IN THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, MURSHIDABAD AT BERHAMPORE.
CASE No. CC/118/2018
Date of Filing: Date of Admission: Date of Disposal:
09.07.18 18.07.18 05.08.22
Complainant: Arun Kumar Mukherjee,
Vill – Radhikanagar,
P.O.-Cossimbazar, , P.S.- Berhampore,
Dist-Murshidabad
PIN-742102
-Vs-
Opposite Party: 1.Manager Heritage Health Insurance
TPA Pvt. Ltd, Nicco House,
5th Floor, 2, Hare Street
Kolkata-700001,
2. Manager, The New India Assurance Co. Ltd.
Vill- Palsanda More,
P.S.- Nabagram,
Murshidabad
Pin-742238
Agent/Advocate for the Complainant : Nilabju Dutta.
Agent/Advocate for the Opposite Parties : Rajdip Goswami
.
Present: Sri Ajay Kumar Das…………………………..........President.
Sri. Subir Sinha Roy………………………………….Member.
Smt. Aloka Bandyopadhyay……………………..Member.
FINAL ORDER
SMT ALOKA BANDYOPADHYAY, MEMBER
This is a complaint under section 12 of the CP Act, 1986.
One Arun Kumar Mukherjee (here in after referred to as the Complainant) filed the case against Manager Heritage Health Insurance TPA Pvt. Ltd, Nicco House & Anr. (here in after referred to as the OPs) praying for relief alleging deficiency in service.
The sum and substance of the complaint case is as follows:-
Brief facts of the case as narrated by the Complainant is that he had obtained a Mediclaim Policy bearing No. 51290734172800000063 from the Opposite Party No. 2 for the duration from 10/10/2017 to 09/10/2018 for sum insured of Rs. 3 lacs after paying premium of Rs. 14950/-. During the currency of policy, the complainant reported the problem of back pain on 13/03/2018 and the doctor advised him for admission into Divine Nursing Home for proper treatment and investigation. Subsequently, the complainant was admitted in the said Nursing Home where treatment was done. Treatment expenses of Rs. 30,805/- incurred during the course of treatment, regarding which he lodged a claim with the opposite parties. The opposite parties repudiated his claim citing clause 4.4.11. The complainant therefore filed a complaint alleging deficiency in service on opposite parties for seeking the cost of treatment along with compensation.
Defence Case
After service of the notice the O.P.s appeared by filing written version and resisted the complaint on the ground of clause 4.4.11. It is stated that complainant’s ailment is a day to day problem and for getting temporary relief from such pain patient may take physiotherapy or traction time to time as and when required and for such treatment there is no need for hospitalization and such type of treatment would not come under the mediclaim policy which was issued by O.P. No. 2 in favour of the complainant. The O.Ps did not violate the terms and conditions of mediclaim policy and not acted of unfair trade practice and there is no deficiency in service on the part of the O.P. and the O.P.s prays for dismissal of the case against them.
On the basis of the complaint and written version the following points are framed for proper adjudication of the case:
Points for decision
1. Is the Complainant a consumer under the provision of the CP Act, 1986?
2. Is the Complainant entitled to get any relief, as prayed for?
Decision with Reasons:
Point no.1 & 2
All the points are taken up together for the sake of convenience and brevity of discussion.
Heard the Ld. Advocate for the complainant & perused the material on record along with the BNA filed by the O.P.s. Admittedly the complainant has a medical insurance of OP No. 2 through OP No. 1. The said policy bearing no. 51290734172800000063 through O.P. No. 1 was valid from 10.10.2017 to 09.08.2018. As per the petition of complaint the complainant was suffering from back pain so he consulted with Doctor Debasis Dutta on 13.03.2018 who advised “admit the pt. under me in Divine Nursing Home for clinical check-up, investigation, traction etc.” (That can be evident from annexture 1). From the discharge certificate of the said Nursing Home it will be clear that the complainant was admitted at the Divine Nursing Home Pvt. Ltd from 13/03/18 to 20/03/18 (Annexture-2) and for the treatment the complainant has paid Rs. 30,805/- (annexture-3). After that the complainant sent a request letter to the O.P. for settlement of his claim on 19/04/2018 but on 11/05/2018 the O.P. 2 vide a letter dt. 11/05/2018 repudiated his claim (annexture-5) for applicable clause of the policy (4.4.11).
We carefully peruse the “New India Floater Mediclaim Policy. We observed the clause 4.4.11 of the Insurance Policy, which is reproduced as under:- “Charges incurred at Hospital primarily for diagnosis, x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any illness or injury for which confinement is required at a Hospital.
Now, we observed the repudiation letter of the O.P. No. 1. The O.P. NO. 1 has repudiated the complaint’s claim on the ground that.
“As per documents provided it is Evident that no such active Treatment has been given. There was no need for Hospitalization. It may be treated in OPD basis. So, as per policy term & condition the claim is not admissible under clause no. 4.4.11 (NIA Floater Mediclaim Policy).
From the aforesaid discussion it is apparent that O.P. No. 1 repudiated the complainant’s claim taking as ground that complaint may be treated in OPD basis as such type of back pain in practically a day to day problem and from getting temporary relief from such pain patient may take physiotherapy or traction time to time as and when required and for such type of treatment there is no need for hospitalization.
For sake of argument if we consider that there was no need for hospitalization but from the materials on record we find that the complainant was admitted to hospital as per advice of the doctor. So in our view the repudiation of claim of the complainant by the O.P.s is not justified.
Considering the facts & circumstances of the case & documents filed before us we are of the opinion that the complaint is able to proof his case & he is entitled to get relief.
Reasons for delay
The Case was filed on 09.07.2018 and admitted on 18.07.2018. This Commission tried its level best to dispose of the case as expeditiously as possible in terms of the provision under section 13(3A) of the CP Act, 1986. Delay in disposal of the case has also been explained in the day to day orders.
In the result, the Consumer case is allowed.
Fees paid are correct.
Hence, it is
Ordered
that the complaint Case No. CC/118/2018 be and the same is allowed on contest against O.P.s with a cost of Rs. 2000/-.
The O.P.s are jointly & severely liable to pay the awarded amount & as such both the O.P.s are directed to pay Rs. 30,805/- along with litigating cost of Rs. 2000/- within 60 days from the date of this order in default the awarded amount i.e. Rs. (30805/- +2000)/- will carry interest @ 6 % per annum from the date of this order.
Let plain copy of this order be supplied free of cost, to each of the parties / Ld. Advocate/Agent on record, by hand /by post under proper acknowledgment as per rules, for information and necessary action.
The Final Order will also be available in the following Website:
confonet.nic.in
