West Bengal

Paschim Midnapore

CC/53/2015

Bholanath Roy - Complainant(s)

Versus

National Insurance Co. Ltd. - Opp.Party(s)

Prosun Chakraborty

26 May 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

Sagarika Sarkar, Member. 

and 

Pulak Kumar Singha, Member.

 

Complaint Case No.53/2015

 

               Sri  Bholanath Roy, S/o Late Panchu Gopal Roy, At Arambagh Municipality, P.O. + P.S.    

              Arambagh, Dist.  Hooghly, W.B. 712601, mob. 9434840527, At present C/o Sumana  

               Ghosh, Saraswati Mondir Lane, Ballavpur, Dist. Paschim Medinipur, PIN-721101.                     

                                                                                                   …………..………..……Complainant.

                                                                              Vs.

1)Principal  Officer, National Insurance Co. Ltdl (Govt. of India under taking), Regd. Office. 3 Middletone street, Kolkata-700071, O.P. no.-1,

2)Divisional Manager, National Insurance Co. Ltd., Medinipur Division Station Road, Dist. Paschim Medinipur, PIN-721101, O.P. no.-2,

3)Principal Officer Apollo Gleneagles Hospital, 58 Canal Circular Road, Kolkata-73054, O.P. no-3,

4)The General Manager Operation, Rathshield, Healthcare (TPA) service Ltd, Kolkata, 5 A Chowrangee Lane, 4^th Flo0or, Flat no. IC, Kolkata-700016……….….Opp. Parties.

                                                     

              For the Complainant: Mr. Prasun Chakraborty, Advocate.

              For the O.P.               : Mr. Mrinal Chowdhury, Advocate.

 

Decided on: -26/05/2017

                               

ORDER

                          Bibekananda Pramanik, President – This is a case u/s 12 of the C.P. Act, filed by the complainant  Bholanath Roy against the O.P.-Principal Officer, National Insurance Company Ltd. and two others.

Contd…………………..P/2

 

( 2 )

  Facts of the case, in brief, are that the complainant is a senior citizen and he

   is practicing as an advocate in Arambagh Court.  The complainant obtained a National mediclaim insurance policy being no.153800/48/13/8500001124 from the O.P.-National Insurance Company Ltd. through its’ agent Sandip Mondal on 16/09/2013 at an annual premium of Rs.8,731/- covering the risk of Rs.2,00,000/- in respect of various diseases  mentioned in the insurance policy.  The said policy was valid from 20/09/2013 to 19/09/2014. During the said coverage period, complainant was admitted in the Apollo Gleneagles hospital on 04/6/2014 with problem of enlargement of Prostate (Prostrato megaly) and soft structure at Bulbar urethra and after necessary treatment and operation, he was discharged on 07/06/2014 from the Apollo Gleneagles hospital (O.P. no.3).  For such treatment and operation, O.P. no.3 Apollo Gleneagles hospital issued a bill dated 07/6/2014 of Rs.76,715/- to O.P. no.4-General Manager Operation, Rathshield, Healthcare (TPA) Service Ltd. for payment.  But unfortunately, O.P. no.4 paid Rs. 20,000/- only without any basis against the said bill of Rs.76,715/-.  The complainant had to pay the rest amount of Rs.56,715 to the said hospital on 07/6/2014 under a receipt being no.RC 274197.  Smt. Sumana Ghosh (Roy), daughter of the complainant, used to look after  medical policy affairs as well as hospital affairs on behalf of  her father. O.P. no.3, the Apollo Gleneagles hospital, insisted Smt. Sumana Ghosh (Roy) to sign and to give undertaking on a printed paper wherein it has been reflected that a sum of Rs.45,000/- was sanctioned under the policy as per PPN package  rate during the hospitalization period.  In that undertaking, the daughter of the complainant was made to say that she understood that any payment over and above charge made by the hospital would be borne by the patient party and would not be reimbursed by the insurer TPA. O.P. no.3 insisted payment for the said amount of Rs.56,715/- for discharge of the complainant and therefore the complainant had pay the said sum to the hospital.  He stated that in view of the terms and conditions of the policy, O.P. nos.1, 2 & 4 are liable to reimburse the amount which was paid by the complainant in cash to the O.P.- Apollo Gleneagles hospital.  It is therefore stated as per terms and conditions of the mediclaim policy, O.P. nos.1 & 2 are liable to pay the entire expenses incurred by the complainant during his stay at the hospital.  Since the O.P. no.4 only paid Rs.20,000/-, so there is deficiency in service on the part of the O.P.-Insurance Company and hence the complaint, praying for directing the O.P. nos.1, 2&4 to reimburse the rest amount to the tune of Rs.56,715/- in favour of the complainant and to pay a sum of Rs.25,000/- for deficiency in service and Rs.10,000/- as litigation cost. 

Contd…………………..P/3

 

( 3 )

                  The opposite party nos.1 & 2 have contested this case by filling a joint written objection.

    Denying and disputing the case of the complainant, it is the  specific case of the opposite party nos.1 & 2 that the complainant submitted claim form along with related papers to the O.P. and from the said in claim form and related papers, O.P. came to know that the complainant was admitted in Apollo Gleneagles hospital in Kolkata on 04/6/2014 as per advice of doctor for undertaking surgical operation.  After process of claim on the basis of document submitted by the complainant, the O.P. settled the claim at Rs.20,000/- which was sent to the account of Apollo Gleneagles hospital through  NEFT against bill of Rs.76,715/- following the policy terms and conditions and barring inadmissible expenses. It is stated that there was deduction of Rs.56,715/-  from the claim amount of Rs.76,715/- and such deduction was made following the clause of insurance policy in cashless benefit and according to policy condition and also for non-furnishing of supporting documents as  recommended  by their TPA i.e. O.P. no.4.  In spite payment of Rs.20,000/-, an undertaking and discharge vouchers was given towards full and final settlement by the complainant’s daughter Sumana Ghosh who is the authorized person in the matter of dealing with the insurance affairs and mediclaim matter on behalf of the complainant and after execution of such discharge voucher, it cannot be said that there is an deficiency in service from the side of the O.P.-Insurance Company.  O.P. no.1 and 2 therefore claim dismissal of the petition of complaint with cost.

O.P. no.3 has contested  this case by filing a written objection. O.P. no.3 has

                stated in the w/o that at the time of discharge of the patient, the O.P. no.3 placed the bill of Rs.56,715/- which was lying due for payment thereof and they never the pressed hard for such payment as alleged in the petition of complaint.  It is stated that since the complainant had paid the entire dues of the patient’s treatment at the time of discharge, so there cannot be any claim against the O.P. no.3 and  the instant case may be dismissed against the O.P. no.3.

                  O.P. no.4 did not appear to contest, this case inspite of service of notice upon him and as such the case was ordered to be heard exparte against O.P. No.4.

                To prove his case, the complainant has examined one Jyotirmoy Roy Chowdhury  as OPW-1 and during his evidence, six documents were marked as exhibit 1 to 6 respectively.  On the other hand, O.Ps adduced no evidence.

Contd…………………..P/4

 

( 4 )

                                                                 Points for decision

1)Is the case maintainable in it’s present form and prayer?

2)Is the complainant a consumer under the provision of C.P. Act?

3)Is there any deficiency in service on the part of the opposite party?

4)Is the complainant entitled to get the reliefs, as sought for?    

                   

Decision with reasons

       For the sake of convenience and brevity, all the above points are taken up   

             together  for consideration.

       From the respective pleadings of the parties, it appears that admittedly the

               complainant is a consumer of the O.P.-Insurance Company having his  medical insurance policy with the O.P.-Insurance Company for Rs.2,00,000/- covering the period from 20/09/2013 to 19/09/2014.  It is also not denied and disputed that the complainant was admitted in Apollo Gleneagles hospital on 04/6/2014 with problem of enlargement of prostate (Prostrato megaly) and soft structure at bulbar urethra and after necessary treatment and  operation, he was discharged on 07/06/2014  from the   Apollo Gleneagles hospital.  Fact remains undisputed that for such hospitalization and treatment, a bill dated 04/6/2014 for Rs.76,715/- was issued by the said hospital and O.P. no.4, on behalf of O.P.-Insurance Company, only paid Rs.20,000/- to the hospital.  In their w/o, O.P. nos.1 & 2 have stated that the complainant submitted claim form along with related papers to the O.P. and after processing the claim on basis of documents submitted by the complainant   O.Ps. settled the claim at Rs.20,000/- and the same was paid to the hospital concerned against bill of Rs.76,715/-. It has been further stated by the O.P-Insurance Company in their w/o that there was deduction of Rs.56,715/- from the said claim amount of Rs.76,715/- and such deduction was following the clause of insurance policy in cashless benefit and also for non-furnishing of support documents and inadmissible expenses which was recommended by their TPA i.e. O.P. no.4. The said reason for deduction of Rs.56,715/- on the ground of non-furnishing of supporting documents and in admissible expenses is vague and the reasons cited by the O.P.-Insurance Company is not at all convincing. They have also not stated clearly as to which  documents were not furnished by the complainant along with his claim form.  Admittedly, the said policy covered a sum of Rs.2,00,000/- and admittedly the complainant has incurred a sum of Rs.76,715/- for his treatment and operation in the said hospital.  In spite of that, the O.P.-Insurance Company has paid only Rs.20,000/- although the complainant’s policy was for hospitalization and

Contd…………………..P/5

 

( 5 )

               domiciliary hospitalization benefit policy.  Non-payment of the rest amount of Rs.56,715/- against the total bill amount of Rs.76,715/- without just and proper cause is an arbitrary act on the part of the O.P.-Insurance Company and it amounts to deficiency in service on their part.  The petition of complaint therefore deserves to be allowed with the following directions.

All the points are accordingly decided in favour of the complainant.

In the result, the complaint case succeeds.

 

                                               Hence, it is,

                                                     Ordered,

                        that the complaint case no.53/2015  is allowed on contest against the O.P. nos.1 & 2 with cost and dismissed against the rest O.Ps without cost.  O.P. nos.1 & 2 are directed to pay Rs.56,715/- towards the balance amount of reimbursement of mediclaim policy to the complainant within a month from this date of order and they are also further directed to pay Rs.15,000/- as compensation and Rs.5,000/- as litigation cost to the complainant within one month from this date of order.

                               Let plain copy of this order be given to the parties free of cost.

                 Dictated and Corrected by me

       

                             B. Pramanik.                 P.K. Singha           S. Sarkar                  B. Pramanik. 

                               President                        Member              Member                      President

                                                                                                                                District Forum

                                                                                                                             Paschim Medinipur