Date of filing: 14.02.2017 Date of disposal: 02.08.2018
Complainant: Phanindra Nath Majumdar, S/o. Late Jitendra Kumar Majumdar, residing at present at Shyambandh, near Chuna Bhati, Opposite of Baidyanath Pally, PO: Burnpur, PS: Hirapur, Dist: Burdwan, PIN – 713 325.
-VERSUS-
Opposite Party: 1. National Insurance Company Limited, having its Branch Office at Durga Market, 46, G. T. Road, Asansol, PS: Asansol (South), Dist: Burdwan, PIN – 713 301, represented by its Branch Manager.
2. The Chairman, National Insurance Company Limited, having its Registered Office at 3, Middleton Street, Post Box No. 9229, Kolkata – 700 071.
3. Medsave Healthcare (TPA) Ltd., having its office at A. K. Trade Centre Pvt. Ltd., 3rd Floor, 1/1, Camac Street, Kolkata, Pin – 700 016, represented by its Manager.
Present: Hon’ble President: Smt. Jayanti Maitra(Ray).
Hon’ble Member: Miss Nivedita Ghosh.
Hon’ble Member: Dr. Tapan Kr. Tripathy.
Appeared for the Complainant: Ld. Advocate, Debdas Rudra & Moumita Bhattacharjee (Haldar).
Appeared for the Opposite Party No.1: Ld. Advocate, Ahi Bhushan De.
Appeared for the Opposite Party No.2 & 3: None (ex parte).
J U D G E M E N T
The complainant by name Phanindra Nath Majumdar with his wife and their son were insured under Hospitalization Benefit Policy bearing No.150504/48/08/8500000047 for the period from 16.04.2008 to Midnight of 15.04.2009. The sum insured was Rs.1, 00,000=00. After that the policy was renewed bearing policy No. 150504/48/09/8500000064 for the period 16.04.09 to 15.4.2010 and thereafter yearly renewed upto 16.04.2007 and sum insured upto 1,00,000=00.
All on a sudden the complainant became seriously ill and was admitted in Apollo Gleneagles Hospitals, Kolkata on 25.09.2016. He was told by the Doctor for clinical test. After that he submitted all the reports before the Doctor. The doctor diagnosed that he was suffering from Hepatitis B. As the complainant was holding the cashless facility, after receiving the intimation. the OP-3 guaranteed initial payment of necessary cost of treatment amounting to Rs. 15,000=00 in favour of the complainant. Finally, the complainant was discharged on 29.09.2016. After discharge of the complainant from the Apollo Hospital the OP No.3 denied the additional cashless authorization for Rs.73, 536=00 for the treatment of the complainant vide letter dt. 29.09.2016 on the plea that the patient was admitted only for diagnostic purpose only. The case was denied under Clause 4.19 and the OP -3 also withdrawn the previous payment of Rs.15, 000=00. The complainant incurred all the medical expenses towards his treatment amounting to Rs. 88,536=00.
After returning Home the complainant lodged mediclaim before the OP on 04.10.2016. After observing all the formalities and submitted all the medical documents before the OP and requested to the OP to settle the claim amounting to Rs. 88,526=00 which the complainant has incurred from his pocket for his treatment. After receiving the said claim the OP.No.3 sent a message being mobile No. 9434 201 434 stating they have received the claim on 04.10.2016 at 1.36 p.m. and trying to settle the claim but till date the OP neither reimbursed the said claim amount lodged by the complainant nor repudiated the claim. But it is seen the unfair trade from the OP. So the complainant has been suffering from great mental pain, agony and harassment. Getting no way the complainant has been compelled to file this case for getting Rs. 88,526=00 for medical expenses for his treatment. The complainant also prayed for direction to OP to pay Rs. 1, 00,000=00 as compensation for deficiency of service and towards mental pain and agony. And he also claimed Rs.20, 000=00 as litigation cost. The cause of action arose on and from 29.09.2016 and it is still continuing.
The Opposite Party-Insurance Company contested the case by filing Written Version. The OP. No. 1-NIC Ltd., Asansol Branch Office begs to submit that the Phanindra Nath Majumdar, being the complainant under policy No. 150504/48/16/8500000032, for the period from 14.04.2016 to 15.04.2017 was admitted in Apollo Hospital, Kolkata from 25.09.2016 to 29.09.2016 with Fever and Back Pain and was diagnosed as Chronic Hepatitis-B and Pancreatitis. The Claim file had been received by this OP from the TPA on 11.04.2017 and it was found from the letter dt. 10.04.2017 received by this OP from TPA Ltd. that the entire medical papers has been closely scrutinized and it is seen all medication was in oral form and his hospitalization not justified. As per discharge certificate there was no pancreatitis detected. Oral medicine been used as treatment of Hospitalization was not justified. But it is mentioned that the Health care TPA Ltd. letter No. 20161004B011R8783 dt. 22.10.16 addressed to the OP-NIC Ltd. Asansol Branch Officer scrutinized carefully that claim is not admissible, as per expenses incurred for diagnostic purpose not consistent with the diagnosis. As such the claim was recommended for rejection by the OP No. 3.
OP No.1-Asansol Office further begs to submit that the claim from OP No.1, Asansol Branch office is untenable. The allegations of deficiency in service and unfair trade practice against this OP No.1-NIC Ltd. as made in the instant complaint petition are wholly misconceived, groundless and false. The OP.No.1 NIC Ltd., Asansol Branch Office further submits that there has not been any deficiency in service. This instant complaint against this OP. No.1-NIC Ltd. is purely frivolous and vexatious one and as such this OP No. 1-NIC Ltd is entitled to get a cost of Rs. 10,000=00 from the complainant. OPs, therefore prayed further to dismiss the instant complaint petition. The case is heard ex parte against OP.No.2 and 3.
DECISION WITH REASONS
To prove the case complainant files affidavit of his evidence where he has stated as per version of his complaint petition and prays accordingly. OP prayed for that written version submitted by affidavit should be treated as his evidence. Complainant files policy papers (Annexure up-to-date renewed) till 2017. He filed the discharged summary and other medical documents of Apollo Gleneagles Hospitals. It appears from the Medical documents that he was admitted in the hospital on 25.09.2016 and was discharged on 29.09.2016 and reason for admission was that he was suffering from fever, low back pain with Chronic Hepatitis B and Chronic Pancreatitis as diagnosed.
Complainant stated in his evidence that he became seriously ill for back pain and fever and he was admitted in the hospital as per advice of the Doctor. He also submitted documents (Annexure I & K) that he intimated his hospitalization and treatment to OP-Insurance Company and OP initially granted Rs. 15,000=00 in terms of the policy. After discharge he submitted Claim Form before the OPs for additional cashless authorization of Rs. 73,536=00. OP.No.3 denied the additional cashless authorization vide its letter dt. 29.09.2016 on the plea that under Clause 4.19 he is not entitled to such additional cashless under the policy as he was admitted in the hospital only for diagnostic purpose. OP also withdrew the amount Rs. 15,000=00 initially granted (Annexure J).
Therefore, Complainant has been able to prove by medical documents that he incurred expenses to the tune of Rs. 88,526=00 for his treatment. In the Medical documents there is a discharge summary wherein it is mentioned that he was admitted in the hospital with serious ailments not for diagnostic purpose. In the discharge summary her ailment and also the treatment received is clearly mentioned. In the discharged summary the patient was admitted in the hospital and the reason for admission clearly stated that he was suffering from fever and lower back pain. He was admitted on 25.09.2015 and was discharged on 29.09.2016. He was diagnosed with Chronic Hepatitis B and Chronic Pancreatitis. OP stated in the written version and also argued that diagnostic and evaluation purpose can be carried out as outpatient procedure and the continuation of patient does not require hospitalization. Op repudiated the claim as per 4.19 of the Exclusion Clause of the policy. But from the medical documents of the hospitalization there is no mention that he was hospitalized only for diagnostic purpose. The admission required considering his suffering and pain and seriousness. He was with Type-2 Diabetes Mellitus with Chronic Pancreatitis and was admitted with complaints of fever and also back pain. There is no mentioning that the treatment he received in the hospital may be given as an OPD patient. Hemodynamically stable condition he was discharged. So from the discharge certificate complainant has been able to prove that his hospitalization was necessary at the relevant period of his sufferings. Nowhere Doctor mentioned that such treatment can be provided with oral medicine by treating in the outpatient Department. Therefore repudiation of the claim by the OP is amounting to deficiency in service.
Ld. Lawyer for OP submits by reference of judgement of Hon’ble NCDRC as reported in I (2013) CPJ 23 (NC) that expenses related to treatment taken as ‘out patient’ for dental problems falls outside scope of policy and claim was repudiated. This judgement is not applicable in this case. Another judgement as reported in III (2012) CPJ 265 (NC) that claim was the subject to general exclusions mentioned in the policy prospectus. But this judgement also not applicable in our case.
After hearing both sides and on perusal of the documents filed by the parties, as well as, hearing argument from both sides and in the light of our above discussion we find that complainant has been able to prove his case by sufficient oral and documentary evidence that he was suffering from serious illness and was hospitalized and incurred expense towards his treatment of the tune of Rs. 88,526=00. He is entitled to receive the said amount from the OP-Insurance Company in terms of the hospitalization benefit policy. The case of the complainant succeeds.
Hence, it is
O r d e r e d
that the Consumer Complaint being No. 26/2017 be and the same is allowed on contest against OP-1 and ex parte against OP No. 2 and dismissed ex parte against the OP-3. OP-1&2 are directed to pay either jointly or severally Rs.88,526=00 to the complainant towards the medical expenses for the treatment of the complainant within 45 days from the date of passing of this award, in default, it will carry 8% interest per annum for the default period and the OPs are also directed to pay to the complainant either jointly or severally compensation to the tune of Rs. 5,000=00 towards mental pain and harassment and Rs.2,000=00 as litigation cost within 45 days from the date of passing of this award, in default, the complainant is at liberty to put the entire award in execution as per provisions of law.
Let plain copies of this final order be supplied to the parties free of cost as per provision of C.P. Reregulation, 2005.
Jayanti Maitra (Ray)
Dictated and corrected by me. President
D.C.D.R.F., Burdwan
Jayanti Maitra (Ray)
President
D.C.D.R.F., Burdwan
(Nivedita Ghosh) (Dr. Tapan Kr. Tripathy)
Member Member
D.C.D.R.F., Burdwan D.C.D.R.F., Burdwan
