This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that as employee of Bengal Chemicals & Pharmaceuticals Ltd. has a medical insurance policy with OPs1 and 2 since 2009 for maintenance/continuance of which complainant regularly paid amount on account of premium towards the insurance policy, as and when required from, his salary and said policy was issued in favour of the complainant by the OP being No.100304/48/11/8500001917 which was renewed even  on 23-06-2011 after deduction of amount of premium from his salary and the said policy certificate was renewed on 213-06-2011.

          During continuance of the said mediclaim insurance policy complainant became ill with complaint of vomiting and weakness of both limbs on 07-10-2011 and was under treatment of Dr. Arun Karmakar, Registered Medical Practitioner, who advised him admission to Midland Nursing Home for management and accordingly, complainant reported Midland Nursing Home on 07-10-2011 and admitted under the care of Dr. T. Chakraborty and the said Nursing Home was covered under health insurance policy.

          On 09-10-2011 complainant developed complication of violent behaviour with sleeplessness for which the opinion of Dr. Anindya Roy, a consultant psychiatrist was required who observed the abnormal behaviour as a current one after 30 hours of admission.  Accordingly, condition of the policy the complainant was entitled to cashless treatment benefit and though the OP3 was requested for cashless treatment benefit but it was denied to him on 10-10-2011 stating reason of “Acute Confusional State with abnormal aggressive behaviour” and as because the cashless-treatment benefit was denied, the complainant deposited the final bill of Rs.24,366/- for the treatment and fact remains that abnormal behaviour of the complainant was a very short-timed and temporary one and never recurred during the period of hospitalization and that never occurred prior to that and treatment record speaks about that and he has never suffered from any such disease prior to that.  Moreover, Dr. D.K. Roy on behalf of the Midland Nursing Home Pvt. Ltd. wrote the OP3 on 13-10-2011 for reconsideration for extending benefit of cashless treatment to this complainant on the basis of a Note(Report) dated 13-10-2011 of Dr. Anindya Roy and in the said report it is clearly mentioned that acute onset abnormal behaviour of the complainant developed after admission was due to metabolic autonomic disturbance caused by vomiting and poor feeding which was the primary cause of the admission and it is also stated in the said report that complainant had no past history of psychiatric treatment prior to that episode and the previous history obtained in confused state of patient was found to be erroneous later on and complainant was discharged on 14-10-2011 at 6.00 p.m. as a fit person.  But anyhow OP repudiated the claim on the ground that the present claim is for treatment of acute confusional state as reflected from discharge summary but no doubt such a repudiation is without any foundation and for which the present complainant is entitled to get such reimbursement and for such redressal.

          On the other hand, OP by filing written statement that as per mediclaim policy’s terms and condition and also from the discharge certificate as advised it is evident that the complainant has suffered from Acute Confusional State as reflected from discharge summary and it was a psychiatric disorder and as per Clause 4.6 of NIC Policy Condition was reported and there was no valid ground for redressal for laches, negligence and deficiency on the part of the OP and further it is submitted that as per the medical certificate and the treatment documents, the insured was initially treated for vomiting and then detected as having symptoms, and as such, insured underwent treatment for both the illness and hence, based on medical certification they may allow 50% of the total cost of treatment for the admissible condition of vomiting and weakness and further mentioned that they are not authorized to repudiate any claim directly so the OP1 directly sent a letter to the insured for repudiation of the said claim under intimation to their authorized ‘TPA’ and after that OP1 sent a letter dated 09-08-2012 to the Office of the Director of Consumer Affairs & Fair Business Practices, Govt. of West Bengal, that the hospitalization was completely a case of psychosomatic disorder and that was diagnosed and treated during his stay in hospital and it comes under the purview of the Exclusion Clause 4.8 and, therefore, Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred in connection with or in respect of such diseases.  Therefore, considering the above facts and circumstances the petition of complaint has no merit.

Decision with Reasons

On careful study of the complaint and written version and including the discharge summary it is found that complainant was admitted at Midland Nursing Home with a history of vomiting and poor feeling which lead to metabolic disturbance that he has no past history of psychosomatic disorder or mental disorder.  But considering the abnormal behaviour developed at hospital help of psychiatrist was taken and after treatment he recovered from such metabolic anatomic disturbances and so discharged on 14-10-2011 as fit person and fact remains he was an employee of the company named Bengal Chemicals & Pharmaceuticals Ltd. and after treatment he was found fit in all respects and joined in his service and has been working without any further treatment and without any history of confusional state.

          Fact remains claim was made by the complainant for reimbursement of the medical treatment cost as paid during the period of his treatment at Midland Nursing Home but it is also admitted fact that the OP repudiated the claim on the ground that he was treated for his mental disorder or psychosomatic problem and as per Clause 4.8 the claim is not reimbursable.  Now, the question is whether there was past history of any psychosomatic disorder or psychiatric problem in this regard it is proved from the treatment document of that complainant that he never suffered from any mental disorder or psychosomatic disorder or psychiatric problem and he was admitted when he was vomiting and he was feeling unwell.  In this context we have gone through the subject from medical science, “confusional states” wherefrom we have gathered that delirium and acute confusional states are only caused in case of aged patient and some critical illness is found in respect of young and aged patient and the cause of confusional states symptoms is for cognitive disorder.  Confusional states itself is not a disease and such sort of disease may be caused due to urinary tract infection, pneumonia or drug effects and it is specifically mentioned in the said medical journal that confusional state is not a symbol or acute brand disorder and factors behind confusional state are stopping alcohol or nicotine or for dehydration or for malnutrition etc.  But no way, it shall be treated as psychiatric problem and confusional state of a patient may be found during treatment generally symptoms for adverse reaction or for medication or for suddenly stopping the sleep aids and in fact, as per said definition of the acute confusional state we find that complainant has not been suffering from any mental disorder prior to his admission.  Probably, the patient has withdrawn himself from smoking or alcohol, sleeping aids for which complainant was feeling ill and vomiting no other symptoms were collected by the doctor as preexisting diseases or disorder and after treatment he became fit and ultimately he has been working as an employee in the Company.  So, under any circumstances, it cannot be said that the treatment as made by the doctors of Midland Nursing Home was related to any preexisting disease or mental disorder or psychosomatic diseases.  Truth is that this complainant himself appeared in this Forum in all the dates of his hearing and from him we have came to learn that due to service reasons he used to work at night duty and for which sometimes he used to take some sleeping aids and used to smoke but he suddenly stopped all those and ultimately became ill and was hospitalized and, thereafter, after 7 days treatment he is now quite fit and we also found that he is also fit and hearty and healthy.  So, considering the fact we have gathered that the decision of the OP to hold that confusional state means suffering from mental disorder is not correct.  Considering the above facts and circumstances, we are convinced to hold that sudden delirium or sudden confusional state of the patient after treatment and during treatment hours does not ipso facto prove that patient had been suffering from mental disorder or psychosomatic diseases and confusion state does not mean that a person(patient) has been suffering from any psychosomatic disorder or mental disorder and in the present case entire matter was caused due to withdrawal from sleeping aids, smoking and other related practice.  So, we are convinced to hold that repudiation of the claim of the complainant by the OP was not justified and truth is that complainant never suffered from any mental disorder or psychosomatic disease but sudden delirium and confusion state was caused due to withdrawal from sleep aids, smoking and stopping of other related drugs.  When he used to work at night hours and for which in fact delirium is not a disease and symptoms of confusions state was not detected when acute cause of delirium is not detected by the doctor and in this case doctor admitted that fact and stating the same to the OP also.  Further from said literature it is found that due to lethargy it may be caused and also for some other correlated matter of cognitive disorder that is delirium/confusional state.  One may suffer from delirium or confusional state if his duty hours is continuous at night hours again and again.  Because sometimes for continuous night duty one may become very ill and feel lethargy for which sometimes a person may vomit again and again and for some other correlated cause also it may be caused but the said term is not related with any particular type of mental diseases in all cases and particularly in this case complainant is a fit person and for his withdrawal from sleeping aid and smoking and other practice he was feeling lethargy, vomiting for which official doctor after admission noted it as confusional state but after treatment it was found that it was not due to any acute confusional state because he has no past history of mental disorder and after treatment he is found quite OK.  Considering the treatment sheet and etc. we are convinced due to mal-nutrition, dehydration, withdrawal from smoking and sleeping aids such sort of behaviour was found after medication and such sort of delirium may appear on the background of acute physical illness etc.

          In the result, after considering the entire materials and factual aspect of the treatment including the medical documents of nursing home we are convinced that the opinion of the OPs regarding repudiation of the claim is without any foundation and it has no medical support from any corner in the particular case and for which complaint succeeds holding that the repudiation was not at all legally reasonable and with medical foundation.

Hence,

Ordered

That the case be and the same is allowed with a cost of Rs.2,000/-(Rupees Two thousand only) against OPs1,2 and 3 but is dismissed against OP4 without cost.

          OPs1 and 2 are hereby directed to pay a sum of Rs.24,366/- (Rupees Twenty four thousand three hundred sixty six only) within 15 (fifteen) days from the date of this order failing which for non-compliance of the Forum’s order OPs1 and 2 shall have to pay punitive damages of Rs.10,000/- which shall be paid to this Forum.

          OPs1 and 2 are hereby directed to comply the order very strictly failing which the penal action shall be taken against them and further penal interest at the rate of Rs.200/- per day shall be imposed till full satisfaction of the decree and if it is collected same shall be deposited to this Forum.