Date of filing: 20.01.2016 Date of disposal: 05.03.2018
Complainant: 1. (a) Anjali Chowdhury, W/o. Lt. Chandrakanta Chowdhury, resident of
14A/8/20, Sepco Township, Durgapur-5, Dist.-Burdwan, Pin-713205.
- (b) Mousumi Das, W/o. Kamal Das, resident of 14A/8/30, Sepco Township,
Durgapur-5, Dist.-Burdwan, Pin-713205.
- (c) Goutam Chowdhury, S/o. Chandrakanta Chowdhury, resident of 18A/8/20, Sepco Township, Durgapur-5, Dist.-Burdwan, Pin-713205.
-VERSUS-
Opposite Party No.1.: E-meditek (TPA) Services Ltd., rep[resented by its Manager, having its
Corporate office at Plot No.577, Udyog Vihar, Phase-5, Gurgaon,
Haryana, Pin-122016.
[Exparte vide order No.15 dated 15.11.2016]
2. National Insurance Company Ltd., represented by its Branch Manager,
having its office at 548, G.T. Road, Bhangakuthi, Kundu Mension,
Town, P.O., P.S. & Dist.-Burdwan, Pin-713101.
3. M/s. Steel Authority of India Ltd., represented by its Chief Executive
Officer, having its office at Ispat Bhavan, Lodi Road, New Delhi,
Pin-1100003.
[ Exparte vide order No.31 dated 6.7.2017]
Present: Hon’ble President: Smt.Jayanti Maitra(Ray).
Hon’ble Member: Miss Nivedita Ghosh.
Hon’ble Member : Dr. Tapan Kr. Tripathy.
Appeared for the Complainants: Ld. Advocate Suvro Chakraborty
Appeared for the Opposite Party No.2: Ld. Advocate, Shyamal Kr. Ganguli.
JUDGEMENT
This is a case U/s. 12 of the C.P. Act for an award directing the O.Ps. to pay Rs.47,127/- towards deficiency in service and unfair trade practice, to pay Rs.25,000/- as compensation for mental pain and agony and to pay Rs.25,000/- as litigation cost.
The complainants’ case in short is that being a retired employee of the O.P. No.3 got a Medi-claim policy bearing number 351200/46/13/8500000174 of the O.P. No.2 and the said policy was valid from 1.1.2014 to 31.12.2014. That during continuation of the policy the complainant began to suffer from ‘exertional angina’. The complainant took admission at Rabindra Nath Tagore Hospital at Kolkata on 23.6.2014, where his treatment continued upto 1.7.2014 and as per advice of the treating doctor ‘Coronary Angiogram’ done on 24.6.2014 and the complainant discharged on 1.7.2014. A bill of Rs.2,84,375/- was raised by the hospital authority and intimated to the O.P. No.1. But very surprisingly after getting the intimation from the end of the hospital authority the O.P. No.1 & 2 provide cashless benefit of Rs.2,13,975/- in favour of the complainant and remaining balance amount of Rs.70,400/- was paid by the complainant. After discharge the complainant lodged claim before the O.P. No.1 for getting the amount of Rs.70,400/- and the O.P. No.1 registered the claim of the complainant vide claim No.100061409632.
That the O.P. No.1 sent a letter dated 28.10.2014 to the complainant through the hospital authority. From the said letter it is learnt that the O.P. paid Rs.2,03,062/- out of Rs.2,85,978/- and Rs.72,003/- deducted by them. After getting such letter the complainant intimated the O.P. No.1 about his disagree with such deduction and he further claimed such amount. After several requests the O.ps. paid Rs.5,519/- on 10.10.2014 and Rs.19,357/- on 12.1.2015 in the bank account of the complainant. The O.Ps. paid total Rs.2,27,938/- but inspite of several requests the O.P. did not take any steps to pay Rs.47,172/- in favour of the complainant. Finding no other alternative the complainant filed this case before this Forum praying for relief as stated above.
The O.P. No.2 contested this case by filing written version denying all the material allegations as alleged by the complainant. This O.P. stated that complainant Chandra Kanta Chowdhury aged about 74 years being an ex-employee of SAIL was enjoying a mediclaim policy bearing No.351200/46/13/8500000174 having its validity from 1.1.2014 to 31.12.2014 with MIN No.02510424 have visited at Rabindranath Tagore International Institute of Cardiac Sciences at Kolkata on 21.6.2014 and doctor advice him for investigation on 24.6.2014. That preliminary tests were carried out on 22.6.2014 and 23.6.2014 and thereafter admitted on 25.6.2014 and discharge on 1.7.2014 at the hospital he was treated for Exertional Angina, CAD, CKD, hypertension. That in the clinical discharge summary issued by the hospital authority it has been stated that the complainant was admitted on 23.6.2014 and date of discharge on 1.7.2014 and PTCA with stinting to SVG to RCA was done on 29.6.2014 and was discharge in a stable condition.
That during the period of treatment between the period 23.6.2014 to 1.7.2014 total bill made by the hospital was Rs.2,84,375.48/- or Rs.2,84,375/- after discount from gross bill of Rs.2,85,978/-. That against the above bill the cashless benefit was extended to the O.P. as per policy condition for Rs.2,03,062/- , was also intimated by the O.P. No.1. to the complainant on 28.10.2014. The reason for deduction of an amount of Rs.72,003/- on account of non-entitlement and the charges which was not admissible in several expenses category was also stated by the TPA.
The O.P. No.2 also stated that after further review of the above bill raised by the Hospital Authority further amount of Rs.5,519/- was released on 10.10.2014 and Rs.19,357/- was also released on 12.01.2015 and the remaining amount of Rs.47,172/- could not be paid since it was not permissible viz. deduction on stent implantment where total expenses was Rs.1,70,075/- while authorized amount was Rs.1,25,075/- and amount deducted Rs.45,000/- since capping of Rs.50,000/- for stent implant is as per policy condition under group Mediclaim Scheme. Hence this case.
DECISION WITH REASONS
To prove the case the complainant filed his evidence on affidavit along with documents. O.P. files questionnaires and also prays for treating his written version as his evidence. The written version is supported by affidavit.
The complainant in his evidence stated the fact that as per the policy condition to provide the cashless benefit to the complainant he has deposited all the relevant documents, medical bills showing that he has incurred expenses Rs.2,85,978/- and O.P. paid Rs.2,03,062/- and deducted Rs.72,003/-. The complainant disagreed with such deduction and raised his objection in writing to the O.P. Thereafter the O.P. reconsider the claim of the complainant and paid Rs.5,519/- and Rs.19,357/-. But the complainant claimed that he is entitled to receive balance amount of Rs.47,172/- from his total expenses which O.P. allegedly failed to pay without any reason. From the evidence on record it is clear to this Forum that the complainant following the policy condition raised the bill for the period 23.6.2014 to 1.6.2014 of the hospital amounting to Rs.2,84,375/- after discount from gross bill of Rs.2,85,978/-. In this connection he placed documents Annexure-C series. However, the cashless benefit was extended to Rs.2,03,062/- on 28.10.2014 and the O.P. relied document Annexure-D series, wherein the O.P. also shows reason as per instruction of TPA that the deduction of an amount of Rs.72,003/-on account of non-entitlement and charges was not admissible in several category of expenses and O.P. placed Annexure-D-2 in this regard. From Annexure-D-2 it shows that the implant charges deducted Rs.45,000/- as per PAC from remark amount claimed Rs.2,85,978/-but Rs.72,003/- is not payable. In the said documents implant charges (N.A.) and expenses incurred by the complainant Rs.1,70,075/- and authorized amount was Rs.1,25,075/- and deducted amount of Rs.45,000/-, reason shown as capping of Rs.50,000/-for stent implant. In this regard the complainant also filed Group Mediclaim Scheme policy paper showing terms and conditions of the policy. From the documents filed by the complainant regarding capping in Page-9, Point No.3 of ‘Implant Utilization of Coronary Stents :Ceiling rates for different types of Coronary Stents to be as per the actual or the rates as mentioned below, whichever is less’. Name of stent different types with ceiling rate serial No.06, Pronova with ceiling rate of Rs.50,000/- + Vat is specifically mentioned goes to show that. Ld. Lawyer for the O.P. argues by citing from this document that O.P. as per policy terms and condition under Group Mediclaim Scheme for the Implant Utilization sub-head 3 Coronary Stents had deducted Rs.45,000/-. So, O.P. rightly deducted Rs.45,000/- from the claim of the complainant.
Complainant admitted that the O.P. already paid in total Rs.2,27,938/- to the complainant. After going through the argument by the parties and documents filed by the parties specially the policy paper showing terms and conditions the dispute regarding non-payment of Rs.47,172/- is rightly justified by the O.P. showing necessary documents. Therefore, we find that the argument of the O.P. is not unreasonable since the capping of Rs.50,000/- for stent implant is specific as per policy terms and conditions and complainant received Rs.50,000/- for this implant stent and the remaining balance of Rs.47,172/- as claimed by the complainant, is not payable by the O.P. in terms and conditions of the policy. Therefore, the complainant has failed to prove that O.Ps. are negligent or deficient in service in this regard. Hence, the complaint case fails. C.F. paid is correct.
Hence, it is
Ordered
that the case be and the same is dismissed on contest against the O.Ps. without any cost.
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
Jayanti Maitra (Ray)
President
D.C.D.R.F., Burdwan
(Nivedita Ghosh) (Dr. Tapan Kr. Tripathy)
Member Member
D.C.D.R.F., Burdwan D.C.D.R.F., Burdwan
