Orissa

Cuttak

CC/88/2022

Sanjib Kumar Bhanjadeo - Complainant(s)

Versus

Oriental Insurance Co Ltd - Opp.Party(s)

Self

25 Jul 2023

ORDER

            IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

C.C. No.88/2022

Sanjib Kumar Bhanjadeo,

S/O:LateKrupasindhuBhanjadeo,

At present:ResidingAt:Plot No.2C/190,

Near Jugal Kishore Park,Sector-9,

CDA,P.S:Markatnagar,Dist:Cuttack-753014.            ... Complainant.

 

          Vrs.

 

Senior Divisional Manager,

Oriental Insurance Company Ltd.,

At:Bajrakabati Road,Cuttack.....Opp. Party.

 

 

Present:            Sri Debasish Nayak,President.

                             Sri SibanandaMohanty,Member.

 

Date of filing:   09.05.2022

Date of Order:  25.07.2023

 

For the complainants     :Self.

For the O.P                       :Mr. A.A.Khan,Adv& Associates.

 

            Sri Debasish Nayak,President.

Case of the complainants as made out from the complaint petition in short is that the complainant alongwith his wife Sonali Balabantray were detected Covid-19 positive on 6.9.2021 for which they had undergone treatment initially at Nilachal Hospital of Bhubaneswar and subsequently at Apollo Hospital at Bhubaneswar being admitted on 14.9.2021.  Since because the complainant alongwith his wife had obtained health insurance policy from the O.P, he had requested on 14.9.2021 for the coverage of the insurance towards the medical expenses as incurred at Apollo Hospital who were allotted beds no.330 &331 at the Apollo Hospital and were under treatment of Dr. Kartik Chandra Jena there with effect from 14.9.21 to 21.9.21.  The hospital authorities had raised the bill of Rs.1,45,000/- towards the treatment of the complainant and a sum of Rs.2,25,370/- towards the treatment of the wife of the complainant but quite strangely, the O.P had reimbursed a sum of Rs.1,34,287/- towards the treatment of Sonali the wife of the complainant only.  The complainant had therefore to bear the balance sum of Rs.85,000/- towards the treatment of his wife besides his treatment expenses and further a sum of Rs.50,000/- which he had spent at Nilachal Hospital with effect from 5.9.21 to 14.9.21.  The complainant has also spent a sum of Rs.8000/- towards oxygen back-up and also a sum of Rs.5000/- towards the post covid-19 care.  Thus, according to the complainant, the total medical expenses was of Rs.44,749/- out of which, the O.P had only reimbursed a sum of Rs.1,34,370/- and the balance amount of Rs.3,13,204/- being not paid was paid by the complainant himself to the hospital authorities, towards the medical treatment as well as for different tests.  The complainant had written many-a- times to the O.P for reimbursement of the whole amount and ultimately when no result yielded, had to file this case before this Commission seeking the balance amount of Rs.3,13,204/- from the O.P alongwith interest thereon @ 15% per annum from the date of filing of the case till the final payment is made.  The complainant has also prayed for a compensation of Rs.1,50,000/- towards mental agony and torture and a sum of Rs.20,000/- towards cost of his litigation.

The complainant together with his complaint petition has filed copies of several documents in order to prove his case.

2.       The O.P has contested this case and has filed his written version wherein the O.P has mentioned that the case of the complainant is not maintainable which is liable to be dismissed with cost.  According to the written version of the O.P, the claim as regards to the payment of the medical expenses of the complainant himself is not payable as per the terms and conditions of the insurance policy.  As regards to the medical expenses incurred towards the wife of the complainant. the same was settled for an amount of Rs.1,34,287/- which has already been paid to the complainant.  Thus, according to the O.P, the complainant has filed this case with an oblique motive only.  The O.P admits to have issued a “Happy Family Floater,2015” policy in favour of the complainant covering the risk of the complainant alongwith his wife Sonali & Daughter Baibhabi which was valid from 10.9.2021 till the midnight of 9.9.2022 with a coverage of the risk upto Rs.3,00,000/- for each of them.  After receiving the claim from the complainant,during scrutiny by the Paramount Health Service and Insurance, TPA it was found that the complainant Sanjib Kumar Bhanjadeo was admitted in Apollo Hospitals Enterprises Ltd., Bhubaneswar on 14.09.2021 and was discharged on 20.09.2021,  From the documents supplied by the complainant it was found that the complainant was detected COVID positive on 6.9.2022 and the medical investigation report reveals that “all inflammatory makes were within normal range – TLC,CRP,D-Dimer,LDH and all blood reports were within normal limits.  So, looking to the available medical documents, that patient found clinically stable with overall fair general condition.  All vitals and reports are within limit, CT sore (0/25, SPO2 98%).  The evaluation of HRCT Thorax done outside revealed normal findings.”  Thus from, the clinical picture the COVID of the complainant was mild which did not require any hospitalisation but only primary isolation with medical counselling under home care facilities should have been done in the case of the complainant.Accordingly, the O.P had not entertained the claim of the complainant for reimbursement of his own medical expenses.  Out of the bill raised towards the medical expenses of Sonali Balabantray, the wife of the complainant, an amount of Rs.1,32,309/- was settled after deducting an amount of Rs.93,061/- from the total bill amount of Rs.2,25,330/- as per the terms and conditions of the insurance policy.  Thus, the O.P has prayed through his written version to dismiss the complaint petition as filed by the complainant as nothing more is to be paid to the O.P.

          The O.P alongwith his written version has filed copies of several documents in order to prove his stand.

          The complainant has filed his evidence affidavit in this case but the same when perused, it is noticed that the evidence affidavit of the complainant is nothing but a reiteration of the averments as made by him in his complaint petition.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.P, this Commission thinks it proper to settle the following issues in order to arrive at a definite conclusion here in this case.

i.          Whether the case of the complainant is maintainable?

ii.         Whether there was any deficiency in service on the part of the O.P and if he had practised any unfair trade?

iii.        Whether the complainant is entitled to the reliefs as claimed by him?

Issue no.II.

Out of the three issues, issue no.ii  being the pertinent issue is taken up  first for consideration here in this case.

          After going through the contents of the complaint petition, written version and evidence affidavit as well as the copies of documents as available in the case record, it is noticed that infact the complainant had obtained a “Happy Family Floater,2015” policy which was valid from 10.9.2021till the midnight of 9.9.2022 covering the health risks of himself, his wife Sonali and his daughter Baibhabi.  It is also not in dispute that the complainant alongwith his wife Sonali were detected Covid-19 positive for which they were initially treated at Nilachal Hospital and subsequently at Apollo Hospital, Bhubaneswar being provided hospital beds there bearing no.330 & 331 from 14.9.21 to 21.9.21.  The hospital authorities had admittedly raised a bill amounting to Rs.1,45,000/- towards the treatment of the complainant and further a sum of Rs.2,25,370/- towards the treatment of the wife of the complainant.  It is also admitted that the O.P had settled the claim amount towards the wife of the complainant only for a sum of Rs.1,34,287/- and had deducted the balance amount thereof.  In order to justify the same, the O.P in his written version has provided a chart at page no.4 wherein the deduction details are provided which amounts to Rs.93,061/-.  As it appears therein, the O.P had deducted a sum of Rs.33,000/- from the room and nursing charges, a sum of Rs.5,810/- from the medicine and consumable charges, a sum of Rs.9,367/- from professional fee charges, a sum of Rs.24,100/- from investigation charges and a sum of Rs.6,083/- from the miscellaneous charges and accordingly they had deducted an amount of Rs,.93,061/- from the total amount of expenditures as raised by the Apollo hospital authorities towards the medical treatment of the patient Sonali Balabantray, who is wife of the complainant of this case.  The O.P considering the Covid-19 of the complainant to be mild in nature could come to a conclusion that only home isolation and home care facility was needed and thus the hospitalisation of the complainant which was unnecessary, for which it required no reimbursement. 

Such activities as observed on the part of the O.P appears to be arbitrary, unilateral and rather whimsical which is only non-application of reasonable mind not with consonance of law.  It is because, the hospital authorities especiallythe doctors and the treating physicians are the best persons to opine that if hospitalisation is required for a patient or not.  The approach in that line by the O.P/insurer appears to be ridiculous as because he is not the fit person to came to such a conclusion.  Moreover, the O.P has not explained that when the medical authorities had raised their bill towards the medical treatment of Sonali Balabantray the wife of the complainant to the tune of Rs.2,25,370/-, under what circumstances the same amount was minimised and a sum ofRs.93,061/- was deducted from the said total amount.  The same is not properly explained by the O.P as to what capacity the said deduction was made.  Such action of the O.P here in this case appears to be contrary to the law and the O.P has not also explained as to what were the terms and conditions of the policy those which were violated/exceeded and as to through which terms and conditions of the said policy the amounts those whichwere deducted by the O.P were justified.  Accordingly, this Commission finds the O.P to be definitely deficient in his service by repudiating the claim of the complainant and reducing the claim of the wife of the complainant.  This attitude of the O.P also signifies the practice of unfair trade by him.  Accordingly, this issue goes in favour of the complainant.

Isssuesno.i& iii

From the discussions as made above, the case of the complainant is maintainable and complainant is thus entitled to the reliefs as claimed by him.  Hence it is so ordered;

                                              ORDER

The case is allowed on contest against the O.P.  The O.P is directed to reimbursethe balance amount of Rs.3,13,204/- to the complainant alongwith interest thereon @ 12% per annum from 28.12.2021 till the amount is quantified.  The O.P is also directed to pay the complainant a sum of Rs.1,00,000/- towards compensation for the mental agony and harassment as caused to the complainant alongwith a further sum of Rs.20,000/- towards the litigation expenses as made by the complainant.  This order is to be carried out within a period of 30 days from the date of receipt of this order.

Order pronounced in the open court on the 25^th day of   July,2023 under the seal and signature of this Commission.          

                                                                                                                  Sri Debasish Nayak

                                                                                                                         President

                     

 

                                                                                                    Sri Sibananda Mohanty

                                                                                                                  Member