Order-11.

Date-26/05/2017.

      Shri Rabideb Mukhopadhyay, Member.

This is an application u/s.12 of the C.P. Act, 1986.

The case of the complainant is that the complainant had purchased a complete health insurance-2007 mediclaim policy (Including his family members) since the year 2010 to till continuing and the complainant policy Number was 4034i/CHC/05275355/00/000, sum insured of Rs.3,00,000/-, premium amount was of Rs.16,998/- but for the 2016 to 2017 was increased to Rs.46,988/- which was also paid in time and the O.Ps. issued the said policy bearing No.4128i/HPR/91130081/02/000 and Cashless Card No.100264219, 100264220 and 100264221, valid up to 14/06/2017. On 25/05/2016 complainant’s wife was admitted to AMRI Hospital Ltd. at Dhakuria for sudden on set of severe sweating with palpitations, type of admission- Emergency and after thorough check up said patient was admitted to ICU on that date. Thw wife of the complainant was discharged on 04/06/2016. After discharged from the said hospital, the complainant’s wife was suffering from Hypoglycemia and further admitted on to said hospital on 09/06/2016. The attending doctor Dr. Sankar Kumar Chatterjee, Senior Consultant Physician, Diabetelogist, Cardiologist, after thorough check up, prescribed for ‘regular check-up’ Blood Sugar & B.P. and as per such advice, complainant check up B.P. regularly by one Snehasish Das from 26/04/2016 to 30/05/2016, from 05/06/2016 to 04/07/2016 and total charges for the said check up was of Rs.14,750/-, Rs.15,140/- and Rs.15,050/- totaling of rs.44,940/-.Then the complainant submitted the total claim of Rs.79,559/- to the O.ps. office on 06/09/2016 which was duly received by O.P. vide claim form No.220100354652-2 but without considering the documents O.Ps.  rejected such claim of the complainant on 23/11/2016. Complainant further received a letter from O.P. on 12/12/2016 wherein O.P. stated that the policy of the complainant would be stand cancelled after 15 days from the date of that letter and the premium amount would be forfeited by them. Complainant also stated that O.ps. accepted the premium amount for the year 2016-2017 being sum of Rs.46,988/- from the complainant in timefor his said mediclaim policy and issued ICICI Lombard Health Insurance Cashless  Card in favour of the complainant’s wife, so the threatening of cancellation of policy and forfeiture of premium amount is illegal and there is no fault on his part. It is also stated by the complainant that complainant requested the O.ps. in his letter dated 12/12/2016 not to cancel the policy as he is an old person. On 23/12/2016 O.P. by letter told that as per standard exclusion clause No.-12- fraudulent claim they rejected the policy, though the claim is not fraudulent at all. Hence, complainant prayed for a direction upon the O.ps. to pay the claim amount of Rs.79,559/- with interest  at the rate of12 percent, not to cancel the mediclaim policy of the complainant, to pay compensation for harassment of Rs.1,00,000/- and litigation cost of Rs.20,000/-.

Despite service of notices O.Ps. neither appeared nor did file any W.V.and case is proceeded ex-parte against the O.P. 

Points for Discussion

1. Whether the OPs are deficient in rendering promised service;
2. Whether the complainant deserves any relief.

Decision with Reasons

It needs be reiterated that neither of the OPs recorded their appearance nor contested the case by way of filing any written version or evidence in spite of receiving summons. So, the case ran exparte against OPs-1&2 but on merit on the basis of documentary evidence filed by the complainant.

We have perused the documents filed by the complainant mainly, inter alia, the following.

1. Postal Track Report showing delivery of Notice/summons,
2. Copy of ICICI Lombard Health Care Policy No. 40341/CHC/05275353/00/000,       
3. Premium Certificate for Rs 12427/- dated 24 April 2010,
4. Letter dated 21 Feb 2014 of ICICI Lombard General Finance on the subject of New Health Plan with enhanced features,
5. Copy of ICICI Lombard Health Care Claim Form (2-page) signed by the complainant,
6. Copy of Form for Electronic Fund Transfer signed by the complainant,
7. Copy of Form filled in by the Treating Doctor/Hospital, and KYC of complainant,
8. Copy of hand written sheet showing total claimed expenses of Rs 79559/-,
9. Copy of Treatment details issued by AMRI Hospitals signed by the RMO/Consultant,
10. Copies of Cash Memo. Nos.4411, 4412, 4415, 4427 and 6630 of SITALA MEDICAL CENTRE, 15, Hidaram Banerjee Lane, Kolkata-12 issued against Mrs. Swapna Chatterjee,
11. Copy of Receipt of Ambulance Charges dated 25/5/16 by Way Side Sporting Club, Hatkhola, Kolkata-5,
12. Copies of OPD Prescriptions of AMRI Hospitals on 09/6/16 and 21/7/16,
13. Copies of Report-Cum-Charges of Blood Glucose(Sugar) B/P & Pulse for the period from 26/4/2016 to 25/5/2016, 05/6/2016 to 04/7/2016 and 05/7/16 to 04/8/2016 (total 3 months),
14. Letter of Durga Chatterjee for patient Swapna Chatterjee stated to have enclosed original documents as asked for in respect of Claim No. 220100364058,
15. Copy of certificate issued by Dr. Sankar Kumar Chatterjee, AMRI Hospitals dated 09/11/16 regarding administration of Blood Sugar,
16. Copy of Termination Notice of Health Policy No.4128i/HP/91130081/02/000 issued by ICICI Lombard General Insurance Co. Ltd.
17. Copy of letter dated 12/12/2016 of Durga Chatterjee addressed to the insurer regarding the Rejected Claim,
18. Copy of letter dated 23 Dec, 2016 to Durga Chatterjee regarding non-settlement of the claim due to Standard Exclusion under fraudulent claims,
19. Copy of email of rejecting pathological tests,
20. Downloaded copies of Customer Information Sheet-Product Description and Comprehensive Health Insurance Policy Wording in respect of ICICI Lombard Health Insurance.

It appears from perusal of records with petition of complaint and the Evidence of the complainant, that the Health insurance policy was initiated in 2010 covering the complainant, his wife Mrs. Swapna Chatterjee and his son Chandradoy Chatterjee with a yearly premium of Rs 12427/- with sum insured Rs. 300000/-. The policy is continued till 14 June, 2017 but for the last policy (2016-17) the premium was charged Rs 46988/- with new policy no.4128i/HP/91130081/02/000. The fact remains that complainant’s wife, Swapna Chatterjee was admitted in AMRI Hospital at Dhakuria for treatment of Hypoglycemia from 25/5/2016 to 04/6/2016 on which date she was discharged. It reveals that the complainant did not claim any charges for the In-hospital expenses and the complainant himself verbally stated during final argument that the OPs paid to him the said expenses though in the four corners of the petition there is no mention of the same.

However, we are concerned of the claim of the Complainant for pre and post hospitalization expenses, which was repudiated by the OPs mainly on two grounds, viz..-

1. As per Part III of the Schedule under clause 12- Fraudulent Claims by the complainant.
2. The Blood sugar and BP tests were not done by a recognized laboratory as observed by the Investigation findings by the OPs.

           The OPs. opined in their letter dated 12 Dec, 2016 addressed to the complainant and in their email copy sent to the customer on 03 January, 2017 that such findings indicate that the insured inflated and manipulated the pre and post Hospitalization daily B.P. and Blood Sugar test bills. A notice for termination of the Contract of Insurance was served. 384 times Blood Glucose and 294 times BP tests were conducted by one Snehasis Das 2 at the rate of Kala da of Sovabazar, Kolkata-5. Notably, the said Snehasis Das  at the rate of Kalada furnished the report of 90 days in 3 sheets total amounting to Rs 44,940/- but without furnishing any detail of the Clinical Nomenclature of the Organization being administered and run by him. The treating doctor’s certificate dated 09/11/16 that regular checkup was meant 3 to 4 times daily for Blood sugar and 2 times daily for B.P.  The certificate was obtained after all the tests were done. All these did not escape our judicial notice.

           It remains the fact that the pre-hospitalization expenses before 30 days from admission and post-hospitalization expenses up to 60 days from the date of discharge together with ambulance charges are entitled to the complainant. But the total claim of Rs 79559/- has been rejected by OPs on fraudulent ground. In discussion with the term of “Fraud” as imposed by the OPs on the complainant, we have very limited scope for discussion but when we see that this view of the OPs rejected total claim of the complainant in a predetermined mind set up, we create our scope for discussion.

          When a person makes some statement or does something affecting another, knowing fully well that such statement or deed is not true, he indulges into Fraud. In the instant case, the complainant’s wife got tested by one Snehasis Das who furnished reports and charged fees. It may be that those tests are not in commensurate with the guidelines given by the Insurer and such reports may be rejected by the OPs but the same cannot be termed “Fraud” adopted by the complainant. If the reports are fabricated or manufactured by the complainant without any knowledge of Snehasis Das  at the rate of Kalada, then only it can be said that the complainant adopted fraudulent means. But the OPs do not appear to have issued such observation to the complainant.     

         We have noticed the nature, manner and dimension of the test reports filed, applied our judicial mind and we are also not inclined to accept such reports. So, from the total claimed amount of Rs 79559/-, the amounts of pre-hospitalization and post-hospitalization testing charges totalled at Rs 44940/- shall be deducted. Moreover, such advice for regular checkup was obtained at the time of discharge. Then how could the complainant carry out such tests before hospitalization?     

        The complainant computed Ambulance charges at Rs 1500/- though the Receipt of Way Side Sporting Club, Hatkhola, Kolkata-5 shows full payment at Rs 1700/- but we consider the claimed amount of Rs 1500/-. Claim for purchase of Medicines as per filed Receipts is calculated as below.

Receipt No. of Sitala Medical Centre Amount

      4411                                                Rs 4594/-

      4412                                                Rs 1498/-

      4415   Rs 3045

      4427                                                Rs 2975

           6630                                   Rs 326/-

 Total Bill amount for Medicines =              Rs 12438/-

 Ambulance charges                 =         Rs1500/-

Total payable amount to Complainant = Rs 13938/- as against total claim of Rs.79559/-.

No bill/cash memo. for doctor’s fees or pathology test as has been claimed in the complaint with supporting document in hand written note by the complainant, has been furnished by the complainant. So, such claim is being ignored.

        This amount of Rs 13938/- should have been paid by OPs to the complainant. Non-payment of the same falls within deficiency in promised service on the part of the OPs. The complainant deserves the amount. We see frequently that the interest shown by insurers in persuading customers for taking policies gets evaporated while allowing claims and insured customers/policy holders are subjected to physical harassment and mental agony. This should not be.

        In the circumstances of what have been analytically discussed above, we are constrained to pass the following orders .-

Hence,

Ordered

That the complaint be and the same is allowed in part, exparte but on merit in terms of section 13(2)(b)(ii) of the C. P. Act, 1986 as amended so far, against the OPs.

            That the OPs are jointly and severally directed to pay to the complainant Rs.13938/-(Thirteen Thousand Nine Hundred Thirty Eight) with compensation of Rs.10000/-(Ten Thousand) for physical harassment and mental agony and Rs.10000/-(Ten Thousand) as suit cost, within 30 days from the date of this order.

             That on non-compliance of above order by the OPs, the complainant shall be entitled to put the OPs to execution of the order in terms of section 27 read with section 25 of the Act ibid.

              Let copies of the order be handed over to the parties when applied for.