The case of the complainant in brief is that the complainant purchased one Mediclaim policy i.e. “Parivar Mediclaim Policy’ from the O.P. No.1 through the O.P. No.2 on 2.3.2011 vide policy No.153600/48/10/8500007353 and the validity period from 2.3.2011 to midnight of 1.3.2012.  The sum assured of the policy is Rs.2,00,000/- for herself, her husband and her son.  The premium of the policy is Rs.4,344/- only. 

That during the continuation of the policy the complainant felt a severe low back pain on 9.12.2011 during the journey to her school.  She consulted with her physician at Bagbazar Nursing Home on 16.12.2011 for her treatment.  The doctor advised her to get admission and accordingly the complainant admitted at the Bagbazar Nursing Home on 16.12.2011.  In the nursing home MRI of the complainant was done.

On 17.12.2011 complainant was under complete bed rest and also under the treatment of the Doctor.  As per MRI report, doctor informed that the complainant suffering from acute PLVS i.e. commonly known as Slipped Disc.  The complainant was discharged from the said nursing home on 18.12.2011.  As per advice of the doctor, complainant consulted with one Neurophysician Dr. K.C. Ghosh on 19.12.2012.

The complainant lodged the formal claim by filing up the claim form before the O.P. No.3 for an amount of Rs.9,668/- and she also submitted all relevant documents/papers for processing the claim which was received by  the O.P. No.1 on 21.3.2012.  But the O.P. did not pay any heed to the claim of the complainant.  Thereafter the complainant sent legal notice through her Advocate on 15.4.2013.  But this time also  O.Ps. did not respond to the legal notice of the complainant. 

The O.P. No.2 by sending a letter to the Advocate of the complainant stated that claim file has again been sent to Medsave Healthcare (TPA) Ltd. on 16.4.2013 for reviewing the file on urgent basis and they await for reply from the TPA and thereafter on 1.7.2013 the O.P. No.2 sent another reply letter vide Ref. No.153600/UW/FCM/PKB dated1.7.2013 stating that the claim of the complainant has been repudiated as no active treatment or therapeutic procedure other than pathological and MRI investigation done during the hospitalization, therefore, the claim is not admissible as per policy exclusion No.4.10.

Finding no other alternative the complainant has been compelled to file this case before this Forum and prayed relief with a direction to the O.Ps. to make payment of Rs.9,668/- as claim amount along with interest @ 18%, to pay Rs.1,00,000/- as compensation for mental pain and agony and to pay Rs.10,000/- as litigation cost.

The O.P. no.1 & 2 contested the case by filing written version denying the allegations leveled against them and averred that the complainant was admitted in the nursing home for one day for the treatment of ACUTE PIVD WITH REDIATION RT LEG as per the discharge summary and the said treatment as given does not justified hospitalization and the patient could not be managed on OPD.  The admission was entirely for diagnostic purpose and that could have been done as an OPD patient and as per exclusion clause 4.10 in the said policy ‘charges incurred at hospital or nursing home primarily for diagnostic, X-ray or laboratory examination or other diagnostic studies not consistent nor incidental to the diagnosis and treatment of positive existence or presence of any ailments, sickness or injury for which confinement is required at a hospital/nursing home’. 

On receipt of the letter of Mr.Avijit Das dated 15.4.2013, the O.P. No.2 sent a reply on 24.4.2013 intimating that the claim file has been again sent to O.P. no.3 for reviewing the file and thereafter the O.P. No.2 sent another letter to Mr. Das on 1.7.2013 intimating the fact that as per exclusion clause No.4.10 of the said policy the claim was not admissible and hence the claim was treated as no claim.

The complainant filed evidence on affidavit which is nothing but the replica of complaint petition.  The complainant filed brief notes of argument, photocopies of policy paper, claim form, letter dated 12.11.2012, prescription of Dr.Bhaskar Das, discharge certificate, prescription of Bagbazar Nursing Home, prescription of Dr.K.C. Ghosh, Advocate’s letter, money receipts and repudiation letter of O.P. National Insurance Company Ltd.

DECISION WITH REASONS

               The complainant in her evidence in chief stated that she was treated at Bagbazar Nursing Home on 16.12.2011.  Dr. Bhaskar Das advised her for treatment.  On 17.12.2011 the complainant was under bed rest and also under treatment of the doctor as per MRI report.  The complainant was informed the problem of slipped Disc.  On 18.12.2011 the complainant was discharged from the said nursing home.  Complainant paid the charge of the nursing home.  Thereafter, the complainant lodged the formal claim by filing the claim form before O.P. No.3 for an amount Rs.9668/- with other relevant documents.  After waiting many days the complainant was informed by the O.P. No.1 & 3 that the claim was not admissible.  Accordingly, after some time the complainant lodged the complaint before this Forum for redressal.  The O.Ps. in the written version has totally denied the allegations but the papers and treatment sheets in the record mainly Med Save Group, the Global Healthcare Company, and other paper of New United Diagnostic Clinic Pvt. Ltd. and some paper of Bagbazar Nursing Home and certificate of Dr. Bhaskar Das and advice of Dr.K.C Ghosh and other prescription, totalling 25 documents along with Advocate’s notice proves the allegation of the complainant.

            National Insurance Company vide letter dated 1.7.2013 informed the complainant that ‘as per findings from the documents in the claim file TPA has opined that no active treatment or therapeutic procedure other than pathological and MRI investigation done during the hospitalization, therefore, the claim is not admissible as per policy exclusion No.4.10.

            The O.Ps. in para-7 of the written version admitted the treatment of ACUTE PIVD WITH REDIATION RT LEG as per discharge summary.  It is stated that treatment does not justification hospitalization.  The O.Ps. put his leg in the exclusion clause 4.10 which runs follows ‘charges incurred at hospital or nursing home primarily for diagnostic, X-ray or laboratory examination or other diagnostic studies not consistent nor incidental to the diagnosis and treatment of positive existence or presence of any ailments, sickness or injury for which confinement is required at a hospital.

            From the document before us and from the admission of the O.P. on record it appears that the complainant was admitted in the nursing home under the doctor to remove her suffering and was in the hospital for the period mentioned herein before.  The reason has not been analytically explained by the O.P. No.3 for refusing the cost of treatment as per spirit of the mediclaim policy.  The reason shown by the O.P. No.3 is utterly not acceptable and devoid of any merit.    The complainant obviously entitled to get cost of expenditure of any treatment, whatsoever, in the hospital or nursing home.  The repudiation is not justified and utter negligence to the spirit of the law of the country.  Accordingly, the O.Ps. are liable for their negligency by not following the principle of the policy.  The O.Ps. have duty to pay the cost of treatment as soon as claim was lodged. But the O.P. did not pay the amount claimed by the complainant for which the complainant has compelled to take the recourse of this Forum, obviously the act of the complainant has caused harassment, mental agony in coming to court for getting her redressal as per Section 14 of the C.P. Act.

            So, after deliberation over the material on record we are fully convinced that the complainant is entitled to get the cost of treatment and a lump sum amount for mental harassment and litigation cost from the O.Ps.   Hence, it is

Ordered

that the case be and the same is allowed on contest against the O.Ps. with cost.

that O.P. Nos.1 to 3 are jointly and severally liable for deficiency in service to the complainant by not providing the relief to the complainant.  The O.Ps. shall pay the claim amount of Rs.9,668/- under policy No.153600/48/10/8500007353  along with interest @ 10 p.a. with effect from 6.5.2014.  The O.P.s are also directed to pay compensation for mental pain, agony and harassment of Rs.50,000/- because it is the O.Ps. who has compelled the complainant to come before this court and complainant is roaming in this court since 6.5.2014 till date.  So, that amount is commensurate with the negligency of the O.P.  The complainant is also entitled to get litigation cost of Rs.10,000/-.  The O.Ps. are directed to issue an A/c. payee cheque in favour of the complaint within 45 days from this date of the order i.d. Rs.200/- shall be given by the O.P. per day till full payment and this amount shall be deposited in the Consumer Legal Aid Account.  Failing which, the complainant is at liberty to execute this order in accordance with law.

Let the copies of this order be supplied to the parties free of cost.