Dt. of filing – 21/12/2017
Dt. of Judgement – 18/02/2019
Mrs. Sashi Kala Basu, Hon’ble President
This consumer complaint is filed by the Complainant namely Sri Madan Mohan Sinha under Section 12 of the Consumer Protection Act, 1986 against the Opposite Parties namely 1) MD Indian Health Care Services Pvt. Ltd. 2) Divisional Manager, United India Insurance Company Ltd. 3) Poorva Eye Care and 4) Dr. Indranil Sarkar.
Case of the Complainant in brief is that on 22/4/2017 he had cataract operation in his left eye at Poorva Eye Care and also had the same operation of his right eye on 24/6/2017. Complainant is a medical policy holder (SAIL) with Min No.3110383 and regularly pays the premium for the said medical policy. Complainant submitted bill of Rs.28,555/- for the said operation of his left eye in order to realize the said amount under the coverage of the said medical policy but the Opposite Parties have only sanctioned Rs.15,915/-. But did not sanctioned rest of the amount i.e. Rs.12,640/-. The Opposite Party Nos.1 & 2 have deducted Rs.13,140/- including the surgeon charges. The Opposite Parties though have already paid the amount towards the second operation dated 22/6/2017, but till date they have not paid the amount of Rs.13,140/- for his left eye operation inspite of his repeated request. A demand notice was also sent by the Complainant through his Ld. Advocate to pay the said balance amount but all in vein. So the present complaint case has been filed by the Complainant for directing the Opposite Parties to pay Rs.12,640/- with interest, to pay Rs.1,00,000/- for harassment and mental agony and litigation cost of Rs.50,000/- .
Complaint petition is contested by Opposite Party No.4 by filing written version stating inter alia that he had conducted cataract surgery in the left eye of the Complainant at Poorva Eye Care and had received the amount of Rs.11,500/- as his professional fee and accordingly had issued the receipt. Opposite Party No.4 is in no way connected with this dispute between Complainant and Opposite Party Nos.1 & 2 and thus he has prayed for dismissal of the complaint against him.
Opposite Party No.2 has also contested the case by filing written version denying allegation made in the complaint petition against it contending inter alia that after meticulous scan considering the scope of the subject policy, said TPA settled the total claim of Rs.15,915/- deducting charges of the Doctor/Surgeon of Rs.11,500/-, since the said bill is not a part of the hospitalization bill and has been issued separately. Clause 1.2C note 2 of subject policy is very categorical that in the event of any claim becoming admissible under the scheme, the Company will pay through TPA to the hospital/nursing home or insured person the amount of such expenses as would fall under different heads. So as Doctor/Surgeon fee of Rs.11,500/- was not in the hospital bill, in terms of Clause 1.2C, Complainant is not entitled to the said amount and thus complaint is liable to be dismissed.
No written version filed by Opposite Party Nos.1 & 3 but during evidence Opposite Party No.3 has filed its evidence.
Complainant has annexed with the complaint petition, copy of the letters sent to the Opposite Party Nos.1 & 2, form submitted for claiming the benefits, letter of Opposite Party No.3, bills of the said nursing home, discharge certificate and copy of the notice sent by the Complainant through his Ld. Advocate.
In course of the evidence both the parties adduced their respective evidence followed by filing of questionnaire and reply thereto. Complainant and also the Opposite Party No.2 have filed the written notes of argument. Ld. Advocate of Opposite Party No.2 has also cited the case law reported in 2013(2) CPR 315(SC).
So the following points require determination:
- Whether there has been deficiency in providing service on the part of the Opposite Parties?
- Whether the Complainant is entitled to the relief as prayed for?
Decision with reasons
Point Nos.1 & 2
Both these points are taken up together for comprehensive discussions.
Complainant is a medical policy holder (SAIL) with Min No.3110383 is not disputed and denied by the Opposite Party No.2 . It is also not disputed by the Opposite Party No.2 that the Complainant had undergone cataract operation of his left eye on 22/4/2017 and a bill of Rs.28,555/- was submitted by the Complainant before the Opposite Party Nos.1 & 2 for its realization. The fact that Complainant had undergone left eye operation on 22/4/2017 is also admitted by Opposite Party No.4 Surgeon who conducted the surgery. Bone of contention in this case appears to be bill of Rs.11,500/- paid to the surgeon. It appears that Opposite Party No. 2 did not allow the same on the ground that it was not stated in the hospital bill. According to the Opposite Party No.2, as per Clause 1.2C of the said Health Insurance Policy, Complainant is entitled to the amount paid to the hospital/nursing home. But in this context it may be pertinent to point out that it is apparent from the bill submitted in this case by the Complainant that the hospital bill did not include the fees of the surgeon. After breakage of entire claim of Rs.28,555/- it appears that Rs.5,000/- is towards hospitalization charge, Rs.10,000/- cost of lens implant, Rs.2,055/- pre hospitalization expenses and Rs.11,500/- towards the fee of the surgeon for the surgery conducted by him. Opposite Party has paid Rs.5,000/- towards the hospitalization cost, Rs.10,000/- towards the cost of lens implant and Rs.915/- towards the pre hospitalization expenses. If the hospital has not included the fee of the surgeon of Rs.11,500/-, it cannot be expected that Complainant shall dictate to the said hospital/nursing home to include the surgeon’s fee. Fact remains surgery was done and surgeon took the fee of Rs.11,500/- for the said surgery conducted on 22/4/2017. Complainant was discharged on the same evening. Without surgery the question of hospitalization would not have arisen. Complainant was admitted for the said cataract operation in his left eye and for which the said hospitalization charge of Rs.5,000/- and cost of lens implant was paid by the Opposite Party. It is absurd to accept that Complainant is not entitled to the cost towards the surgery of Rs.11,500/- only because Doctor who conducted the surgery, issued bill separately and was not included in the hospital bill . The said nursing home being Opposite Party No.3 in this case ought to have issued the bill for entire expenses towards the hospitalization charge and the fee of the Doctor for the surgery which happened in the same process during hospitalization but for not doing the same by the Opposite Party No.3, Complainant cannot be made to suffer specially when the Opposite Party No.4 who conducted the surgery has also stated that he had issued the bill separately to the Complainant even though the surgery was conducted in the said nursing home being Opposite Party No.3. Clause 1.2C of the policy is also categorical that insured person is entitled to surgeon, anesthetist etc fees. In such a situation we hold that the Complainant is entitled to the said amount of Rs.11,500/-.
However, pre hospitalization charge claimed by him of Rs.2,055/- cannot be allowed as he has already been paid Rs.915/- towards the pre hospitalization expenses. Barring a bill of Rs.500/-, no other document is filed to show the expenses borne towards pre hospitalization. Complainant has also claimed compensation but in the given facts and situation of this case, no compensation is awarded, however he is entitled to litigation cost of Rs.15,000/-.
These points are answered accordingly.
Hence,
ORDERED
CC/709/2017 is allowed on contest against Opposite Party Nos.2 & 4 and ex-parte against the other Opposite Parties. Opposite Party Nos.1 & 2 are hereby directed to pay Rs.11,500/- to the Complainant within 45 days from this date. Opposite Parties are further directed to pay Rs.15,000/- towards the litigation cost within the aforesaid period of 45 days failing which the entire amount shall carry interest @ 10% p.a till realization.
