Complainant by filing this complaint has submitted that complainant has been holding a Medi Claim Policy under the op No.1 company continuously from 17.06.1997 without any interruption till now and ultimately the continuation of the policy bearing No. was 101100/48/98/13/8500002813 valid for the period from 17.06.2013 to midnight of 16.06.2014.

          Fact remains that complainant became serious physically ill due to vertigo, nausea and vomiting and serious condition he was taken to Dr. Dipak Kumar Paul on 17.09.2013 who attended the complainant who advised for quick ECG and also issued one prescription in the name of the complainant and when the situation became worst, complainant was taken to Dr. PrabitraMitra Cardiologist who attended the complainant and advised for hospitalization in writing and in such situation complainant was admitted to present hospital of MedicaSuperspeciality Hospital in Kolkata and finding no other alternative the complainant was admitted on 17.09.2013 at 23:45 hours and was discharged on 20.09.2013 at 13:09 hours.

          After recovery and at the relevant time he was aged 58 years.  Thereafter complainant submitted mediclaim for Rs. 46,686/- on 17.10.2013.  But ultimately complainant received an email on 18.09.2013 from op no.1 repudiating the claim of the complainant which caused suffering and deficiency of service on the part of the op and challenged the said clause and complainant thourgh his lawyer sent a demand notice  on 08.03.2014 stating the fact  that the claim for reimbursement so made by the complainant is bona fide, just and proper and complainant challenged that repudiation as illegal and it was also reported to the op that complainant has been continuing this policy for last 17 years and never demanded any claim except Rs. 5,000/- for treatment out of the accident of the complainant’s son in the year 2003 and Rs. 12,000/- for complainant’s eye operation in the year 2007 and the present treatment it was a treatment for saving the life of the complainant but that was not rejected on the ground that it was only for investigation and in the above circumstances complainant is prayed for redressal and for compensation of Rs. 3,50,000/- against op.

          On the other hand op by filing written statement submitted that complainant being a policy holder aged about 58 years has been suffering from vertigo and vomiting and nausea and he was advised for medications and few investigations.  But insured got admitted on the same day to Medica Super specialty Hospital for evaluation as noted in the discharge certificate and ongoing through the discharge summary notes of the said hospital it is clearly evident that the patient had symptoms of vertigo and vomiting for 2 days prior to hospitalization and on admission his physical examinations were within normal limits and he was released from the hospital.  But such sort of investigation is not required for admitting him in the hospital and the discharge certificate had not made any specific mention.  So it was not the actual treatment as it was conservative treatment.  So, there was no need of the complainant for hospitalization and got such investigation for admitting for which the claim was rejected and there was no laches on the part of the op and further submitted that insurance company took decision after due application of his mind and said decision cannot be said to have been taken otherwise on good faith based on material collectedpursuant.  So, there was no deficiency in service and op denied all the allegation for which the present complaint should be dismissed.

Decision with reasons

          On careful study of the complaint including written version and also the discharge summary and the argument advanced by the Ld. Lawyers of both the parties including the repudiation letter dated 27.10.2013 issued by TPA, it is found that the repudiation was made only on the ground that discharge summary reflected the certain investigations but no active treatment was taken.  But considering the repudiation and also considering the discharge summary we find that practically the ground for repudiation is not at all legal, correct and fact remains in a complicated situation complainant was readily admitted as per advice of the private doctor and no doubt the treatment was given such a medical treatment cannot be done keeping the patient inside the house because for proper investigation he was admitted that it was one type of disease which can be searched out only by scan on brain that was detected and by further continuation of check that disease was finally diagnosed and no doubt it is a serious complication of heart.  The medicine was applied by the hospital authority for 4 days and it was under control.  But after release further medication is highly required and he is in continuous process of treatment but any how proper medical knowledge has not been properly applied by the TPA for which the claim was repudiated.

          So, considering that fact we are convinced to hold that the repudiation as made by TPA is not justified, legal, valid in view of the medical science and cardiology expert and authority also advised that in such situation hospital admission is must for observation and for medication.  But anyhow that matter was overlooked by the TPA and in fact op/insurance Company had no fault in view of the fact for wrong decision of TPA doctors.

          So, we do not find any negligence on the part of the op no.1.  But TPA cannot be made a party in view of the fact that TPA is the appointed authority for deciding the claim  for perspective of medical jurisprudence.  But anyhow in this case the opinion of the TPA and subsequent repudiation by the op no.1 are found not as per medical science and the theory of cardiologist.  Accordingly we are allowing this complaint directing the ops to settle the claim as filed by the complainant treating the repudiation as bad in law and op nos. 1 & 2 shall have to decide the settlement on appropriate way considering the final bills in details and give him such a relief what complainant is entitled to out of the total amount as prayed for against the total mediclaim.

          But under any circumstances, ops cannot any way repudiate the claim further to decide the claim in respect of the amount what complainant is entitled to as per terms of the policy and clause 4 is not applicable in this case.

          Hence, it is

ORDERED

          That the complaint be and the same is allowed on contest against the op no.1 without any cost and same is dismissed on contest against the op no.2 without any cost.

          Op no.1 NIC is hereby directed to decide the claim treating it as a treatment for cardiological disorder and only the op no.1 shall have to decide how much the complainant is entitled to and what amount shall be settled by the op no.1 that shall be sent to the complainant by transmitting the said amount to the account of the complainant in this regard op no.1 shall have to collect the bank account number of the complainant and to finally settled the present claim within one month from the date of this order and if within one month it is not settled by the op no.1 in that case op no.1 shall have to pay a sum of Rs. 35,000/- to the complainant forthwith and without any further delay by transmitting the same in the account of the complainant.

          If op fails to comply this order in that case penal action shall be started for which further penalty and fine shall be imposed for which op shall be liable for that.