District Consumer Disputes Redressal Commission, Hooghly
PETITIONER
VS.
OPPOSITE PARTY
Complaint Case No.CC/108/2019
(Date of Filing:-08.08.2019)
- Ranjan Banerjee
162, Bijoy Krishna Street, P.O. and P.S. Uttarpara
Dist. Hooghly, Pin:-712258…..Complainant
- National Insurance Company Ltd.
Registered and Head Office:- 3, Middleton Street, Kolkata-700071.
- National Insurance Company Ltd., Kolkata Division XXII
National Insurance Building (Ground Floor)
8, India Exchange Place, Kolkata-700001
- Mr. Manisankar Halder
148, Netaji Subhas Road, P.O. and P.S. Uttarpara
District:- Hooghly, Pin:- 712258
- Woodland Multispeciality Hospital Limited
8/5, Alipore Road, Kolkata-700071
…..Opposite Parties
- Dr. Debidas Chattopadhyay
105/2 B. K. Street
P.O. and P.S. Uttarpara
District:- Hooghly (near Telephone Exchange)
Pin:- 712258
……Proforma Opposite Party
Before:-
Mr. Debasish Bandyopadhyay, President
Mr. Debasis Bhattacharya, Member
PRESENT:
Final Order/Judgment
DEBASIS BHATTACHARYA:- PRESIDING MEMBER
Being aggrieved by and dissatisfied basically with the service extended by National Insurance Company Ltd. in general (hereinafter referred to as OP 1 and 2) of the address as mentioned above, in the matter of lodging of a claim of reimbursement of medical expenses related to the medical treatment of the Complainant and subsequent repudiation of the said claim by the insurance company, the instant case has been filed by the complainant, u/s 12 of the Consumer Protection Act 1986.
The fact of the case after trimming the unnecessary details is as follows.
In the year 2018, the Complainant claims to have suffered from uncommon warm and syncope and had a medical consultation with one Dr. Debidas Chattopadhyay on 21.04.18 and the said medical practitioner prescribed medicines and certain medical investigations. However as the condition of the Complainant patient deteriorated, advice was given by the doctor for hospitalization.
Accordingly the Complainant got admitted to the OP 4 Hospital on 21.05.2018 and underwent treatment and several medical tests on recommendation of the attending doctors of the hospital. However the Complainant was discharged from the hospital on 24.05.2018 after ‘proper’ treatment. The medical bill in this regard was to the extent of Rs.1,03,701/- for the stay in the hospital for the period from 21.05.18 to 24.05.18.
The complainant, being a holder of the medical Insurance Policy bearing No. 154400501710005328 valid for the period from 16.12.2017 to 15.12.2018, through the OP 3 Agent of the OP 1and 2 Insurance Company, preferred a claim on 13.06.2018 for reimbursement of the medical expenses arising out of the medical treatment and certain medical tests undergone by him in OP 4 Multispeciality Hospital. On receipt of the claim OP 2 Insurance Company asked for certain documents and reportedly the Complainant without wasting any time submitted the same.
However on 17.08.18 OP Insurance Company repudiated the claim assigning the reason “hospitalization of the patient was not followed by any active course of treatment; the said hospitalization was done for the purpose of the evaluation and investigation purpose only; the stay of hospitalization was not medically necessary.”
The repudiation letter prompted the Complainant to write a letter to the OP Insurance Company.
Considering the stance taken by the OP Insurance Company as a negligent one the Complainant claims that there was deficiency of service on the Opposite parties’ part.
Ventilating the grievances against OPs the Complainant approaches to the Commission with a prayer to impose direction upon the OP 1, 2 and 3 to reimburse the amount of Rs.1,03,701/-, to pay an amount of Rs.50,000/-for deficiency of service, Rs.50,000/- for harassment and suffering, Rs.25,000/- towards litigation cost and any other relief as provided by the statute.
The Complainant along with his petition has annexed copies of certain supporting documents viz. prescription of the first attending doctor i.e. the profrma opposite party, diagnostic reports, exhaustive medical documents of the hospital, discharge summary, intimation letter regarding the hospitalization, Claim form submitted before the OP insurance Company, communications made to the OP Insurance Company, repudiation letter received from the OP Insurance Company, rebuttal letter sent to the OP Insurance Company by the Complainant and brochure connected to the Policy documents.
In view of the above discussion and on examination of available records it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(1)(d)(ii) of the Consumer Protection Act 1986 are concerned.
The Complainant in this case purchased the policy against payment of premium and in turn the Insurance Company was the service provider.
The complainant, OP 3 and the proforma OP are resident within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.20,00,000/-
Thus, this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
The issues related to the questions whether there was any deficiency of service and whether the complainant is entitled to get any relief, being mutually inter-related, are taken together for convenient disposal.
Evidence on affidavit and brief notes of argument are almost replicas of the Complaint petition.
The OP has contested the case by filing written version. On prayer, the written version filed by the OP Insurance Company has been treated as evidence on affidavit. Brief notes of argument filed by the OP Insurance Company are almost replica of the written version.
The case runs ex parte against OP 3 agent, OP 4 Hospital and Proforma opposite party. However so far as the Complaint petition is concerned, OP 3 agent, OP 4 hospital and OP 5 proforma opposite party medical practitioner appear merely formal party against whom no relief is claimed.
Defense Case
In the written version turned evidence on affidavit the OP Insurance Company has denied all the material allegations leveled against them. OP 1 and OP 2 claim that the claim of the Complainant is fabricated, manufactured illegally with mala fide intention and for wrongful gain.
It is further claimed that the hospitalization of the Complainant was not followed by any active course of treatment and the said hospitalization was done only for the purpose of evaluation and investigation only. The OP Insurance Company alleges that the stay in the hospital was not medically necessary and it is pointed out that as per policy condition the Company is thus not liable to make any payment.
The OP Insurance Company argues that from the papers and documents submitted by the Complainant it is found that the medical tests viz. USG of whole abdomen, Echo, ECG, Chest X-Ray, Urine RE/C etc. were only for diagnosis and there was no necessity for hospitalization.
OP Insurance Company thus asserts that there was no deficiency of service on their part.
In this Connection, the said OP relies on the judgment pronounced by the Hon’ble Apex Court in the case of Lakhmi Chand vs. Reliance General Insurance in which it was observed that ‘in a contract of insurance, the rights and obligations are governed by the terms of the said contract. Therefore, the terms of a contract of insurance law have to be strictly construed and no exception can be made on the ground of equity’
Decision with reasons
The complaints with which the Complainant patient was admitted to the hospital were Bilateral swelling of legs for 5 days and Shortness of breath on exertion. Past medical history was Hypertension and Hypothyroidism. Stay in hospital was for the period from 21.05.18 to 24.05 18.
However the two main decisive issues here in this instant case are whether there was any active course of treatment and whether hospitalization was medically necessary.
Now firstly let us focus on the term ‘active course of treatment’.
Active course of treatment means (1) a medically necessary, ongoing course of treatment for a life threatening condition, (ii) a medically necessary ongoing course of treatment for a serious condition, (iii) medically necessary care provided during the second or third trimester of pregnancy, or (iv) a medically necessary ongoing course of treatment for a condition for which a treating healthcare provider attests that discontinuing care by such healthcare provider would worsen the covered person’s condition or interfere with anticipated outcomes.
In the instant case the OP Insurance Company rejected the Complainant’s claim because they did not find any evidence of the treatment or tests that would require hospitalization. The medication and tests recommended for the Complainant could have been conveniently conducted on an OPD basis.
Now referring to the exclusion clauses (4.18 and 4.19) of the policy the OP Insurance Company claims that they are not supposed to make any medical reimbursement under the policy in respect of any expenses incurred in connection with or in respect of Outpatient Department treatment and Diagnostic and evaluation purpose where such diagnosis and evaluation can be carried out as outpatient procedure and the condition of the patient does not require hospitalization.
However active course of treatment appears to be a vague term. These terms are created just to assign a reason for repudiation of a claim by hook or by crook. Even if a patient with certain complaint of indisposition approaches to a medical practitioner for the first time and on clinical examination the medical practitioner on the very first occasion opines that the patient requires hospitalization, the patient has to be hospitalized. The District Commission is not supposed play the role of a more competent medical expert to decide whether the medical practitioner who recommended the hospitalization was justified or not. In the instant case, it is apparent that the attending doctor recommended hospitalization. The patient also had to undergo extensive treatment and medication during his stay in the hospital.
Thus the OP Insurance Company cannot repudiate the claim on the plea that there was no active course of treatment and the treatment exclusively was for diagnostic and evaluation purpose. Moreover the OP insurance Company could not substantiate their point by producing any medical expert’s opinion in this regard.
On meticulous scrutiny of all the aspects of the case, this Commission is of the view that there was gross deficiency of service on the OP Insurance Company’s part.
Hence it is
ORDERED
that the complainant case no.108/19 be and the same succeeds on contest but in part.
Resultantly the opposite parties 1 and 2 Insurance Company i.e National Insurance Company Ltd. in general will be liable to reimburse the treatment expenses as claimed, to the extent of Rs.1,03,701/- with interest @9% for the period from the first date of repudiation i.e. 17.08.18 to the actual date of reimbursement.
Besides, a further amount of Rs. 25,000/- will have to be paid by the OP Insurance Company to the complainant for his mental agony and harassment and Rs.5,000/- towards litigation cost, within 45 days from the date of this order. In the event of failure to comply with this order, the opposite party will pay cost of Rs.20,000/- by depositing the same in the Consumer Legal Aid account.
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/sent by ordinary post for information and necessary action.
The final order will be available in the website www.confonet.nic.in
