IN THE COURT OF THE LD. DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT S I L I G U R I.

CONSUMER CASE NO. : 47/S/2015.                         DATED : 02.11.2017.   

BEFORE  PRESIDENT              : SMT. KRISHNA PODDAR,

                                                              President, D.C.D.R.F., Siliguri.

                      MEMBER                : SMT. PRATITI BHATTACHARYYA.

COMPLAINANT             : SRI TAPAN DAS,

  S/O Late Amulya Chandra Das,

  Aged about 38 years, Hindu by faith, 

  Business by occupation,

  Residing at C/o. M/s N. T.  Solution,

  Dey’s Lodge, 1^st Floor, Nazrul Sarani, Ashrampara,

  P.O. & P.S.- Siliguri, Dist.- Darjeeling, Pin - 734 003.     

O.P.  Nos.      1.                        : IFFCO-TOKIO GENERAL INSURANCE CO. LTD.,

  A limited company within the meaning of the

  Companies Act, 1956 having its registered office at

  IFFCO SADAN, C1, Distt Centre, Saket,

  New Delhi-110 017.

2.                     : NORTH BENGAL CLINIC PRIVATE LIMITED,  

  at A limited company within the meaning of the

  Companies Act, 1956 having its registered office at

                          Meghnad Saha Sarani, Pradhan Nagar,

              Siliguri – 734 003, Dist.- Darjeeling.

Proforma O.P. No.    3.                 : DR. PRASANTA PAUL,

  Son of not known, Resident of “DUO VILLA”,

  50, Rabindrasarani, Rabindra Nagar,

  Oppo. to Rabindra Sangha, P.O.- Rabindrasarani,

  P.S.- Siliguri, Dist.- Darjeeling.   

FOR THE COMPLAINANT         : Sri Avrojyoti Das, Advocate.

J U D G E M E N T

Smt. Krishna Poddar, Ld. President.

Brief facts of the complaint case are that the complainant and his family members were/are having a health policy enrolled with OP No.1 i.e., Swasthya Kavach (Family Health Policy) being Policy No.52192739 for the period from 0000 hours on 05.06.2011 to midnight 04.06.2012, the said policy was renewed time to time.  Policy No.52225375 for the period from 0001 hours on

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05.06.2012 to midnight 04.06.2013.  Policy No.52271177 for the period from 0001 hours on 05.06.2013 to midnight 04.06.2014.

On 27.11.2013 the wife of the complainant Mrs. Gopa Das visited the chamber of OP No.3 Dr. Prasanta Paul complaining of fever, sore throat and OP No.3 advised her for certain medical investigations.  Immediately the complainant took his wife to BS Diagnostic Centre and there certain medical investigations were performed and from the report it transpired that the wife of the complainant was suffering from Dengue.  The OP No.3 after going through the investigation report suggested the complainant to get his wife admitted to a nursing home immediately for proper treatment.  Complainant then made contact with OP No.1 at his toll free number and OP No.1 instructed him to get his wife admitted with the OP No.2 North Bengal Clinic Pvt. Ltd. being one of the preferred service provider of the OP No.1 for Siliguri.  Accordingly, on 27.11.2013 the complainant admitted her wife with the OP No.2 for her treatment.  At the time of admission, Mrs. Gopa Das’s Dengue serology was negative and after further investigation by the OP No.2 the USG of Mrs. Gopa Das revealed “splenomegaly with cholelithiasis and urine showed features of urinary tract infection.  Further distended multiple echo reflective substances were seen in lumen of gall bladder”. 

Complainant applied for cashless hospitalization with OP No.1 through the OP No.2 which was turned down by the OP No.1 on 30.11.2013 vide a letter and the reason shown for the denial of the cashless facility was “as per submitted documents no active line of treatment is given, hospitalization is not justified.  So, cashless liability cannot be ascertained, so case is denied”.  In the said letter it was also mentioned that “denial of cashless facility should not be considered as denial of treatment/claim and claim documents may be sent by the insured for reimbursement”. 

The complainant being a man with limited source of income was forced to request the doctors of the OP No.2 to discharge his wife and to that effect the OP No.2 discharged the wife of the complainant on 02.12.2013 with findings that “a 30 years old female, presented with irregular fever of 15 days duration associated with headache and body ache.  On evaluation, CRP was raised, her KFT was normal, her dengue serology was negative.  USG abdomen showed cholelithiasis with splenomegaly, urine showed features of UTI.  She was gradually improving and at this stage party requested for discharge”. 

Complainant paid Rs.31,334.00 only to the OP No.2 i.e., the cost

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incurred by the complainant towards treatment of his wife.  On 12.12.2013 the complainant submitted all relevant documents of the treatment of his wife with the OP No.1 and the OP No.1 also acknowledged the receipt of the said documents.  On 12.01.2014 the complainant was bamboozled after receipt of a letter dated 07.01.2014 from OP No.1 wherefrom the complainant came to know that his claim has been repudiated and the reason cited for such repudiation is “patient admitted and diagnosed as a case of fever, urinary tract infection and underwent conservative management.  During scrutiny of documents in claim file, we observed that no active line of treatment is given, hence hospitalization was not justified and patient could have been managed on OPD basis, hence claim is not admissible under following clauses……….”. 

Thereafter, complainant several times visited the local office of OP No.1 and requested to reimburse his claim, but his claim was turned down.  Complainant being an insured was debarred by the OP No.1 from enjoying the cashless benefit and further for no reason whatsoever his claim was repudiated.  The OPs are jointly guilty of unfair trade practice and deficiency in service and on account of dereliction of duty and negligence on the part of the OPs the complainant suffered loss and injury due to deprivation, harassment, mental agony and loss of professional practice and for which he is entitled to compensation.  Hence this case.     

OP No.1 & OP No.3 have entered appearance and contested the case by filing two separate written versions.  OP No.2 duly received notice but did not turn up to contest the case and accordingly the case proceeds exparte against him.  “It has been contended by the OP No.1 that the investigation report clearly shows that wife of the complainant has not been suffering from Dengue and from the report it is found that anti-salmonila typhi (1 gM) and anti-salmonilla Typhi antibody IgG are negative and therefore physician did not recommend the specified medicine for Dengue.  It has been further contended by the OP No.1 that the complainant knowing fully well that the ailment of his wife was simple in nature and her treatment could be done as a outdoor patient forcefully admitted his wife in the nursing home of OP No.2 with a malafide intention to squeeze illegal claim from the OP No.1.  It has been further contended by the OP No.1 that as per submitted documents no active line of treatment is given by the OP No.2.  Therefore, hospitalization is not justified and under the above circumstances the cashless treatment is denied by the OP No.1.  It has been further contended by the OP No.1 that there was

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no deficiency in service on the part of the OP No.1 and as such the complainant is not entitled to get any relief as prayed for and the instant case is liable to be dismissed.                            

It has been stated by OP No.3 by filing a separate written version that this may be fact that on 27.11.2013 Smt. Gopa Das visited to the OP No.3 with the complaint as mentioned in Xerox copy of the prescription and it may also be fact that OP No.3 might have advised for certain test including the test of blood for CBC Dengue subject to verification of the original prescription as issued by the OP No.3 and it might be fact that Prof. OP No.3 after going through the investigation report has suggested the said Gopa Das for hospitalization but it is absolutely false to say that OP No.3 has suggested the complainant to get her admitted to a nursing home immediately for proper treatment.  It has been further contended by the Prof. OP No.3 that there is no deficiency of service and negligence on the part of OP No.3 and as such the complainant is not entitled to get any relief as prayed for against the OP No.3 and the case is liable to be dismissed with heavy cost against the complainant.     

To prove the case, the complainant has filed the following documents:-

1.       Photocopy of the Insurance Policy certificate.

2.       Photocopy of the prescription dated 27.11.2013 issued by the OP No.3.

3.       Photocopies of the diagnostic reports issued by B.S. Diagnostic Centre.

4.       Photocopy of the list of preferred service provider of the OP No.1.

5.       Photocopies of the diagnostic reports issued by OP No.2.

6.       Photocopies of the Bills issued by OP No.2.

7.       Photocopy of the form submitted by the complainant for availing cashless facility.

8.       Photocopy of the cashless denial letter.

9.       Photocopy of the discharge summary.

10.     Photocopy of the claim form.

11.     Photocopy of the Repudiation Form.

          Complainant has filed evidence in-chief.

OP No.1 has filed evidence-in-chief.

          Complainant has filed Written Notes on argument.

OP No.1 has filed Written Notes of Argument.

Points for determination

1.       Is there any deficiency in service on the part of the OP ?

2.       Is the complainant entitled to get any relief as prayed for ?

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Decision with reason

          Both issues are taken up together for the brevity and convenience of discussion.

It is admitted position that the complainant and his family members obtained a health policy from the OP No.1 which was valid on and from 05.06.2011 to 04.06.2012 and thereafter the policy was renewed from time to time.  It is also not disputed that the wife of the complainant Mrs. Gopa Das visited the chamber of Dr. Prasanta Pal, OP No.3 here in on 27.11.2013 complaining of fever, sore throat and OP No.3 advised her for certain medical investigations.  It is also not disputed that complainant took her wife to B.S. Diagnostic Centre and there certain medical investigations were performed. 

This is the case of the complainant that the OP No.3 after going through the investigation report suggested the complainant to get his wife admitted to a nursing home as the investigation report showed that wife of the complainant was suffering from Dengue.  The further case of the complainant is that on 27.11.2013 he contacted the OP No.1 over its toll free number and according to instruction of OP No.1 admitted his wife with the OP No.2 for her treatment and after further investigation by the OP No.2 the USG report of Mrs. Gopa Das revealed “splenomegaly with cholelithiasis and urine showed features of urinary tract infection and further distended multiple echo reflective substances were seen in the lumen of gall bladder”.  The complainant applied for cashless hospitalization with the OP No.1 through OP No.2 which was turned down by the OP No.1 on 30.11.2013 vide a letter and the reason shown for denial cashless facility was “as per submitted documents no active line of treatment is given.  Hospitalization is not justified.  So, cashless liability cannot be ascertained, so case is denied” and in the said letter it was also mentioned that “denial of cashless facility should not be considered as denial of treatment/claim and claim documents may be sent by the insured for reimbursement”.  Due to such denial by the OP No.1 the complainant was compelled to request the doctors of OP No.2 to discharge his wife and accordingly OP No.2 discharged the wife of the complainant on 02.12.2013 with a finding that “a 30 years old female, presented with irregular fever of  15 days duration with headache and body ache.  On evaluation CRP was raised.  Her KFT was normal, her Dengue serology was negative, USG abdomen showed, cholelithiasis with splinomegaly, urine showed features of UTI.  She was gradually improving and at this stage party requested for discharge”.

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Complainant paid Rs.31,334/- to the OP No.2 towards total cost incurred for the treatment of his wife.  Thereafter, complainant on 12.12.2014 submitted all relevant documents to the OP No.1 for reimbursement of the cost incurred by him for the treatment of his wife but the OP No.1 vide their letter dated 07.01.2014 has repudiated the claim on the plea that during scrutiny of documents in claim file it was observed that “no active line of treatment is given.  Hence, hospitalization was not justified and patient could have been managed on OPD basis, hence claim is not admissible under the clauses given in the letter”. 

From the contents of the written version of the OP No.1 we find that during scrutiny of documents in claim file, it was observed that no active line of treatment is given by OP No.2 and hospitalization not justified and the patient could have been managed on OPD basis. 

In this case, on the side of the complainant the prescription issued by OP No.3 Dr. Prasanta Paul, dated 27.11.2013 and the investigation report of B. S. Diagnostic Centre have been filed.  On scrutiny of the prescription we find that the wife of the complainant Mrs. Gopa Das was suffering from fever and sore throat and she was advised for certain test including the test of blood for CBC Dengue and after going through the investigation report of B.S. Diagnostic Centre which showed NSI Antigen negative, Dengue antibody 1 gM weekly positive, Dengue antibody 1gG-weekly positive, the OP No.3 advised the patient for immediate hospitalization/N.H.    

On perusal of the evidence of the complainant (PW 1) as well as documents furnished we find that as per prescription of OP No.3 the complainant admitted his wife with OP No.2 and there certain investigations were done.  But in the midst of treatment, the OP No.1 turned down the request of the complainant for cashless benefit and as a result complainant was forced to request the OP No.2 to discharge the patient from their Nursing Home and accordingly, the OP No.2 discharged the patient on 02.12.2013.  The discharge certificate issued by the OP No.2 Medica North Bengal Clinic has stated the case history that “a 30 years old female presented with irregular fever of 15 days duration associated with headache and body ache.  On evaluation CRP was raised, her KFT was normal, her Dengue serology was negative.  USG abdomen showed cholelithiasis with splinomegaly, urine showed features of UTI.  She was gradually improving and at this stage party requested for discharge”.  If we consider this report, we find that the wife of the

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complainant Mrs. Gopa Das was suffering from irregular fever of 15 days duration associated with headache and body ache.  Her USG abdomen showed cholelithiasis with splinomegaly and urine showed features of UTI although after investigation Dengue serology was found negative and she was gradually improving.  This report of OP No.2 clearly shows that patient was suffering from fever with symptoms of Dengue for which the OP No.3 suggested her for immediate hospitalization/Nursing Home for necessary treatment and in the Nursing Home of the OP No.2 on the basis of investigation report the treatment of the patient was going on.  OP No.1 claimed that the disease of the wife of the complainant was nothing but simple in nature and the patient could be treated as a OPD patient and OP No.1 in order to deny the claim of the complainant for cashless treatment, in the midst of treatment refused to allow his cashless benefit by its letter dated 30.11.2013.  It is unfortunate that on receipt of such refusal letter of the OP No.1 the complainant has been compelled to take discharge of his wife although she was not fully recovered and thereafter when the complainant submitted all relevant treatment papers to the OP No.1 for reimbursement of the amount spent for the treatment of his wife the OP flatly refused to pay the amount on the plea that they observed that no active line of treatment was given hence hospitalization was not justified and the patient could have been managed on OPD basis. 

From the acts and conduct of the OP No.1 it is clear that OP No.1 with a malafide intention to avoid the claim of the complainant has flatly denied to pay the amount which was incurred for the treatment of his wife.  OP No.1 also denied cashless benefit when the wife of the complainant was admitted with OP No.2 with fever, sore throat and symptoms of Dengue on the basis of prescription of OP No.3 and such denial of OP No.1 forced the complainant to take discharge of the patient from OP No.2 in the midst of treatment.  This inhuman conduct of the OP No.1 clearly shows that they are not willing to give service properly to the consumer.  If a patient is forced to be discharged from hospital/Nursing Home in the midst of treatment, it is not possible for the patient party to produce all the relevant documents regarding line of treatment given by the concerned hospital/Nursing Home.  When the complainant is holding insurance policy and when he is paying the premium regularly, he is obviously entitled to get service from the service provider, but it is unfortunate that the OP No.1 totally repudiated the claim of the complainant and not only that OP No.1 opined that the patient could be treated as a OPD patient.  If a

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patient is suffering from fever with sore throat and on examination by doctor suspected as a patient of Dengue and advised to be admitted in hospital/Nursing Home then how the OP No.1 opined that the disease of the patient was nothing but simple in nature and hospitalization was not justified and the treatment could have been managed on OPD basis. 

Considering all these aspects it is clear that OP No.1 has failed and neglected to provide service to the complainant as a service provider and there was deficiency in service on the part of the OP No.1.  Under such circumstances, complainant is entitled to get the amount of Rs.31,334/- i.e., the cost incurred by the complainant towards treatment of his wife and complainant is further entitled to get Rs.25,000/- for negligence on the part of the OP No.1 to provide service and also for mental agony suffered by the complainant and the complainant is further entitled to get Rs.5,000/- towards litigation cost.          

In the result, the case succeeds.         

Hence, it is

                     O R D E R E D

that the Consumer Case No.47/S/2015 is allowed on contest in part with cost against the OP No.1 and dismissed on contest against the OP No.3 without cost and dismissed exparte against the OP No.2 without cost.

Complainant is entitled to get Rs.31,334/- for cost incurred by the complainant towards treatment of his wife from the OP No.1.

The complainant is further entitled to get Rs.25,000/- towards compensation for mental agony and deficiency in service and negligence on the part of the OP No.1.

The complainant is further entitled to get a sum of Rs.5,000/- towards litigation cost from the OP No.1

The OP No.1 is directed to pay a sum of Rs.31,334/- by issuing an account payee cheque in the name of the complainant for cost incurred by the complainant towards treatment of his wife within 45 days from the date of this order.

The OP No.1 is further directed to pay a sum of Rs.25,000/- by issuing an account payee cheque in the name of the complainant towards compensation for mental agony and deficiency in service and negligence on the part of the OP No.1 within 45 days from the date of this order.

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The OP No.1 is further directed to pay a sum of Rs.5,000/- by issuing an account payee cheque in the name of the complainant towards litigation cost within 45 days from the date of this order.

Failing which the amount will carry interest @ 9% per annum on the awarded sum of Rs.56,334/- from the date of this order till full realization. 

In case of default, the complainant is at liberty to execute this order through this Forum as per law. 

Let copies of this judgment be supplied to the parties free of cost.