DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
MUCHIPARA, BURDWAN.
Consumer Complaint No 104 of 2015
Date of filing: 17.04.2015 Date of disposal: 18.12.2015
Complainant: Banamala Banerjee, W/o. Late Madhusudan Banerjee, resident of Village: Bitra, Police Station: Memari, District: Burdwan, PIN – 713 422.
-V E R S U S-
Opposite Party: 1. The National Insurance Company Limited, represented through its Divisional Manager, having its office at: “Kundu Mansion”, 548 G.T.Road, Bhangakuthi, Burdwan, PIN – 713 101.
2. The Medi Assist India TPA Pvt. Ltd., represented through its Branch Manager, having its branch office at: 4, Premier Court, 4th Floor, Chandi Chowk Street, Kolkata – 700 072.
Present: Hon’ble President: Sri Asoke Kumar Mandal.
Hon’ble Member: Smt. Silpi Majumder.
Appeared for the Complainant: Ld. Advocate, Suvro Chakraborty.
Appeared for the Opposite Party No. 1: Ld. Advocate, Shyamal Kumar Ganguli.
Appeared for the Opposite Party No. 2: None.
J U D G E M E N T
This complaint is filed by the complainant u/S. 12 of the C.P. Act, 1986 alleging deficiency in service as well as unfair trade practice on the part of the OPs as the OPs have arbitrarily and illegally repudiated her insurance claim.
The brief fact of the case of the complainant is that she purchased one Varistha Mediclaim Insurance Policy from the National Insurance Company for the year of 2013-2014 covering the risk of herself for treatment and hospitalization expenditure. The risk of the policy was covered to the tune of Rs.1, 00,000=00 for the said year. The policy number was 154100/48/13/8500000501 and the number of the previous policy was 154100/48/12/8500000046. During continuation of the policy the Complainant began to suffer from acute pain on the upper abdomen and for this reason her son consulted with Dr. Sujan Sarkar and Dr. M. K. Roy at Burdwan. As she did not get any relief she consulted with Dr. D. Todi, who advised her getting admission at the West Bank Hospital, Howrah. As per advice she was admitted at the said hospital on 15.01.2013 and during admission her son submitted all the relevant documents along with the claim form for cashless hospitalization before the Hospital Authority for getting the insurance claim and the said authority informed the same to the OP-2. After treatment she got discharge from the hospital on 23.01.2013 and thereafter she intimated the OP-1 regarding her treatment and lodged a claim for indemnification and the claim was accordingly lodged. The Complainant had to incur medical expenditure to the tune of Rs.31, 059=00. The son of the complainant went on several occasions at the office of the OPs requesting for settlement of the claim but unfortunately the OP-1 had repudiated the legitimate claim of the complainant as ‘No Claim’ by issuing repudiation letter dated 10.07.2013. The reason for repudiation of the claim was mentioned by the OPs that as the insured was admitted at the hospital only for investigation purpose and not for any emergency treatment and the claim of the complainant attracts the Exclusion clause of the terms and the conditions of the policy. It is stated by the Complainant that she being a bonafide customer of the OPs did not commit and act detrimental to the interest of the OPs, but the Ops have repudiated her legitimate insurance claim illegally, forcefully and unjustified manner, for which the Ops are liable to compensate her. Being dissatisfied with the action of the OPs and having no alternative the Complainant has approached before this Ld. Forum by filing this complaint praying for direction upon the OPs to pay a sum of Rs.31,059=00 towards insurance claim, Rs.25,000=00 as compensation due to mental pain, agony and harassment and litigation cost of Rs.25,000=00.
The petition of complaint has been contested by the OP-1 by filing written version contending that one Varistha Mediclaim Insurance Policy was issued to the Complainant aged 63 years under the name of Hospitalization and Domiciliary Hospitalization benefit policy for the period from 04.06.2013 to 03.06.2014 and due premium for Rs.4, 697=00 was received under a contractual obligation between the insured and insurer as per terms and conditions as laid down of the said senior citizen policy. The Complainant after knowing the policy condition had accepted the policy proposal and the OP-1 accordingly issued the policy. The Complainant was primarily treated by two doctors and at last got admission at the West Bank Hospital, Howrah on 15.01.2013 without any referral and after undergoing various tests at the said hospital she was discharged on 23.01.2013. From the discharge summary it is evident that the patient was admitted with diagnosis of abdominal pain due to constipation and lumber spondylosis. It is also revealed that she was admitted for investigation and did not receive any actual treatment. After discharge the insurance claim was lodged by filing claim form and treatment related papers on 01.02.2013 which was subsequently forwarded to the TPA Medi Assist India Private Limited-OP-2. The OP-2 had forwarded one letter to the Complainant on 12.02.2013 requesting to provide some relevant papers for processing of the claim towards reimbursement. The OP-2 vide the letter had intimated to the Complainant that on verification of document it has been observed that the patient was admitted with the complaint of abdominal pain due to LBP and as IPD patient was treated conservatively with oral medications and no active line of treatment required in hospitalization was done and such hospitalization was basically for investigation purpose hence, the said hospitalization was not justified and for this reason the claim was not admissible as per the exclusion clause of the policy conditions. Thereafter the OP-2 by issuing letter dated 21.05.2013 sent back the original file to the Insurance Company with the observation that the claim required to be repudiated as per policy exclusion clause no-4.10 and requested to take appropriate action. Upon receipt of the said observation made by the OP-2, the OP-1 forwarded the detailed case history to an eminent physician namely Dr. K. K. Arora on 20.06.2013 requesting him to submit his independent opinion about the case. The said doctor had submitted his observation on 04.07.2013 stating that ‘……. It is apparent that the patient was admitted primarily for investigations and did not receive any treatment that actually required hospitalization. Therefore the said claim in my view attracts the provision of the exclusion clause 4.10 as per the terms and conditions of the mediclaim policy.’ Accordingly the Op-1 had duly intimated the Complainant by issuing repudiation letter on 10.07.2013 that the claim for reimbursement cannot be payable as the same hits the exclusion clause of the questioned policy. It is further submitted by the OP-1 that earlier another complaint being no- CC 258/2013 was filed by one Krishnendu Banerjee regarding non-settlement of the claim by the Insurance Company for treatment of his mother Banamala Bannerjee, on the self-same issue, but the same was withdrawn subsequently with unknown reason and this fresh complaint was filed with changes made in the cause title only. According to the OP-1 as the repudiation was done rightly and the same has been duly intimated to the insured by issuing repudiation letter, hence the action of the OP-1 did not suffer from any deficiency in service as well as unfair trade practice. Hence, prayer has been made by the OP-1 for dismissal of the complaint.
The Complainant has filed evidence on affidavit along with several documents and the Op-1 has also submitted some documents in support of its contention.
After admission admitting the complaint notices were issued upon the both OPs through the office of this Ld. Forum. Though the Op-1 had entered appearance by filing vokalatnama and filed written version to contest the complaint, but the OP-2 inspite of receipt of the notice did not turn up to contest the complaint either orally or by filing written version. Therefore the complaint was taken up for hearing ex parte against the OP-2.
We have carefully perused the entire record; papers and documents filed by the Complainant and the Op-1 in support of their respective contentions and heard argument at length advanced by the ld. Counsel for the contesting parties. It is seen by us that in the instant complaint there are some admitted facts i.e. the Complainant obtained a Varistha Mediclaim Insurance Policy from the OP-1 for the year 2013-2014 covering risk of herself for treatment and hospitalization expenditure, risk was covered to the tune of Rs.1,00,000=00, due premium paid, she had previous policy for the year 2012-2013, during validity of the policy the insured became ill due to acute pain on her upper abdomen, she consulted primarily with two doctors namely Dr. S. Sarkar and Dr. M. K. Roy, subsequently she consulted with Dr. D.Todi as her pain did not subside, lastly she got admission at the West Bank Hospital, Howrah on 15.01.2013, got discharge therefrom on 23.01.2013, she intimated the OP-1 about her treatment after getting release from the hospital, lodged the claim form along with relevant papers and documents for reimbursement of the expenditure, she had to incur treatment expenditure at the said hospital only for Rs.31,059=00, the policy was valid for the period from 04.06.2013 to 03.06.2014, during inception of the policy the terms and the conditions was provided by the OP-1 to her, after knowing the same the complainant obtained the said policy, the Op-1 has repudiated the claim of the complainant by issuing repudiation letter date 10.07.2013 based on the exclusion clause of the policy condition as no active line of treatment was done, the claim was closed as ‘no claim’. The allegation of the complainant is that the Ops have arbitrarily and illegally repudiated her legitimate insurance claim and hence this complaint filed seeking redressal of her grievance. The rebuttal case of the OP-1 is that the repudiation of the claim was done rightly based on the terms and the conditions of the policy and hence there is no deficiency in service and unfair trade practice on its part and prayed for dismissal of the complaint.
During argument the Ld. Counsel for the Complainant has submitted that the Complainant was suffering from cyst in her liver, constipation and for these reason there was upper abdominal pain. Not only that she was suffering from lumber spondylosis and for this reason she was advised by Dr. D. Todi for getting admission at the West Bank Hospital. In this respect we are to say that no evidence is adduced by the complainant for showing that the Complainant was suffering from cyst in her liver and moreover the ultra sonography report does not reveal the same. Most surprisingly it is noticed by us that the Complainant was not referred by any doctor for getting admission at the hospital for her treatment. The prescription of Dr. D. Todi reveals that there was no referral. So it can be easily said that the Complainant got admission at the West Bank Hospital of her own motion and choice and the said admission cannot be treated as emergent in nature. From the discharge certificate of the West Bank Hospital it is evident that the Complainant was admitted with constipation, abdominal pain and low back pain, some investigations were done i.e. MRI of L/S Spine; patient was treated with analgesic and regular physiotherapy and some medicines were prescribed. The Op-1 has submitted that as the claim of Complainant hits the exclusion clause being no 4.10, the claimant is not entitled to get any amount towards reimbursement of her treatment expenditure. We have carefully gone through the said exclusion clause which runs as follows-
4.10. ‘Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence or any ailment, sickness or injury for which confinement is required at a Hospital/Nursing Home.’
Upon perusal of the said clause we are of the view that in view of the said clause the complainant is not entitled to get any amount towards reimbursement from the OP-1 because during the tenure of her stay at the Hospital some tests were done only, no active line of treatment was done. Admittedly, at the time of taking out the policy the Complainant after knowing the said clause had obtained the policy by putting her signature in the proposal form and hence neither the Complainant nor the Op-1 can travel beyond any clause/terms and the conditions of the said policy rather entire terms and the conditions are strictly binding upon the insured and the insurer.
It is seen by us that upon receipt of the observation from the TPA-Op-2, the OP-1 remitted the papers and documents of the claimant along with detailed case history to an impartial doctor namely Dr. Arora for his opinion as to whether the claimant is entitled to get any amount towards reimbursement or not from the OP-1 in respect of the policy. Dr. Arora has opined that the patient did not receive any emergency treatment following her hospitalization. The details of the treatment given to the patient also do not indicate that she had severe pain. It is therefore apparent that the patient was admitted primarily for investigations and did not receive any treatment that actually required hospitalization. Therefore the said claim attracts the provisions of the exclusion clause 4.10 as per the terms and conditions of mediclaim policy. In respect of the above-mentioned observation of Dr. Arora, we are of the opinion that the Complainant did not bother to take any step to cross-examine Dr. Arora by way of filing questionnaire in respect of the said observation and therefore the observation of Dr. Arora has reached in its finality.
In the conclusion we are to say that the OP-1 had repudiated the claim of the Complainant rightly, not arbitrarily, based on the exclusion clause and as per the terms and conditions of the policy. So such repudiation cannot be termed as deficiency in service as well as unfair trade practice and moreover the OP-1 intimated the insured about such repudiation by issuing letter dated 10.07.2013. As the Complainant has miserably failed to substantiate her case and claim by adducing cogent document, hence the complaint fails and she is not at all entitled to get any relied as prayed for.
Going by the foregoing discussion hence, it is
O r d e r e d
that the complaint is dismissed on contest without any cost against the OP-1 and dismissed ex parte against the OP-2 without any cost.
Let plain copies of this final order/judgment be supplied to the parties free of cost as per provisions of Consumer Protection Regulations, 2005.
(Asoke Kumar Mandal)
Dictated and corrected by me. President
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
