Consumer Complaint No. 100 of 2016
Date of filing: 30.05.2016 Date of disposal: 23.12.2016.
Present :
Sri Asoke Kr. Mandal Hon’ble President,
Smt. Silpi Majumder Hon’ble Member,
Sri Pankaj Kr. Sinha Hon’ble Member,
Sudip Kumar Ghosh, resident of 49, Steel
Employee’s Co-Op. HSG. Society Ltd.,
Kururiadanga, P.O.-Amriai, Durgapur,
Burdwan, Pin-713203. Complainant.
VERSUS
- National Insurance Company Ltd., Burdwan Division,
Represented by its Division Manager, having its office
At 548, G.T. Road, Bhangakuthi, Kundu Mantion, Town,
P.O., P.S. Dist.-Burdwan, Pin-713101.
- E-Meditek (TPA) Services Ltd., represented by its Divisional
Manager, having its Corporate Office at Plot No.577, Udyog
Vihar, Phase-5, Gurgaon, Haryana, Pin-122016. Opposite Parties.
Appeared for the complainant : Ld. Advocate Suvro Chakraborty.
Appeared for the O. P. No. 1 : Ld. Advocate Shyamal Kumar Ganguli.
Appeared for the O. P. No. 2 : None.
JUDGEMENT
This is a case U/s. 12 of the C.P. Act for an award directing the O.Ps. to pay a sum of Rs.22,206/- for the expenses of treatment of the complainant, to pay Rs. 50,000/- as compensation for mental pain, agony and harassment and to pay Rs.20,000/- as litigation cost, to the complainant.
The complainant’s case in short is that the complainant being an employee of Steel Authority of India got a mediclaim policy of the O.P. No.1 by covering the risk of health of his own and for his spouse namely Sukriti Ghosh, in the year 1996 and said policy was renewed year after year and lastly for the year 2014-2015, having policy No.351200/46//13/8500000174. The wife of the complainant has been suffering from cancer since 1993 and she used to get her treatment at Durgapur Steel Plant Hospital and Saroj Gupta Cancer Centre and Research Institute at Calcutta. She on 8.7.2014 was admitted in Durgapur Steel Plant Hospital and discharged there from on 9.7.2014 for her treatment and for such treatment an amount of Rs.748/- was spent. The complainant made a claim before the O.P. no.2 vide claim No.100071408630 under Steel Authority of India Ltd. on 17.7.2014. By receiving a litter on 23.8.2014, the complainant came to know that the O.P. No.2 asked the details case summary with line of treatment during hospitalization duly certified by the treating doctor along with other documents. The complainant after collecting those documents submitted the same before the O.P. No.2 but no action has yet been taken.
The wife of the complainant was again admitted on 22.8.2014 in Saroj Gupta Cancer Centre and Research Institute at Calcutta and her treatment was continued upto 11.9.2014. After such admission, the hospital authority sent an estimate of treatment expenses of Rs.1,00,000/- to the O.P. No.2. The O.P. No. 2 initially allowed payment of Rs.45,000/- only. Accordingly the complainant got cashless hospitalization facilities. On the date of discharge the hospital authority sent intimation the total Rs.97,426/- as cost of treatment of the wife of the complainant and sent a bill of the same to the O.P. No.2. The O.P. No.2 lodged the claim of the complainant vide claim No.10081411993 under policy No.351200/46/13/8500000174. The O.P. No.2 thereafter vide their letter dated 11.9.2014 intimated the hospital authority as well as the complainant that the claim has been settled at Rs.75,968/- to the hospital authority and denied the reimbursement of the remaining amount of Rs.21,458/- on the ground of non-medical and non-payable expenses. As such the complainant was forced to pay such Rs.21,458/- to the hospital authority in three installments of Rs.6,000/- on 22.8.2014, of Rs.14,500/- on 11.9.2014 and of Rs.958/- on 26.9.2014 and in that connection the complainant obtained money receipts from the hospital authority. Thereafter, the complainant requested the O.P. No.2 to reconsider the mater for reimbursement of the rest amount of Rs.21,458/- as well as Rs.748/- which was spent for the treatment within the period from 8.7.2014 to 9.7.2014 but no fruitful result was made. The O.P. No.2 to harass and to deny the complainant took various pretext. The O.P. No.2 vide its letter dated 9.12.2014 asked the complainant for providing documents regarding amount of Rs.958/- with the intimation that in that connection first letter dated 3.12.2014 was issued. Actually the complainant did not receive the letter dated 3.12.2014. The complainant on 23.12.2014 submitted a written representation before the O.P. No.2. In reply the O.P. No.2 vide its letter dated 31.12.2014 intimated the complainant that they treated the claim as ‘No Claim’ on the ground of non-submission of document as they asked vide their letter dated 3.12.2014. Thereafter, the O.P. No.2 asked the complainant to make contact with the O.P. No.1, insurer and to provide the description regarding Rs.958/-. The complainant vide his letter dated 22.1.2015 and dated 28.3.2015 intimated the O.P. No.2 that he submitted all original documents before them on 28.8.2014. The complainant also sent all scan copies of documents again to the O.P. No.2 vide his letter dated 28.3.2015. The O.Ps. inspite of getting all the original documents from the complainant as well as from the hospital authority neither settled the claim in respect of the hospitalization for the period from 8.7.2014 to 9.7.2014 by making payment of Rs.748/- nor reimbursed the amount of Rs.21,458/- related to the treatment for the period from 22.8.2014 to 11.9.2014. To harass the complainant, the O.Ps. again and again asked the complainant for details of Rs.958/-. The O.Ps. have taken unfair trade practice and for the illegal act of the O.Ps. the complainant has been suffering from mental pain, agony and harassment and has been forced to come before this Forum to get relief. Hence, this case with the prayer as mentioned above.
Inspite of service of notice, the O.P. No.2 did not contest this case by filing written version and accordingly this case was heard ex-parte against the O.P. No.2.
The O.P. No.1 contested this case by filing written version while denying the case of the complainant and stating inter-alia that case is not maintainable, the complainant has no locus standy to file this case against this O.P. and this Forum has no jurisdiction to try this case as there is no relationship of consumer and the service provider in between the complainant the and O.P. In written version the O.P. No.1 has further stated that the complainant Sudip Kr. Ghosh being a retired employee of SAIL was enjoying a medicalim policy bearing No.351200/46/13/8500000174 for the period of 2014-2015, the wife of the complainant named Sukriti Ghosh was admitted at DSP Hospital and stayed there from 8.7.2014 to 9.7.2014 but the O.P. No.2 has failed to settle such claim due to non-submission of detailed case summary with line of treatment duly certified by the treating doctor, the spouse of the complainant was admitted at Saroj Gupta Cancer Centre and Research Institute at Calcutta on 22.8.2014 and she was treated upto 11.9.2014, prior to that the O.P. No.2 vide letter dated 25.8.2014 intimated Medical Superintendent of said hospital that admissible limit was Rs.45,000/- subject to production of necessary document, on 11.9.2014 the O.P. No.2 intimated the medical superintendent of Saroj Gupta Cancer Centre and Research Institute that approval was accorded for CA Bladder treatment of Sukriti Ghosh covered under policy No.351200/46//13/8500000174 held with O.P. No.1 and proposed dates of hospitalisation from 22.8.2014 to 11.9.2014 total of 21 days and admissible limit for expenditure at Rs.75,968/- against estimated expenses of Rs.77,416/-, PAC approval for active treatment only and non-medical and non-payable expenses are not payable at all, subject to submission of document for treatment, at the time of discharge of the patient on 11.9.2014 total bill of Rs.97,426/- was forwarded by the hospital authority to the O.P. No.2 and against total bill of Rs.97,426/- cashless benefit extended by the O.P. No.2 upto Rs.75,968/- and balance amount of Rs.21,458/- which was consider by the O.P. No. 1 as non-medical and non-payable expenses as per verification of O.P. No.2 (TPA), was paid by the complainant. It has been further stated by this O.P. that subsequently on 31.12.2014 the O.P. No.2 again requested to submit necessary document related to the expenditure of Rs.958/-, reply of which have not yet been made to the earlier communication dated 3.12.2014 from the complainant and due to non-providing documents as per instruction of O.P. No.1 the claim was treated as ‘No Claim’ according to the terms and conditions of the policy and same was communicated to the complainant vide letter dated 31.12.2014 and also as per recommendation of TPA and as per policy condition the admissible amount have been paid which was considered as just and proper and the amount of Rs.21,458/- and Rs.748/- were not paid due to non-medical and non-payable expenses. It is, therefore, claimed by this O.P. that the case is liable to be dismissed against this O.P. No.1.
DECISION WITH REASONS
In support of his case the complainant has relied upon the contents of the complaint, evidence on affidavit submitted on 30.05.2016, photocopies of several documents like money receipt showing payment of Rs.6000/-, letter dated 23.8.2014 issued by the O.P. No.2, mail copy showing authorization to admit the wife of the complainant in hospital by the O.Ps., final bill issued by the hospital authority of Saroj Gupta Cancer Centre and Research Institute, another two money receipts showing payment of Rs.14,500/- and Rs.958/- by the complainant, letter dated 23.12.2014 issued by the complainant to the O.P. No.2 with the prayer for reconsideration and reimbursement of the amount of Rs.21,458/-, mail dated 31.12.2014 sent to Sudip Kr. Ghosh asking him to provide details of the amount of Rs.958/- and intimating that the claim was treated as ‘No Claim’, letter dated 22.1.2015 showing prayer for reconsideration made by the complainant etc.
On the other hand the O.P. No.1 has also filed the copies of some documents on which the complainant has also relied upon.
We carefully perused the contents of the pleadings and other materials on record. The complainant in his complaint has stated that his wife Sukriti Ghosh was admitted in DSP Hospital on 8.7.2014 and she was discharged therefrom on 9.7.2014 and for such treatment an amount of Rs.748/- was spent. The materials on record shows that inconnection with the claim made by the complainant bearing No. 1008141199310081411993 dated 17.7.2014 the O.P. No.2 asked the complainant to submit the details case summary with line of treatment during hospitalization duly certified by the treating doctor along with other documents. Though in the complaint the complainant has stated that he complied such request by submitting the documents as asked for. But from the side of the complainant no documentary evidence has been adduced showing that he complied with such request of the O.P. No.2 by supplying the case summary with line of treatment during hospitalization from 8.7.2014 to 9.7.2014 duly certified by the treating doctor and other documents. So, in this connection we find that the complainant is not entitled to get any award in respect of such amount of Rs.748/- incurred for the treatment of his wife.
Now the question whether the complainant is entitled to get total Rs.97,426/- as incurred by the complainant for hospitalization and treatment of his wife in Saroj Gupta Cancer Centre and Research Institute for the period from 22.8.2014 to 11.9.2014, is required to be decided. In written version and also by submitting the copies of some documents related to this matter, the O.P. No.1 has admitted that the O.Ps. gave approval for admission of Sukriti Ghosh for the period from 22.8.2014 to 11.9.2014 total 21 days in Saroj Gupta Cancer Centre and Research Institute and in that connection the O.Ps. considering the estimated cost of Rs.1,00,000/- approved Rs.45,000/- at the first instant and cashless benefit. The O.P. No.1 has also admitted that the hospital authority of Saroj Gupta Cancer Centre and Research Institute submitted a final bill of Rs.97,426/- for hospitalization and treatment of the wife of the complainant. The copy of such bill has been filed in this case. On perusing the copy of the bill it appears that the hospital authority has claimed the cabin rent of Rs.1,700/- which is within the limit of the rate as mentioned in ‘Group Medicalim Scheme For Retired Employees and Their Spouses’. In such bill Laboratory Charges, Chest X-ray P/A, Semi major operation HPE charges, Nebulizer charges, Oxygen charges, cost of blood, blood transfusion charges, MRI –KUB and cost of medicine including such cabin rent total Rs.97,426/- have been claimed by Saroj Gupta Cancer Centre and Research Institute. Any of such cost as mentioned in the final bill issued by the hospital authority is not coming under the provision of Important Exclusion as mentioned in Group Mediclaim Scheme For Retired Employees and Their Spouses issued by the E-meditek. So, as per policy coverage as mentioned in Mediclaim Scheme for Retired Employees of SAIL and their spouses (2014), the complainant is entitled to get total Rs.97,426/-. In the written version the O.P. No.1 has stated that the O.Ps. by issuing letter asked the complainant to submit necessary document related to the expenditure of Rs.958/-. But the final bill issued by the hospital authority does not show that such amount of Rs.958/- was not claimed for any purpose. From the side of the O.P. No.1 no evidence has been adduced showing as to why it has asked the complainant to submit necessary documents related to expenditure of Rs.958/-. It is admitted that the O.P. No.1 has already paid Rs.75,968/- in place of Rs.97,426/- and the O.P. No.1 has not granted the rest amount of Rs.21,458/- treating the same as non-medical and non-payable expenses relying on the verified made by the O.P. No.2(TPA). In written version and also by adducing evidence the O.P. No.1 has not given any explanation as to why such amount of Rs.21,458/- has been treated as non-medical and non-payable expenses. It has already been stated that the cost as mentioned in the final bill is not coming under the ‘Important Exclusion’ as mentioned in Group Mediclaim Scheme for Retired Employees and their Spouses. So, the refusal for reimbursement of Rs.21,458/- is no doubt illegal. From the materials on record it appears that the complainant made claim for reimbursement of such Rs.21,458/- and he submitted original document related to the treatment of his wife for the period from 22.8.2014 to 11.9.2014 but the O.Ps. have not granted the claim of the complainant regarding reimbursement of Rs.21,458/- and they have made several correspondences with the complainant with an intention to delay and to refuse such reimbursement. For such act of the O.Ps. the complainant has been suffering since long and the complainant has been forced to come before this forum to get relief. So, the complainant is entitled to get an award directing the O.Ps. to pay Rs.21,458/- along with interest, to pay compensation and to pay the litigation cost. Considering the facts and circumstances of this case and also considering the period of harassment we are of the opinion that Rs.10,000/- and Rs.2,000/- as compensation and litigation cost restively, shall meet the ends of justice.
In view of the above, the case succeeds in part. Fees paid, is correct. Hence, it is
Ordered
that complaint being No.100/2016 is allowed in part on contest against the O.P. No.1 and ex-parte against the rest,
that the complainant do get an award directing the O.Ps. jointly or severally to pay Rs.21,458/- along with interest @ 9% p.a. from 30.5.2016, the date of filing of this case till the date of realization, to pay Rs.10,000/- as compensation for mental pain and agony and also to pay Rs.2,000/- as litigation cost to the complainant within 45 days, failing which the total awarded amount will carry interest @ 12% p.a. upto the date of realisation and the complainant will be at liberty to put this award in execution in accordance with law.
Let the copies of this order be supplied to the parties free of cost.
(Asoke Kr. Mandal)
Dictated and corrected by me. President,
D.C.D.R.F., Burdwan
(Asoke Kr. Mandal)
President
D.C.D.R.F., Burdwan
(Silpi Majumder) (Sri Pankaj Kr. Sinha)
Member Member
D.C.D.R.F., Burdwan D.C.D.R.F., Burdwan
