in 2^nd unit/1^st mmw ward bearing no.119.   The complainant was advised for several clinical tests with payment.  The Xerox copies of reports are filed as Aannexure-3 series.  The complainant was discharged from the hospital on 6.8.2017 and was advised to attend the O.P.D after 15 days of discharge.  The discharge certificate is attached as Annexure-4.  After the complainant got discharged from the hospital, he intimated the O.P.2 about the hospitalization and claimed an amount of Rs.12,202/- as the expenses of treatment and thereby submitted the original documents to them.  But the O.P No.2 remained silent over the matter for which the complainant sent a notice to the O.P.2 on 31.5.2018 and again through his counsel on 29.9.18.  The O.Ps received the above said notice but did not take any action.  The copy of the notice, registered letters, receipts and postal acknowledgement are attached as Anenxure-5 series.  But after receipt of notice, the O.Ps have remained silent.

The complainant has prayed before the Forum to direct the O.Ps to pay Rs.12.202/- along with Rs.5,000/- as compensation and Rs.5,000/- towards cost with interest till realization.

2. The O.P.1 appeared through its counsel and filed written version for both the O.Ps.  The case of the O.ps is that the O.P No.1 is a public sector insurance company and it had issued a universal health insurance policy for a sum insured of Rs.30,000/- floating over the complainant and his wife.  It was the first policy purchased by complainant and the policy among other exclusions stipulated that no claim under the policy shall be payable in respect of any expenses whatever incurred by the complainant/insured in connection with or in respect of all diseases/injuries which are pre-existing when the cover is accepted for the first time.  Copy of policy and clauses are attached as Annexure-D/1 series.

During subsistence of policy, the complainant felt sudden breathlessness and was admitted to S.C.B. Medical College,Cuttack on 2.8.2017 and was discharged on 6.8.2017.During that period he has undergone various tests and was prescribed medicines.The discharge certificate recorded the disease for which the complainant was admitted is “Old CAD C Ischemic Cardiomypathy, Early CKD CCVA(Infraction)”.The original discharge certificate is attached as Annexure-D/2.On being discharged, the complainant sent the claim form to the servicing TPA and on receipt of documents, the TPA called for the doctor’s advice for admission and kept reminding for the same but in spite of repeated reminders, the complainant failed to submit the same.So the TPA intimated the complainant that the claim was closed for non-compliance of their query.Copy of medical officer review form of the TPA and the reply are attached as Annexure-D/3 series.

3. We have heard from the advocates of the parties at length, gone through their respective pleadings and perused the documents and papers filed by the parties.

Admittedly the complainant and his wife have taken a Universal Health Insurance Policy from O.Ps and its validity was from 2.12.2016 to 1.12.2017.The complainant was admitted to S.C.B.Medical College on 2.8.2017 and was discharged on 6.8.2017 and during that period he has undergone various tests and was prescribed various medicines.After discharge from hospital, the complainant submitted the documents and claimed for reimbursement of expenses towards hospitalization but the claim was closed.

During the course of argument, the counsel for the complainant submitted that the O.ps have illegally and unilaterally closed the claim on the ground of non-compliance of query with regard to doctor’s advice for admission.But the O.Ps have not made any communication with the complainant after receipt of document and that apart the plea of doctor’s advice for admission is a vague one as without the advice of doctor the patient cannot be admitted in the hospital.The counsel for the complainant further contended that the Insurance Company has not produced any document with regard to repeated reminder from the side of O.Ps.Per contra the counsel for the O.ps contended that the complainant has not produced any document with regard to advice of doctor for admission for which the case was closed.

After hearing rival submissions, we are of considered view that no patient can be admitted in the hospital without the advice of the doctor and the closure of the claim on that ground is not sustainable and O.Ps have not produced any document with regard to reminders to the complainant for the doctor’s advice for admission.So the contention of the O.Ps is not acceptable and closure of the claim is not tenable which amounts to unfair trade practice.

                                                                                ORDER

Basing upon the facts and circumstances, the complainant succeeds and O.Ps are directed to pay Rs.12,202/- to the complainant towards medical expenses, Rs.5000/- as compensation and Rs.5000/- towards litigation cost within a period of 45 days from the date of receipt of copy of this order.

Typed to dictation, corrected and pronounced by the Hon’ble Member in the Open Court on this the 24^th day of November,2020 under the seal and signature of this Commission.

                                                                   

                                                                                                                                               

 

Smt. Sarmistha Nath

Member(W)

 

Sri D.C.Barik.

President.