Complainants by filing this complaint have alleged that they obtained mediclaim insurance policy bearing No.100300/48/10/8500003772 for the period from 2002-2003 on payment of premium and subsequently year to year complainants continued their medicalim policy under the present insurance company and renewed every year without any interruption and default and presently for the year 2010-11 the complainant paid annual premium of Rs.6,478/- only and it is a valid insurance policy and renewal of the policy was paid from time to time in accordance with the said Rules of the Insurance Co.

          It is further alleged that the wife of the complainant sometime in the month of November, 2010 suffered from breathlessness, unconsciousness and accordingly she was admitted to Belle Vue Clinic for her treatment being advised by Dr. Abhijit Chattrerjee, on 01.12.2010 where she was under treatment from 01.12.2010 to 07.12.2010 and was released from the said Clinic on 07.12.2010.

          As per policy, policy holder can avail of a cashless benefit and complainant obtained such facilities as per insurance policy term and requested the op no.2 to provide such assistance but op no.3 denied to give any cashless facilities and for which complainant was paid the same and ultimately op no.3 vide its letter asked the complainant to submit all papers.  Complainant against that submitted all required papers in respect of terms and bills of the Clinic along with details of the future expenditure, medical certificate etc.  But even then she was not granted any benefit and finding no other alternatives, complainant again reported the matter.  But practically they did not respond and ultimately complainant submitted her claim form under policy No.100300/48/10/8500003772 along with original documents, papers to the op for reimbursement.  But on 23.02.2011 by a letter complainant’s claim was repudiated on the ground that the patient was suffering from Generalized Anxiety Disorder which is a psychosomatic disorder and it is not payable as per Clause 4.8 of the Standard Mediclaim Policy.

          After receiving of the said purported letter of repudiation by their letter dated 05.05.2011 she reported the matter to op no.2 expressed his anxiety and also requested for reconsidering their repudiation on 23.02.2011.  But anyway the matter was not considered for which for redressal this complaint is filed.

          On the other hand, the op Insurance Co. by filing written statement submitted that as per the policy condition, the company shall not be liable to make any payment under the policy expressed whatsoever incurred by any person or any respect of the nature of the disease as envisaged in the said Exclusion Clause 4.8 and in the present claim complainant comes under the purview of Exclusion Clause 4.8 for which the claim is liable to be repudiated and the decision of the op no.3 cannot be termed as deficiency in service on the part of the op and in the circumstances, ops prayed for dismissal of this case.

                                            Decision with reasons

          On comparative study of the argument as advanced by the Ld. Lawyers of both the parties and also relying upon the discharge summary and certificate issued by Belle Vue Clinic, it is found that Bhawagati Debi Sarawgi was admitted to said Belle Vue Clinic on 01.12.2010 and was discharged on 07.012.2010  and during her treatment period at that Clinic/ hospital she was under treatment of Dr. Abhijit Chatterjee who diagnosed and came to a finding that Generalized Anxiety Disorder and said Dr. A. Chatterjee also issued one certificate on 06.12.2010 stating that the said lady has been suffering from Synocopal attack with stiffness of the body for four months for which she was admitted with Synocopal with breathing difficulties and for which general treatment and investigation were done for evaluation of the cause.  Fact remains that Dr. Abhijit Chatterjee is the doctor having MBBS Cal, MD Cal, DM Neuro and he is a consultant Neurologist and he treated her and no doubt during that period Belle Vue Clinic handed over bill for treatment and other cost and doctors fees.  No doubt all the papers were submitted to the ops by the complainant along with claim application but fact is that same was repudiated on the ground that the patient was suffering from Generalized Anxiety Disorder and insurance company also repudiated the matter on 09.08.2010 and fact remains complainant claimed only Rs.40,202/- in respect of said mediclaim policy but ops’ version is that as per Clause 4.8 all psychosomatic or psychiatric disorder or disease are not covered by the said policy and no doubt as per Clause 4.8 of the insurance policy bond all psychosomatic and psychiatric disorders or diseases are not covered by the present policy.  So, no doubt if the present disorder of the patient comes under the purview of the said definition Clause 4.8 of the insured bond in that case there is no question of granting any amount against such treatment.  But question is whether the Generalize Anxiety Disorder comes under the purview of Clause 4.8.

          In this regard, we have considered the medical certificate of Dr. A. Chatterjee the Neurologist and it is found that the present doctor is not a psychiatrist but he is neurologist.  So, it is clear that the treatment of the present patient was done by Dr. Abhijit Chatterjee not as psychiatrist and there is no such opinion of any doctor that she had been suffering from any psychosomatic disorder but it is generalize anxiety which may be caused for different reasons and a person may suffer from anxiety different causes due to family troubles or for other causes.  But general anxiety disorder does not come under the purview of the definition psychosomatic or psychiatric.  

          Moreover the op did not consult the doctor Abhijit Chatterjee in this regard to collect his opinion about the nature of disease of the patient for which she was treated by the Neurologist Dr. A. Chatterjee.  So, considering the above fact and also considering the present medical treatment as done by Abhijit Chatterjee, it is found that she was suffering from only Generalize Anxiety Disorder.  But this term had been converted into the group of psychosomatic or psychiatric disorder and such sort of opinion of the ops for repudiating his claim is completely unscientific and illegal.  It is to be mentioned in this regard that from the said treatment sheet it is clear that lady was aged about 61 years old a married lady and at that age probably not a single fellow of middle class family is free from anxiety or depression and after reading the very chapter from the psychology we have gathered  that a lady after 50 years suffers from different type of mental agony due to family cause, sometimes for financial stringency of the family, sometimes for their daughters, sons and for their family members and it is now a common disease of all parents at the age of 50 in case of mother and 60 in case of father and general depression including general anxiety must be with the parents always because in the present society no doubt the different type of complication to lead life in this society has already been increased and no doubt status of our life has been changed for which we are trying to cope.  But due to several type of financial stringency it is not possible.  But sons and daughters of the parents are not willing to accept financial condition of the parents and for which in most of the families parents are suffering from anxiety and depression and it is no doubt a general cause of physical unfitness of parents in most of the families and in the present case invariably such an incident was there in the family of the present complainant for which a 61 years old mother suffered from Generalize anxiety/depression and such sort of sufferings cannot be treated as psychosomatic disease, but anyhow the TPA the so called most expert of the World Health Administration converted that generalized anxiety into psychosomatic disease only to repudiate the claim.  What has promoted us to pass a comment against the TPA.  So we have stated that TPA are here and there to act as supari killer on behalf of the insurance company to murder the mediclaim of the insured and in fact it is proved that there is or was an nexus in between the TPA and Insurance Co. for repudiating the claim and fact remains most of the mediclaims are being repudiated by the TPAs and insurance companies are supporting the said decision without any verification from the doctors under whom the patient (the so called mediclaim policy holder) was or were examined and the above procedure as adopted by the insurance company and TPA is no doubt immoral, illegal, unwarranted, unwanted and uncalled for. 

          At the same time we are confirming that Insurance Act was promulgated for the purpose of social protection of the people at large and for future protection, but this social approach is vanished from the mind of the National Insurance Companies and in fact Nationalized Companies are becoming trader of mediclaim policies for collecting money and to procure capital to increase their business without their any sort of liability to be discharge in future against any claim and when that is the approach of the insurance company then we can say such sort of insurance company should be shut down at once.  In the light  of the above observation and considering the whole episode we are convinced to hold that complainant have no doubt proved that the very patient the wife of complainant no.1 was suffering from so called anxiety but she was not suffering from psychosis disease or psychosomatic diseases and practically the ops have made this patient a mad.  Reason is that the ops are not in a mood to release the claim and such an expression of the ops is no doubt a mad’s expression and by adopting such procedure practically ops have adopted unfair trade practice for which they should be penalized at first.  When that factor has been proved by the complainant, invariably complainant is entitled to get relief as prayed for.

          In the result, the complaint succeeds.

          Hence, it is                    ORDERED

          That the complaint be and the same is allowed on contest against contesting op nos.1 & 2 Insurance Co. and same is allowed exparte op Heritage Health TPA Pvt Ltd. cost of Rs.10,000/- each.

          Op nos. 1 & 2 are hereby directed to issue a cheque of Rs.40,210/- along with compensation of Rs.10,000/- to the present complainant no.2 Bhagwati Debi Sarawgi within one month from the date of this order along with the litigation cost.

          For adopting unfair trade practice by the op nos. 1, 2 & 3 they are directed to pay a punitive damages of Rs.10,000/- each to the State Consumer Welfare Fund for adopting such unfair trade practice to refuse, repudiate, cancel and reject the so called mediclaim of many consumers and to check up this activities the present order is passed against all the ops.

          Ops are directed to comply the order and to satisfy the decree within one month from the date of this order failing which for each day’s delay an interest @ Rs.150/- per day shall be assessed against the op nos. 1, 2 & 3 respectively and separately till full satisfaction of the decree and if it is collected same shall be deposited to the Head A/C of State Consumer Welfare Fund.  If there is any approach of the ops to defy the order of this Forum and not to comply in that case penal action shall be taken against them by starting the proceeding u/s 27 of C.P. Act 1986 for implementation of this order even by sending them to jail by imposing such penalty.