Order No. . This is an application u/s.12 of the C.P. Act, 1986. Complainant by filing this complaint has submitted that complainant is the legally married husband of Late Chhanda Ray Barman who died intestate on 20-08-2013 and accordingly present complainant as substitute heir is contesting the case stating that complainant is the husband of Late Chhanda Ray Barman who was admitted to Paramount Nursing Home on 18-02-2011 under the advice of family physician, Dr. Basu and subsequently after treatment she was discharged on 28-02-2011 and it was diagnosed that she was suffering from Confusional State followed by Fall and Bowel Irregularity and during that period from 18-02-2011 to 28-02-2011 a sum of Rs.61,601/- was incurred by the complainant for her medical expenditure and said Chhanda Ray Barman was a policy holder being No.101100/47/10/8500010398 under National Insurance Company Ltd., and as per said policy OP is legally bound to pay the said medical expenses because the policy was valid for the period from 18-02-2011 to 28-02-2011 during the period of treatment also and complainant’s wife preferred a claim to the OP vide TPA Claim No.71848 for Rs.61,601/- after due discussion with Third Party Administrator said claim was rejected by the Company on 03-06-2011 on the ground that the present claim is for the treatment of Confusional State followed by Fall and Bowel Irregularity as reflected from discharge certificate which is psychiatric illness and as per policy it is not payable and so, claim was denied. Though there is no specific opinion of the doctor after diagnosis that complainant was suffering from any psychiatric ailing and so, they prayed for reconsideration of the same but that was also turned out and in the above situation complainant has prayed for release of the said amount as per policy and with interest etc. OP1 by filing written version submitted that the claim is not maintainable in law as per mediclaim policy terms and rules as framed therein and they have also stated that OP2 is already reported that as it is not admissible in terms and condition of the Mediclaim Policy including Exclusion Clause 4.8 wherein it is specifically mentioned all psychiatric & psychosomatic disorders/diseases, accidents due to misuse or abuse of drugs/alcohol or use of intoxicating substances no claim can be entertained and after scrutinizing the above claim documents OPs penal doctor opined that present claim is for the treatment of acute Confusional State followed by Fall and Bowel Irregularity as reflected from discharge certificate and as same is psychiatric illness so the claim is not payable. So, OPs have submitted that they have their no negligence and deficiency on the part of the OP. Decision with Reasons No doubt in this case after meticulous study of the complaint and the written version and also considering the discharge certificate it is found that the said lady was admitted to hospital for treatment of acute Confusional State followed by Fall and Bowel Irregularity as reflected from Discharge Certificate and as per medical treatment Confusional State means a patient who has been suffering from psychiatric illness and, in fact, there is no scope to deny such observation of the doctors of the TPA or the doctors of the OP/Insurance Company in view of the fact in the discharge certificate same has been specifically mentioned when that is the fact then in view of the provision of 4.8 of the policy the complainant cannot get relief of the claim release as there is exclusion clause and considering the present discharge certificate including decision of the OPs and also 4.8 of the Mediclaim Insurance Policy Clause it is clear that due to psychiatric or psychosomatic disorders/diseases, accidents due to misuse or abuse of drugs/alcohol or use of intoxicating substances no claim can be entertained and apparently considering that fact we are of opinion that apparently there is no negligence or deficiency on the part of the OP but considering the whole aspect and to get the opinion of Dr. Bose who treated that lady we find that matter should be further reinvestigated by the OPs and for which we are allowing this complaint with direction to the OP to call for opinion of Dr. Bose who treated that lady and to collect specific opinion in writing what is the actual meaning of Confusional State because such a diagnosis is made for several reasons as evident from the medical dictionary and further to collect such opinion from Dr. Bose whether that lady suffered from any psychiatric or psychosomatic disorder at that time. In the result, the case succeeds. Hence, Ordered That the case be and the same is allowed on contest against the OPs but without any cost. OPs are directed to reconsider the claim of the complainant after collecting specific opinion of Dr. Bose who treated that lady and also his specific opinion about the term “Confusional State followed by Fall and Bowel” and further specific opinion from Dr. Bose whether that lady was suffering from any psychiatric and psychosomatic disorder or not and if she had been suffering from psychiatric illness in that case the OP shall have to send their such decision to the complainant and in that case complainant shall not get any benefit in the future but if the opinion of the Dr. Bose goes against such opinion of the psychiatric illness in that case OP shall have to reconsider the mediclaim of the complainant afresh brushing aside their previous denial of the claim and release such amount as complainant is entitled to. OPs are directed to complete the entire matter as per direction and spirit of the order within two months from the date of this order and to report to the complainant finally whether his claim has been honoured or dishonoured.
| | [HON'ABLE MR. Ashok Kumar Chanda] MEMBER[HON'ABLE MR. Bipin Muhopadhyay] PRESIDENT[HON'ABLE MRS. Sangita Paul] MEMBER | | 
