DIST. CONSUMER DISPUTES REDRESSAL FORUM
NORTH 24 Pgs., BARASAT
CC- 265/2017
Date of Filing: Date of Admission:- Date of Disposal:
19.05.2017 06.06.2017 06.03.2020
Complainant :- 1. PROSANTA KUMAR BOSE
12/2, Jogi Para Lane
P.O.&P.S. - Barasat
Pin -700124.
=Vs=
Opposite Parties :- 1. THE BRANCH MANAGER OF
Oriental Bank of Commerce
Sodepur Road, Madhyamgram
P.S.- Madhyamgram
Pin - 743275.
2. The Senior Divisional Manager of
The Oriental Insurance Co. Ltd.
P-4, Dobson Lane, 4th Floor
Howrah-711101.
3. Dr. Amit Dey of
Narayana Multispeciality Hospital
78, Jessore Road (South)
Barasat, Pin-700127.
P R E S E N T :- Sri Karna Prasad Burman ………..…………... President
:- Smt. Monisha Shaw ………………………….….Member
Judgment
This complaint is filed by the Complainant u/s 12 of the Consumer Protection Act, 1986 alleging deficiency in service as well as unfair trade practice against the OPs as the OPs did not take any step to redress his grievance till filing of this complaint.
The brief fact of the complaint is that the Complainant, Prosanta Kumar Bose is a Mediclaim Policy Holder of the Company OP No.2 vide his policy no.311700/48/2016/6886 in the covering period 06.11.2015 to midnight of 04.11.2016 in his name Serial No.1 and his wife Prity Bose Serial No.2 covering amount Rs.4,00,000/-. On 23.05.2016 wife of the Complainant was admitted at NH Narayana Multispeciality Hospital, 78, Jessore Road (South), Barasat, North 24 Parganas for her treatment who has been suffering from Nausea, shortness of breath, swelling of ankles and feet etc. under Dr. Amit Dey (OP No.3) of the said hospital. After admission the said Doctor advised to make
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CC- 265/2017
pathological test like ESR, FBS, HB%. CRT, USG of whole abdomen, chest x-ray, lipid profile etc. After treatment the patient was discharged from the Hospital on 27.05.2016.
The Complainant stated that as per doctor’s opinion his wife has been suffered from diabetic nephropathy and CKD and recent history HBsAg+ . The Complainant apply for mediclaim to OP No.2 under proper mediclaim form vide Claim No.CCN12744506 dated 30.05.2016 amounting to Rs. 37,578/- but the mediclaim was rejected by OP No.2 showing reason as per policy T&C under exclusion clause no.4.10.
As a result having been constraint the Complainant took legal recourse by filing this case and prayed for direction upon the OPs :-
to pay his expensed amount Rs.37,578/- as mediclaim along with compensation Rs.20,000/- for harassment and mental agony.
Litigation cost of Rs.5,000/- inter alia.
It is evident from the record that the OP Nos.1 and 3 received the notices on 21.06.2017 and 13.06.2017 respectively. Despite they did not turn up. Hence the case did proceed exparte against the OP No.1&3 (vide order No.4 dated 04.08.2017).
The OP No. 2 filed W/V on 26.07.2017 wherein categorical denials are made and took plea by invoking “exclusions” which are laid down in clause 4.10 under terms and conditions of the policy (mediclaim policy) that the Complainant is not entitled to his claimed amount as he concealed such “exclusions” before this Forum.
As per W/V of OP No.2, “Exclusions” under clause 4.10 is “The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of :
Expenses incurred at Hospital or Nursing Home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period OR expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalization or primary reasons for admission, referral fee to family doctors, out station consultants/Surgeons fees, Doctor’s home visit charges/Attendant/Nursing charges during pre and post hospitalization period. etc.
To substantiate his plea he banked upon the opinion of the Neutral Medical Expert dated 25.09.2016 and 02.10.2016 collectively (Annexure-‘A’). He prayed for rejection of the case with exemplary cost.
Considering the above pleadings as well as nature and character of this case the following points are necessarily come out for consideration to reach just decision of the case:-
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CC- 265/2017
Is the Complainant a consumer U/S 2(1)(d)(i) of the consumer Protection Act,1986?
Has this Forum jurisdiction to entertain the instant case?
Have the OPs any deficiency in service as alleged by the Complainant?
To what other relief/reliefs the Complainant is entitled?
Decision with reasons
Considering the facts and circumstances as well as nature and character of this case all the points are interlinked to each other and as such all the points are taken up together for consideration for the sake of brevity and convenience.
Point No.a
The complainant is a consumer under the OPs with the strength of his policy No.311700/48/2016/6886.
Point No.b
The Complainant resides under P.O.&P.S.- Barasat within the District of 24 Parganas (North) and the OP Nos. 1&3 both are situated under the P.S.-Madhyamgram and Barasat respectively under same District within the territorial jurisdiction of this Fora and the claim amount does not exceed the pecuniary limit. As such this Fora has ample jurisdiction to entertain this case.
Point No.c
On perusal of the materials available in the case record as well as hearing of argument of both parties are found admission came out from the OP side in respect of the treatment of the patient Smt. Prity Bose in NH Narayana Multispeciality Hospital at Barasat. The medical expensed amount of Rs. 36,880/- + Rs.698 = Rs.37578/- has not been challenged by the OP side. The OP side denied to pay the expensed amount banking on the opinion of their empanelled medical expert wherein he found that the patient “found to have undergone various investigation to evaluate cause of Pedal Aedema in the background of Diabetes and was found to have been suffering from Diabetic Nephropathy – Chronic Kidney disease. The various investigations done were possible on OPD basis did not need hospitalization therefore”. By this opinion of the empanelled medical expert. The OP side denied to pay the complainant by way of invoking the clause 4.10 of the Mediclaim agreement. The opinion of the expert has not been produced. Treatment of the insured Prity Bose has not been denied and the medical expenses of the patient has not been challenged. The medical certificate in respect of the patient Mrs. Prity Bose issued by Dr. Amit Dey speaks that “to add further patient had a recent history of HBsAg+. On the day of admission the patient’s present condition was very critical, there were no other alternative way. The patient’s hospitalization was must”. This medical certificates has not been disproved by the OP side resulting which the clause No. 4.10 of the Mediclaim agreement does not support the reluctant trend of the OP side particularly wherein the treatment of the patient in hospitalization has not been denied. Therefore, we are of the view that there is deficiency in service on the part of the OP side.
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CC- 265/2017
Considering the positive results of the discussed points Point No. d) also bears positive result and that should be reflected in the ordering portion. Thus all the points are disposed of accordingly.
Fees paid are correct.
Hence for ends of Justice:
it is
Ordered,
that the instant case be and the same being No. CC 265/2017 is allowed on contest against the OPs with cost. The complainant do get a decree of his expense amount of Rs. 37,578./- OPs as his Medi claim along with compensation amount to Rs. 3,000/- for his harassment and mental agony plus Rs. 2,000/- as litigation cost. The OPs are directed to pay total decretal amount of Rs.42,578./- to the complainant within 35 days from this day failing which the complainant will be at liberty to put this decree into execution according to law.
In realization of the aforesaid decretal amount through execution the complainant will be entitled to 8% interest p.a. on the aforesaid decretal amount from the date of filing of this case from 19/05/2017 till realization of the entire decretal dues.
Let the plain copy of this order be supplied to the parties free of cost as per the provision of the CPR, 2005.
Dictated & Corrected by President
Member
Member
