The fact of the case is that complainants had Family Insurance Policy head by Tapas Kumar Nandi. Daughter Tanisha Nandi became ill in the month of July, 2012 and she was admitted on 11.7.2012 and discharged on 10.8.2012. The Op no.2 was informed on 18.7.2012. After that complainant filed claim before the Opposite party. Petitioner no.1 became ill in the month of August 2012 and discharged on 13.8.2012. Accordingly, a claim of Rs. 27,992 and Rs.38,694/- were raised in respect of hospitalization of petitioner no.1 and 2. But after lapse of many days their claim was not sanctioned by the oP . Hence this claim before this Forum.
Op no.1 and 2 have contested the case by filing Written version denying inter alia all material allegations . The complainants had not mentioned wherefrom he was discharged , did not mention ailments . The oP depends on the exclusion clause no. 4.8 and 4.10 i.e. company shall not be liable to make any payment for expenses incurred primarily for evaluation diagnosis purpose not followed by active treatment during hospitalization. It is also stated by the OP that the complainant had not filed any document relating to treatment of the patient . No document certificate from the treating doctor has also been filed.
Though Op no.3 and 4 received summons but they did not contest the case. So the case against them has been heard exparte.
Complainant filed Discharged certificates and bills and also treatment sheets. The complainants also file Evidence in chief and Written Notes of Argument. Op on the other hand filed Evidence in chief, Written version and Written Notes of argument.
POINTS FOR DECISION
- Whether the complainant is a consumer?
- If there is any deficiency on the part of the oP ?
- If complainant is entitled to get any relief?
DECISION WITH REASONS :
All the points are taken up together for easiness of discussion.
The complainant has filed Discharge certificate and other Test report of petitioners no.1 and 2 . It appears that there was some disease . The Discharge certificate of Soma Nandi shows she was treated and was administered medicines. She was treated with Analgysis Stress Ulcer Prophylaxis and other supportive care . She underwent Excision Biopsy on 13.8.2012. Post operatively she is improving . This discharge certificates shows that she was treated in the hospital . Discharge certificate of Tanisha Nandi shows that this 7 year old female was admitted with complainants of 2 episodes of LOC. Complaints of constipation 1 month, vomiting present. Started on treated for constipation. No history of fever. Complaints of weight loss present. No history of cough. Not a known case of DM/HTN.
It appears from the Discharge summary and other reports of investigation that the patients were admitted in the hospital with some ailments . The doctor treated them and discharged them with advice. So this act of the hospital does not come within the purview of exclusion clause as stated by the oP in their Written version. Such types of Health Insurance are
generally instructed to the people to be good in health physically and mentally. So, we have no hesitation, after going through the great volume of records to hold that patient was treated in the hospital and both the patients were under the Health scheme. Accordingly, the OP should consider the claim and Op had duty either to allow the claim or to reject the claim with reason. In this case, after searching the record we do not find any single scrap of paper that Op has repudiated the claim stating reason inspite of getting application from the complainant. Such conduct of the oP is itself a deficiency in service and neglect of duty towards the complainants who have been insured under the Policy. Moreover, the complainant has paid the billing amount issued by the hospital.
Considering the case of both sides we are of opinion that complainants are entitled to get the expenses for treatment in the hospital from the alleged period. Hence it is –
Ordered
That the CC no. 234 of 2014 be and the same is allowed on contest. The OP no. 1 and 2 are jointly and severally liable to pay Rs.27,922/- and Rs. 38,694/- to the complainants. The Op no.1 and 2 are also jointly and severally liable to pay Rs.15,000/- to the complainants for unnecessary harassment , mental agony and pain to the complainants. The Op no.1 and 2 are
further jointly and severally liable to pay Rs.10,000/- to the complainants towards litigation cost.
The Ops are directed to comply the above orders within 45 days from the date of this order i.d. complainants are at liberty to file Execution case for executing the above order.
Let a copy of this order be made over to the parties free of cost.
