Judgment : Dt.9.1.2018
Shri S. K. Verma, President
This is a complaint made by (1) Manish Debnath, son of Mihir Debnath and (2) Kamalika Debnath, wife of Sri Manish Debnath, both are residing at 174, Vivekananda Park P.O.-Kalikapur, P.S.-Purba Jadavpur, Dist.-South 24 Parganas, PIN-700 099 against Heritage Health Care, TPA Pvt. Ltd., Nicco House, 5th floor, 2, Hare Street, P.S.-Hare Street, Kolkata-700 071, OP No.1 and United India Insurance Co. Ltd., Dakshinapan Complex, Door No.2, Floor No.2, Gariahat Road (S), P.S.-Lake, Dist.- South 24 Pargana, Kolkata-700 068, OP No.2 praying for a direction upon the O.P. to pay the petitioners the actual amount incurred by the petitioner for her treatment i.e. Rs.27,757/- with interest @ 24% p.a. and further direction for compensation of Rs.30,000/- and to pay Rs.20,000/- as damage and litigation cost of Rs.20,000/-.
Facts in brief are that Complainant is an Advocate practicing in Alipore Police Court, purchased Mediclaim Health Policy bearing No.0308002815P105951056 under the OP No.2 for himself and his family consisting of his wife, Complainant No.2 and his daughter who is minor. Complainant renewed the policy from time to time. OP No.2 is a company engaged in Insurance Business. OP No.1 is TPA involved with OP No.2 for processing the claim. Due to some gynecological disorder Complainant No.2 underwent treatment gall bladder polyp operation from 29.5.2016 to 3.6.2016 at Hindustan Health Point Nursing Home and the Complainant was granted cashless facility during the tenure of entire treatment. For the post operative treatment Complainants were advised to raise bill for reimbursement of the expenses. Complainant No.1 incurred expenditure to the tune of Rs.45,915/-. After discharge of Complainant No.2, Complainants lodged claim with OP No.2 through OP No.1 for reimbursement of her postoperative treatment. OP No.2 vide its letter dt.26.9.2016 asked for some documents which Complainants have already submitted. However, the Complainants again submitted the documents and requested OPs to process the claim. After that OP No.1 paid Rs.18,158/- directly to the Account of Complainant No.1 and repudiated the rest of the claim. Complainant categorically asserted that the repudiation is unjustified. But OPs did not pay any heed to that. So, Complainant filed this case.
OP No.2 filed written version and denied the allegations of the complaint. Further, OP No.2 has stated that he paid Rs.18,158/- for post-operative treatment and disallowed the claim of Rs.27,757/- for the fact that bill exceeding PPN package is not payable and Rs.15,000/- claimed for dressing for 5 days is abnormally excessive and an inflated claim. OP No.2 has allowed Rs.2,000/- in total. Service charges not payable as per policy and Rs.296/- was not allowed because no supporting document was produced. In addition, the OP No.2 has denied all the allegations and prayed for dismissal of the complaint.
Decision with reasons
Complainant filed affidavit-in-chief to which OP No.2 filed questionnaire to which Complainant filed affidavit-in-reply. Similarly, OP No.2 filed evidence to which Complainant filed questionnaire and OP No.2 filed affidavit-in-reply.
Main point for determination is whether Complainant is entitled to the reliefs as prayed for.
On perusal of the complaint petition, it appears that the Complainant has sought for reimbursement of Rs.27,757/- with 24% interest. In this regard, on perusal of the copy of the policy document, it appears that Complainant had a policy in their favour. Further clause 4.21 of the terms and conditions reveal that any kind of service charges, surcharges, admission fees, registration charges, luxury tax levied by the hospital is permissible, if the policy has run for 4 years. Ld. Advocate for OP did not make any submission that policy did not run for four years. Further, bone of contention between parties is that Complainant is not entitled to inflated dressing charges. To this Ld. Advocate for Complainant argued that the bills were not manufactured by his client and it is the duty of the insurer to verify it with the hospital where the patient was admitted. Considering the above, it appears that Complainant is entitled to the dressing charges as well as the service charge.
So, we are of the view that except Rs.296/-, Complainant is entitled to reimbursement Rs.27,461/-.
Complainant has also prayed for compensation of Rs.30,000/- and litigation cost of Rs.25,000/-. Considering the facts OP provided cashless facility, we are of the view that no compensation can be granted. However, litigation cost of Rs.5,000/- needs to be allowed.
Hence,
ordered
CC/247/2017 and the same is allowed ex-parte against OP No.1 and on contest against OP No.2. OPs are directed to pay Rs.32,461/- within two months of this order, in default the amount shall carry interest @ 10% p.a. The liabilities of OPs are joint and several.
