IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
MURSHIDABAD AT BERHAMPORE.
CASE No. CC /116/2014.
Date of Filing: 28.08.2014. Date of Final Order: 30.10.2015.
Complainant: Archan Kumar Ghosal, S/O Late Biswanath Ghosal,
21, Radhakrishna Khan Lane, P.O. Khagra, P.S. -Berhampore town,
Dist.- Murshidabad. Pin- 742101.
-Vs-
Opposite Party: Manager, United India Insurance Company Ltd, Berhampore Branch,
3/20/A, K.K. Banerjee Road, 1st floor, P.O.& P.S. Berhampore, Dist. Murshidabad.
Pin -742101
Present: Sri Anupam Bhattacharyya ………………….President.
Sri Samaresh Kumar Mitra ……………………..Member.
Smt. Pranati Ali ……….……………….……………. Member
FINAL ORDER
Sri Anupam Bhattacharyya, Presiding Member.
The instant complaint has been filed by the complainant u/s 12 of C. P. Act, 1986 praying for payment of Rs.315387/- in respect of Insurance Scheme and cost of Rs.5000/- and compensation of Rs.10,000/- for mental pain and agony.
The complainant’s case, in brief, is that the complainant was suffering from low back pain associated with right knee pain and left shoulder pain. While it was so severe at his sister’s in-laws house at Raghunathganj he was admitted at Jangipur S.D. Hospital on 28.4.14 and for better management the complainant was advised to get admission at any State Medical College at Kolkata and being referred from the said Jangipur S.D. Hospital the complainant in severe spinal pain was admitted at Woodland Multi Specialty Hospital on 29.4.14 and remained there as indoor patient up to 1.5.14. Again he was admitted in said hospital on 20.5.14 and was discharged there from on 22.5.14. He informed the OP Insurance Company about his hospitalization. The complainant spent Rs.1, 47,387/- for the above treatment (Rs.28, 735/- for the admission on 29.4.14 and Rs.1, 18,652/- for his admission on 20.5.14). In addition to the said expenses the complainant is still undergoing treatment and injection namely Embrel 50 units is administered in alternative 7 days the cost of each injection is Rs.11,250/- and he will have to take such injection in such interval for another 11 numbers and he will have to pay the cost of injection Rs.1,23,750/- . So total cost of such injection during the six months course in every after 7 days will be of Rs.1, 68,000/- total cost so far incurred by the complainant for his such illness of Rs.3, 15,387/- and the complainant submitted his claim for the said amount in the prescribed form before the OP Insurance Co. who repudiated the same on 29.5.14 arbitrarily without any cogent reason. Then, the complainant has filed the instant complaint. Hence, the instant complaint case.
The written version filed by the OP-Insurance Co, in brief, is that after inspecting the treatment documents and discharge certificate it was found that he was admitted only for Investigation purpose, all medicine taken oral route. As such the claim is not admissible under Clause 4.11 Gold Policy and as per exchange claim in 4.11 of the Gold Policy the claim cannot be entertained. During the stay of the petitioner in the Hospital only Investigations were done. For such Investigations it was not necessary to take admission in the Hospital. The medicine was taken Oral Route. There is no deficiency in service. The OP-Insurance Company has rightly repudiated the claim. Hence, the instant written version.
Considering the pleadings of both parties the following points have been fixed for the disposal of the case.
Points for consideration.
- Whether the complaint is maintainable or not?
- Whether the complainant is a ‘consumer’ or not?
- Whether the case is barred by law of limitation or not?
- Whether the complainant is entitled to get the relief as prayed for?
- To what other relief/reliefs the complainant may get?
Decision with reasons.
Point Nos. 1 to 5.
All the points are taken up together for the sake of convenience.
The complainant has filed the instant complaint for realization of medical expenses including future expenses for Rs.3,15,387/- along with cost of Rs.5,000/- and compensation of Rs.10,000/- .
The complainant’s case, in brief, is that the complainant was admitted in the Woodland Multi Specialty Hospital on and from 29.4.14 to 1.5.14 being referred from Raghunathganj S.D. Hospital on 28.4.14 and was again admitted there on and from 20.5.14 to 22.5.14 and undergone treatment there and spent Rs.1,47,387 (Rs. 28,735/- + 1,18,652/- for the period 29.4.14 and 20.5.14 to 22.5.14) and future treatment for administering injection @Rs.11,250/- per injection as per advice to be administered in alternative seven days where cost is Rs.1,68,000/-.Thus total expenditure will be Rs.3, 15,387/-.
On the other hand the OP’s case, in brief, is that after inspecting the treatment documents and discharge certificate it was found that he was admitted only for Investigation purpose, all medicine taken oral route. As such the claim is not admissible under Clause 4.11 Gold Policy and as per exchange claim in 4.11 of the Gold Policy the claim cannot be entertained. During the stay of the petitioner in the Hospital only Investigations were done. For such Investigations it was not necessary to take admission in the Hospital. The medicine was taken Oral Route. There is no deficiency in service.
The dispute is that whether the injection administered being admitted in the hospital will be treated as treatment and the same is admissible as per terms of the policy
To prove the complaint’s case the complainant has adduced his evidence –on- affidavit and has also filed the relevant documents in support of this case.
From the documents filed by the complainant it appears that the complainant has filed a discharge certificate of the complainant issued by the Apollo First Med Hospital for the period from 15.04.10 to 16.4.10.
Relying upon this document the ld. lawyer for the complainant has advanced argument that this complainant is an old policy holder and he got payment from the OP-Insurance Co. on earlier occasion for this identical treatment for the period of this document relied upon.
He has argued that as the OP-Insurance Co. has paid the insurance claim on earlier occasion in the year 2010 for the identical treatment, the OP cannot repudiate the instant claim and for that the complainant is entitled to get the same and the OP-Insurance Company is liable to pay the insurance claim for the impugned treatment.
The contention of this argument is not in the pleading of the complainant. Also, no document has come before this Forum as to payment for the referred period by the OP to the complainant.
The question of precedent cannot be raised as the same is not in the pleading of the complainant.
Now, the dispute is whether mere administering injection admitting in the woodland Hospital will come under the purview of this policy or in other words whether the complainant is entitled to get claim for that purpose and if so to what extent, even for future treatment for administering injection @ Rs.11, 250/- per injection for 15 injection amounting to Rs.1, 68,000/- during six months course in every seven days.
Regarding entitlement of the claim of the complainant in respect of the policy for administering injection the Ld. lawyer for the OP-Insurance Co. has referred the terms No. 4.11 of the Policy by filing the relevant documents which provides as follows:-
“Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory examination or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or inquiry, for which confinement is required at a Hospital/Nursing Home.”
Relying upon this provision the ld. lawyer for the OP-Insurance Co has advanced argument that the complainant is not entitled to get any payment for the expenditure incurred during admitted in the Hospital , if the said expenditure was incurred for investigation . He has also advanced argument relying upon the a foresaid terms of the policy that mere injection is not treatment and as per the instant terms bearing No. 4.11 the term ‘conservation’ means observation and regarding administering injection the Ld. lawyer for the OP-Insurance Co has advanced argument relying upon expert’s opinion that mere injection is not treatment and is not admissible in the policy and for that the complainant is not entitled to get any relief.
Against this argument the Ld. Lawyer for the complainant has advanced argument raising strong objection against the expert’s opinion.
In this regard he has advanced argument that the said expert has not been examined and in this case this is inconsistent. Here is positive ailment and from the document the discharge certificate filed by the complainant issued by the Apollo First Medical Hospital for the period from 15.4.10 for identical treatment it is clear that the instant admission of the complaint in the Woodland Hospital is not for investigation
Considering the argument advanced by both sides and also considering the documents filed on the question of entitlement of the claim being not treatment we find that the admission in the Woodland Hospital is not for mere investigation but for treatment also and for that the complainant is entitled to get claim for the treatment.
Considering the complainant’s case and also considering the documents filed by the complainant we find that the complainant was referred to by Jangipur S.D. Hospital on 29.4.14 at 4-35 A.M. where in the word ‘A.M” the letter “A’ was overwritten and it appears that first it was written as ‘P’ then it was written as “A’ and it also appears that there is no initial signature against that over-writing.
Also, in the referral and there is no whisper about the period of detention in the Jangipur S.D. Hospital where in the complaint petition there is a clear averment that the complainant was admitted at Jangipur S.D. Hospital on 28.4.14 and was advised to get admitted at any State Medical College at Kolkata.
Complainant’s case is that he was admitted in the Woodland Hospital on 29.4.14 to 1.5.14 and 205.14 to 22.5.14 and paid Rs. 28735/- and 1,18,652/- respectively totaling to Rs.1,47,387/-.
For future treatment for administering 15 injections @ Rs.11,250/- per injection during six months course in every after seven days totaling to Rs.1,68,000/-.
The complainant has claimed total cost of treatment for Rs.1, 47,387/- + Rs.1, 68,000/- = Rs.3, 15,387/-.
To justify the total amount of medical expenses incurred on two occasions amounting to Rs.1,47,387/- the complaint has filed two cash receipts of Woodland Multi Specialty Hospital for Rs.10,000/- and Rs.11,759/- for 29.4.14 and 1.5.14 respectively against the bill of Woodlands for Rs.21,759/- for four different X-rays on 29.4.14.
The complainant has filed two cash memos and one prescription showing purchase of medicines on 8.5.14 for Rs.1588.50 and on 10.5.14 for Rs.4,488/- against the prescription issued by doctor Abhrajit Roy of Woodland dt. 6.5.14 in his personal chamber. From this prescription it appears that the complainant consulted with this doctor further only on one occasion on 13.5.14.
The above two cash memos are not relating to the treatment of the complaint in the Woodland Multi Speciality Hospital.
Besides, the aforesaid two money receipts of Woodland Multispecaility Hospital of Rs.10,000/- and Rs.11,759/- totaling to Rs. 21,759/- and the aforesaid two c ash memos of Rs.1588.50 and Rs.4488/- totaling to Rs.6,076/- , the complainant has not filed any documents relating to the claim of the complainant for expenses incurred by him for Rs.1,47,387/- for the cost of treatment in the Woodland Multi Speciality Hospital and Rs.1,68,000/- for cost of future treatment for administering 15 injections @ Rs.11,250/- per injection, totaling to Rs.3,15,387/-.
In this case the claim of the complainant for the Insurance Claim is Rs.3,15,387.00 where the Insurance Policy is for Rs.1,50,000/-.. Thus the limit of the complainant for getting relief in respect of the Insurance Policy is Rs.1, 50,000/-only. Accordingly, there is no scope to get the claim beyond Rs.1, 50,000/-.
In this regard considering the above discussions without the documents such as vouchers to the payment for cost of treatment, there is no question of getting relief beyond that and for that we can safely conclude that in this case the complainant has filed only two cash memos amounting to Rs.21, 759.00 issued by the Woodland Multi Speciality Hospital for the period from 29.04.14 to 01.05.14 where the complainant was admitted and got treatment.
Two cash memos showing purchase of medicines for Rs.1588.50 dt. 08.05.14 and for Rs.4488.00 dt. 10.5.14 against the prescription issued by Dr. Abhijit Roy in his personal Chamber.
Those two cash memos are relating to the treatment in the personal chamber of Dr. Abhijit Roy. Those two cash memos are not relating to treatment during the period of admission in Woodland Hospital from 29.04.14 to 01.05.14.
Considering the two cash memos issued by the Woodland Hospital for rs.21, 759.00 we find that the complainant is only entitled to get relief for Rs.21, 759.00 and Rs.2, 000/- towards compensation for mental pain and agony.
On the basis of the above discussions we find that all these points are disposed of in favour of the complainant in part and the complainant is entitled to get award of Rs.21,759.00 plus compensation of Rs.2,000/- .
Hence,
Ordered
that the Consumer Complaint No. 116/2014 be and the same is hereby allowed in part. The complainant is entitled to get Rs.21, 759.00 as Insurance Claim and Rs.2000/- as compensation.
The OP /Insurance Company Ltd is directed to pay Rs.(21, 759.00 + 2,000.00= 23,759.00) to the complainant within 60 days from the date of this order, failing which the OP is to pay Rs.50/- per day’s delay as fine and the amount so accumulated shall be deposited in the “Consumer Legal Aid Account”.
Let a plain copy of this order be made available and be supplied free of cost, to each of the parties on contest in person, Ld. Advocate/Agent on record, by hand under proper acknowledgment / be sent forthwith under ordinary post to the concerned parties as per rules, for information and necessary action.
