Date of filing: 23.11.2016 Date of disposal: 18.09.2017
Present :
Smt. Jayanti Maitra (Roy) Hon’ble President,
Sri Pankaj Kumar Sinha Hon’ble Member,
Miss Nivedita Ghosh Hon’ble Member,
Kanak Pati, W/o. Shyama Das Pati,
Resident of H2/26, Milanpally,
Kururia Danga, P.O.-Amri, Durgapur,
Dist.-Burdwan, Pin-713203.
Complainant
VERSUS
- E-Meditek (TPA) Services Ltd., Durgapur Branch,
Represented by its Branch Manager, having its
Office at No.A-2/4, City Centre, near Chaturanga
Puja Maidan, Durgapur, Dist.-Burdwan, Pin-713213,
(Exparte vide order 6, dated20.3.2017)
- The Director, E-Meditek (TPA) Service Ltd., having its
Corporate office at plot No.577, Udyog Vihar, Phase-V,
Gurgaon, Haryana-122016.
(Exparte vide order 5, dated 27.2.2017)
- United India Insurance Company Ltd., Burdwan Head
Office, represented by its Divisional Manager, Having
Its office at Palika Bazar, 3rd floor, G.T. Road, Town,
P.O. & P.S.-Burdwan, Pin-713101.
Opposite Parties.
Appeared for the complainant : Ld. Advocate Suvro Chakraborty.
Appeared for the O. P. No. 1 & 2 : None.
Appeared for the O. P. No. 3 : Ld. Advocate Ahibhushan De.
JUDGEMENT
This is a case U/s. 12 of the C.P. Act for an award directing the O.Ps. to pay Rs.10,400/- towards expenses of treatment of the complainant, to pay Rs.30,000/- as compensation for mental pain, agony and harassment and to pay Rs.20,000/- as litigation cost to the complainant.
The complainant’s case in short is that husband of the complainant was an employee of Steel Authority of India Ltd., Durgapur (SAIL). As an employee the complainant and her husband got a medi-claim policy of the O.P. No.3, Insurance Company. In respect of that policy of Insurance the O.P. No.1 & 2 is that TPA, i.e. 3rd party Administrator. In the year 2015 the husband of the complainant renewed the policy of Insurance by paying Rs.3,311/- on 29.4.2015. It is pertinent to mention here that a MIN No.2522320 was allotted in favour of the complainant. The complainant submits receipt of amount for renewal of Medi-claim policy the Opposite Party No.3 renewed the same and the policy was valid till 31.3.2016. the policy number was 041100/48/15/41/00000002 for the year 2015-2016. The complainant further begs to submit that during continuation of the policy the complainant began to face some troubles with her eyes. As such the complainant consulted with Dr.Sujit Gharai of Disha Eye Hospital Pvt. Ltd. at Barrackpore. As per advice of the said doctor the complainant took admission before the said hospital for undergoing an operation in her left eye. After underwent operation the complainant was discharged from the said hospital. In this context it is important that an amount of Rs.10,400/- was incurred for her treatment.
The complainant further submits that as there was existence of valid medi-claim policy, the hospital authority lodged a claim before the O.P. No.1 & 2 on behalf of the complainant and the same was registered by the O.P. No.1 & 2 vide claim No.100101512571. After discharged from the hospital the complainant returned to her house. Very surprisingly the complainant received a letter from the hospital authority from which she came to know that O.P. No.1 & 2 repudiated her legitimate claim vide their letter dated 15.10.2015 on the ground that “ 1. Other Non-Policy General Clause- Hospitalization Expenses under this claim are paid by the insured in entirely, 2. The above said procedure not covered under day care procedure.” The complainant became surprised as the O.P. repudiated her legitimate insurance claim with all sorts of false, frivolous and fabricated ground which is nothing but an illegal, arbitrary and whimsical acts of the O.Ps. Hence, this case filed by the complainant before this Ld. Forum for relief.
The O.P. No.3 contested this case by filing written version denying all the allegations as made by the complainant. This O.P., United India Insurance Company further begs to state that insured complainant,Kanak Pati is the wife of Mr. Shyama Das Pati, who is retired employee of Steel Authority of India (SAIL), and is covered under their SAIL Group Mediclaim Policy for retired employees of SAIL. It is learnt that Mrs. Kanak Pati was hospitalized at Disha Eye Hospital, Barackpore for Silicon Oil Removal Membranectomy and it was diagnosis as SOR AC WASH Membranectomy and Tricort, which procedure is not included in SAIL’s Day Care procedure Listed in the Medical Scheme for the retired employees of Steel Authority of India Ltd. (SAIL). That the said Medical Scheme has defined 134 Nos. of Dare CARe Procedure and the Procedure for which the Insured was admitted at Disha Eye Hospital, Barackpore is not listed and also not included in the said 134 Nos. Procedure. The complainant, Mrs. Kanak Pati was diagnosed for SOR AC WASH MEMBRANECTOMY, which is defined in Medical Term as under:-
“SOR – Stands for Silicon Oil Removal :-It is a procedure by which an Injection is given for filing of the Eye with Liquid Silicon to hold the detached Retina in place.
MEMBRANECTOMY: It is Removal of layers of Unhealthy Tissues from the Retina with minute Instruments, such as Forceps (tiny grasping tools), Picks (miniature hooks) and Visco-Dissction (separating layers for tissues with jets of fluids)”.
O.P. No.3 further submitted that the above procedure is outside the scope of policy Coverage and as such the claim was repudiated. Be it mentioned that the said matter was duly intimated to the complainant, Kanak Pati by the O.P. No.3, United India Insurance Company Ltd., vide its letter dated 19.12.2016. It was specifically stated in the said letter that on scrutiny of the claim form and associated documents, this O.P. observed that he/she was admitted/ consulted in Disha Eye Hospital, Barackpore for Silicon Oil Removal and Membranectomy, nor included in SAIL’s Day Care Procedure and as such the claim is not payable, as per Hospital Benefit Scheme/Section, as per terms of the policy. The O.P. No.3 stated that the said matter was also duly informed by the Authorised Signatory of E-Meditek (TPA) Services Private Ltd. to Disha Eye Hospitals, Barackpore, regarding denial of Cashless facility towards treatment of Kanak Pati, vide its letter dated 15.10.2015, stating that Cashless Request has not been sanctioned due to the below marked reasons:
- Other Non-Policy General Clause-(Hospitalization Expenses under this claim are paid by the Insured in entirely).
The above said procedure not covered under Dare Care Procedure and it was also stated in the said letter dated 15.10.2015 that the said Hospital is requested to collect the expenses from the patient him/ herself. Since the above Dare Care Procedure outside the scope of the policy coverage and as such this O.P. No.3 United India Insurance Company Ltd. has duly repudiated the claim of the complainant, Kanak Pati on 19.12.2016.
The O.P. No.3 also submits that this Opposite Party, Insurance Company cannot entertain any claim beyond the terms, conditions, definitions and exclusions of the policy issued by this O.P., Insurance Company and this O.P. No.3, United India Insurance Company Ltd. shall also not be liable under the policy for payment of any claim, when the claim is beyond the terms, conditions and exceptions of the policy. Hence, this O.P. prayed for dismissal of the complaint of the with cost.
DECISION WITH REASON
Heard the argument at length and perused all the documents submitted by the complainant as well as O.P. No.3 on affidavit. On perusing the submission of the complainant and the O.P. it is seen that the claim of the complainant has been repudiated on the ground that that “ 1. Other Non-Policy General Clause- Hospitalization Expenses under this claim are paid by the insured in entirely, 2. The above said procedure not covered under day care procedure.” Perused the list of disease for which the concerned policy covers from where it is evident that the policy covers for any treatment relating to surgery for retinal detachment. From the submission of the O.P. No.3 the complainant was hospitalized for Silicon Oil Removal Membranectomy and it was diagnosed as SOR AC WASH Me Tricort. SOR stands for Silicon Oil Removal. It is a procedure by which an injection is given for filling of the eye with liquid silicon oil to hold the detached retina in place i.e. therefore it may be inferred that it is related with the surgery for retinal detachment. The O.P. argued that Membranectomy is not at all a surgery. In their written version O.P. also submitted that removal of Membranectomy is a process of removal of layers of Unhealthy Tissues from the retina with minute instruments such as Forceps (tiny grasping tools), picks (miniature hooks) and Visco- Dissection (separating layers for tissues with jets of fluids). In common parlance of medical science application of any sorts of instrument whether it is miniature or a big size is involved in a procedure of surgery where medicine is not the only remedy for curing the disease. As there is application of forceps picks and Visco-Dissection, therefore, it may be concluded that Membranectomy is a procedure related with surgery allied with retinal detachment. So, the reasons in support of the O.P’s. submission is not correct. Hence, the complainant wins the case. Hence it is
Ordered
that C.C. No.202/2016 is allowed on contest on cost against the O.P. No.3 and exparte against the O.P. No.1 & 2. The O.P. No.3 is directed to pay Rs.10,400/- towards treatment expenses of the complainant, to pay Rs.10,000/- as compensation for mental pain, agony and harassment and also Rs.2000/- as litigation cost to the complainant within 45 (forty five) days from this date of order, failing which the O.P. No.3 will bear 10% interest on the total amount. The complainant is at liberty to put this order in execution in accordance with law.
Let the copies of this order be supplied to the parties free of cost.
Jayanti Maitra (Ray)
Dictated and corrected by me. President
D.C.D.R.F., Burdwan
(Sri Pankaj Kr. Sinha)
Member
D.C.D.R.F., Burdwan
(Nivedita Ghosh) (Sri Pankaj Kr. Sinha)
Member Member
D.C.D.R.F., Burdwan D.C.D.R.F., Burdwan
