JUDGEMENT

          Complainant by filing this complaint has submitted that he obtained one Mediclaim policy for his wife, for himself and daughter having Policy No.100400/48/12/8500000615 from the op and during validity period of the said policy is his wife Smt Swati Ghosh was treated under Dr. P. Das Mahapathra at Kothari Medical Centre on 06.08.2012 and during her treatment many medical tests were done as per advice of the said doctor and one injection was also infused for following up case of Adenomyosis with fibroid and for such giving injection Dr. P. Das Mahaparthra advised admission at Kothari Medical Centre on 06.08.2012 and accordingly to such advised the complainant approached Kothari Medical Centre for immediate admission of his wife by providing information regarding mediclaim policy with cashless benefit.

          Accordingly to such information Kothari Medical Centre submitted one pre-authorisation request Form before the op no.3 with the entire information regarding treatment, hospitalization and total expenditure of Rs.17,000/-.  Immediately after receiving the request Form the op no.3 asked two documents from Kothari Medical Centre like USG and Doctor’s opinion and the Kothari Medical Centre submitted USG report on 25.06.2012 and doctor opinion dated 09.08.2012 to op no.3 and according to such information and reports, the op no.3 approved cashless benefits for Rs.9,000/- as part claim in favour of complainant and Kothari Medical Centre on 10.08.2012 and accordingly the complainant’s wife admitted in the said Nursing Home on 13.08.2012 and discharged on 14.08.2012.

          That on demand of the claim amount from op no.3 the complainant was shocked to note that the op no.3 vide letter dated 14.08.2012 rejected the claim as the treatment should be done in OPD basis.  Having no other alternative the complainant paid Rs.16,500/- to the Kothari Medical Centre and discharged his wife and subsequently lodged a complaint before the ops for reimbursement of medical expenditure of Rs.16,500/- but the ops did not consider such claim on 30.11.2012.

          But peculiar factor is that doctor’s opinion as filed by the complainant that Kothari Medical Centre was not followed and practically Kothari Medical Centre as per particular opinion treated the patient and pushed injection and it was done as per advice of the doctor and practically after thorough examination admitted the patient for her betterment and for giving that injection properly.  So, op have no authority to say that the said treatment can be done as OPD treatment and that such illegal denial of the claim and making payment of the Mediclaim Policy at the time of discharge, complainant is mentally and physically harassed and suffered financial loss and in the above circumstances, the present complaint is filed for redressal.

          On the other hand op by filing written statement submitted that the reasons of repudiation was made by the op in details against the claim patient of the complainant and as per policy conditions and terms parties are bound to follow and in the instance case it is evident that wife of the complainant for injection Decapaptyl which can be taken even as Out Patient Department and as OPD procedure.  So, mode of treatment does not come under the scope and ambit of the policy condition and hence it is not payable. So there was no latches on the part of the op and for which the present complaint should be dismissed.

                                               Decision with reasons

          On overall evaluation as advanced by the Ld. Lawyers of both the parties and also considering the complainant’s written version including the discharge summary, it is found that admittedly patient was admitted for injection Decapaptyl to follow up case of Adenomyosis with fibroid.  Practically no treatment was done and another factor is that admission was made on 13.08.2012 and after giving injection she ought to have been discharged but discharge on 14.08.2012.

          Fact remains that the patient had a history of Munorrhegia with passage of clots and dysmenorrhoea and fact remains she had been under treatment of the doctor for long period which is evident from other prescriptions and after considering the material, documents and also considering the medical books of authority in respect of Gynecology we have gathered that such an injection can easily be made by any fellow at OPD or at any house and reason for admission is not at all justified.  But it has become a practice of the private nursing home anyhow admitted the patient as and when there is a mediclaim policy because the cost of the injection is very high and if it is infused during admission in any hospital, in that case cost of the injection can be realized from the Insurance Company and that is the practice which is being followed in so many cases and we have gone through such history in so many cases.  When it is found that the valuation of injection is very high then they are requesting the doctor to admit her and to infuse it and in that case it shall be realized the amount, can be realized when the patient is covered by any mediclaim policy.

          At the same time the nursing homes are also very much interested to admit such patient because they can charge huge rate of such injection and above the MRP and in this case most interesting factor is that the no bill of purchase of such injection is also filed by the Kothari Medical Centre.  But it is mandatory provision of law that any medicines used and purchased by any authority or hospital authority that purchase bill shall be tagged with the discharge certificate.  But that is not being followed and in such a manner all private nursing homes and hospitals are squeezing money and in respect of the cost of the medicines by charging higher price.  But private nursing homes have no legal right to take more money than that of MRP as noted in the cover or the sealed pack or on the body of the item.  But this practice is being followed and that is no doubt unfair trade practice on the part of the Kothari Medical Centre in this regard and truth is that Kothari Medical Centre has failed to produce the purchase bill in respect of that injection.

          Peculiar factor is that for that injection, Kothari Medical Centre received Rs.6,300/-.  But no purchase bill in respect of that injection is filed.  Considering all the above facts and circumstances, we have gathered that practically complainant has failed to prove that there was any fault on the part of the op for repudiating the claim.  On the contrary we have gathered that billing procedure has been adopted by the complainant only for the purpose of getting the reimbursement of the injection bill and truth is that in any treatment she was not admitted and only for injection, hospitalization is not necessary except only in case of post management of Byepass Surgery and placement of Stem cell including Pace-Maker etc.

          But in the present case there was no admission and such injection can be infused at ease by any competent nurse under the supervision of any doctor at house or OPD.  But fact remains even then op gave previous approval for admission but it was not disclosed at that time by the complainant that his wife is going to be admitted only for giving injection Decapaptyl and for which after considering the entire discharge summary and materials op cancelled the whole claims after cancelling their previous approval which has been secured by the complainant by suppressing that fact.  So, apparently after considering discharge summary it is found legally as per medical treatment there is no cause of admission because there was no cause for her treatment.

          On the other hand it is found that since prior to practically on 25.06.2012 it was detected that she had been suffering from Bulky Uterus with heterogenous myometrium and small fibroids and that report was given after USG made by Dr. Pinak Pani Bhattacharya of Quardra Medical Services Pvt. Ltd. and truth is that she was under constant treatment in conservative form and outside and not only that on 28.06.2012 she was treated by a doctor at Kothari Medical Centre and previously also she was given such an injection on 06.08.2012 in her own house but she was not admitted at that time.  But that was suppressed.

          So, considering all the above fact and also the repudiation as made by the op, we are confirmed that violating the terms and conditions of the policy that injection was infused by admitting the lady in Kothari Medical Centre and there was no legal ground for admission but only for the purpose of realizing that amount of the high cost of the injection with consultation with doctor and it was done and with connivance of the Kothari Medical Centre authority and it has become a practice of the nursing home authorities.

          So, repudiation as made by the op as per terms and conditions of the policy and in respect of clause is quite correct and no doubt with the spirit of the terms and conditions of the policy and in view of the judgement reported in 2013 (4) CPR 165 (NC) is highly applicable and no doubt the parties are governed by the policy conditions and there is no exception and relaxation can be made on the ground of the equity.

          No doubt the Ld. Lawyer for the complainant raised one vital question stating that then what is the necessity to take a mediclaim policy if the treatment cost is not covered by the said mediclaim policy and in this regard we have realized the grievances of the complainant, but we are sure that in that case the entire regulations and conditions as passed by the Finance Insurance Company Department year to year in respect of the Insurance Policy or Mediclaim Policy or other policies must be knocked and if it is found that it is ultra-------- in that case the matter can be made particular in the Hon’ble High Court, the Constitution Bench for declaring such clauses are ultra otherwise there is no scope to enter into such a matter by this Forum because the Forum will consider whether there is any negligence or deficiency on the part of the op.  In this regard we have gathered that there is no negligence or deficiency on the part of the op and at the same time the repudiation was not made illegally or arbitrarily.  But it was made rightly when the entire admission procedure was made with such connivance with the hospital authority and doctor only for the purpose of getting reimbursement in respect of huge price of the particular injection and prior to that this incident complainant also received such injection in her house.

          In the light of the above observation we are convinced to hold that there is no merit in this case.

          Thus the complaint fails.

          Hence, it is

                                                           ORDERED

          That the complaint be and the same is dismissed on contest but without any cost against the ops