West Bengal

Birbhum

CC/151/2016

Debabrata Mondal, S/O Saranan Mondal - Complainant(s)

Versus

Manager, The National Gen Ins Co Ltd.Suri Branch - Opp.Party(s)

Mohammad Sajimuddin

10 Jan 2018

ORDER

One Debabrata Mondal has filed a complaint stating that he is a Mediclaim policy holder under National General Insurance Co. Ltd. Suri Branch. Mita Roy Mondal, wife of the policy holder suffered from serious disease and she was admitted at the New Union Nursing Home Pvt. Ltd. in Kolkata. Mita Roy Mondal cured from her serious disease after spending a huge money for medical treatment. Thereafter Debabrata Mondal filed claim for treatment expenses to Insurance Co. as per terms and conditions of Mediclaim policy. The claim application has been registered by the Insurance Co. The O.P claimed some documents and papers from the applicant. The petitioner has been submitted all documents and papers of treatment to the O.P. But the O.P did not pay any claim compensation to the petitioner. The petitioner sent several reminders to the O.P Insurance Co. The O.P No.2 claimed documents one after another on behalf of the O.P No.1. Inspite of submitting all the documents the O.Ps did not pay any heed.  Being aggrieved the petitioner filed the complaint.

O.P No.1, Branch Manager, National General Insurance Company Ltd. Suri Branch appeared and contested the case. He stated in his written version when insured intimate any loss in connection with the Mediclaim policy it is the duty of Insurance Co. to settle the claim through Medi Assist India TPA duly licensed by Insurance Regulatory and Development Authority. O.P No.1 referred the claim for settlement to Medi Assist India. Medi Assist India submitted a report after examining and verifying all the medical documents stating that Mita Roy Mondal was an outpatient. She need not be admitted in Nursing home. Therefore the claim is repudiated.

O.P No.2  was expunged vide order No. 17 dated 11.05.2017.

Both the petitioner and O.P No.1 filed certain documents in support of their case. The petitioner is examined and cross examined as P.W.

Upon pleading of the parties following points are to be considered for discussion.

 

Points

1. Whether there is deficiency in service on the part of the O.P?
2. Is complainant entitled to get relief as prayed for?

Decision with reasons

The points being interlinked each other are taken together for discussion.

Admitted fact that the petitioner is a Mediclaim policy holder having policy certificate No. 150401/48/15/8500000027 effecting from 12.04.2015 to 11.04.2016 under the National Insurance Co. Ltd. It is also admitted that the wife of the petition admitted in Nursing home at Kolkata on 23.01.2016due to Acute Torticolles with Radiculopathy (RT). But the dispute raised by the O.P is that the patient need not be admitted in Hospital for such illness as it was outpatient department. In support of their claim they filed the report of Medi Assist India TPA Pvt. Ltd. duly licensed by Insurance Regulatory and Development Authority i.e. Insurance Regulator to investigation into the cause of loss and assess the extent of loss if any. Medi Assist India are medically qualified third party who opined that on scrutiny of claim documents the wife of the petitioner Debabrata Mondal was outpatient.

According to exclusion clause 4.18 the Company shall not be liable to make any payment under the policy in respect of any expenses incurred in connection with outpatient department diagnostic and evaluation purpose where such diagnosis and evaluation can be carried out as outpatient procedure and the condition of the patient does not require hospitalization. The beneficiary, Mrs. Mita Roy Mondal was admitted in New Union Nursing Home, Kolkata on 23.01.2016 with complaints of pain in cervical region diagnosed as Acute Torticolles with Radiculopathy (RT). After scrutiny of submitted claim materials, the O.P observed that hospitalization of patient as inpatient from 23.01.2016 to 30.01.2016 was mainly for observation and monitoring with no active line of treatment. The insured for his complaint took the route of medical management through physiotherapy which could be done on OPD basis without admission to the hospital.

The petitioner filed certain documents like discharge certificate, treating doctor’s letter, medical bills etc. From the discharge certificate issued by New Union Nursing Home Pvt. Ltd. Kolkata, it is clear that Mita Roy Mondal was admitted in 23.01.2016 under Dr. Kalyan Mukherjee, FRCS, with Acute Torticolles with Radiculopathy (RT) and discharged on 30.01.2016 i.e. she was under treatment in Nursing Home for 7days.

Letter of treating doctor addressed to Medi Assist India TPA Ltd. dated 26.04.2016 in response to Medi Assist’s quarries dated 14.03.2016 and 25.03.2016 reveals that “the patient, Mrs. Mita Roy(Mondal) come to us with Acute Torticolles with C-5, C-6 Radiculopath (RT) with weak pinch (RT) which clearly showed neuroditict.

Hence, this patient could not be treated at home. Therefore, the patient was admitted at Nursing Home for proper management and treatment..”

Clause 3.14 of the Mediclaim policy says that inpatient means an insured person who is admitted in hospital upon the written advise of duly qualified medical practitioner for more than 24 continuous hours for the treatment of covered disease/insury during the policy period.

The treating doctor Dr. Kalyan Mukherjee, FRCS is a qualified medical practitioner. The letter of treating doctor clearly shows that “this patient could not be treated at home. Therefore the patient was admitted at Nursing Home for proper management and treatment”. The O.P did not challenge the aforesaid letter.

Therefore, the patient was inpatient as per Clause 3.14. The O.P is claim as the patient was OPD does not stand. The Forum thinks exclusion clause 4.18 should not be applied here.

From the above discussion it is proved that the O.P has deficiency in service.

The petitioner is entitled to get claim of Rs. 62036/- as per medical bills for treatment expenses and Rs. 5000/- for litigation cost.

Proper fees have been paid.

Hence,

O R D E R E D

                                                that C.F case No. 151/2016 be and the same is allowed on contest against the O.P No.1 without cost.

The O.P No. 1 is directed to pay Rs. 62036/- for treatment expenses and Rs. 5000/- for litigation cost within one month from the date of this order failing which the complainant shall be at liberty to execute the order as per law and procedure.

            Copy of this order be supplied to the parties each free of cost.