DATE OF FILING : 27-11-2013.
DATE OF S/R : 16-12-2013.
DATE OF FINAL ORDER : 28-08-2014.
Sri Sajal Bhattacharyya,
son of late Surendranath Bhattacharyya,
G-3/2, Labony Estate, Sector – 1,
Salt lake ( near Tank No. 1 ),
Kolkata – 700064.--------------------------------------------------------------- COMPLAINANT.
- Versus -
1. The Senior Divisional Manager
The Oriental Insurance Company Ltd.,
Howrah Divisional Office,
P-4, Dobson Lane ( 4th floor ), P.S. Golabari,
Howrah - 711101.
2. The Chairman & Managing Director,
The Oriental Insurance Company Ltd.,
“Oriental House” A-25/27, Asaf Ali Road,
New Delhi – 110002.
3. The Office –in – Charge,
Medi Assist India TPA Pvt. Ltd.,
53-1, Rafi Ahmed Kidwai Road,
opp. Hotel Gulsham,
Kolkata – 700016.
4. The Senior Manager,
Punjab National Bank,
New Market Branch,
Kolkata, West Bengal,
PIN – 700087. -----------------------------------------------------OPPOSITE PARTIES.
P R E S E N T
President : Shri T.K. Bhattacharya, M.A. LL.B. WBHJS.
Member : Shri P.K. Chatterjee.
Member : Smt. Jhumki Saha.
F I N A L O R D E R
1. The instant case was filed by complainant U/S 12 of the C.P. Act, 1986
wherein the complainant has prayed for direction upon the o.ps. to settle the medi claim amount of Rs. 55,398/- together with 12% interest p.a. from the date of repudiation of the claim and a compensation of Rs. 10,000/- together with litigation costs of Rs. 6,000/- as the o.ps. in spite of repeated reminders did not settle the medi claim amount done with the PNB Oriental Medi Claim Policy no. 311700/48/2013/964 for his right eye treatment by Dr. Partha Biswas as an indoor patient.
2. The o.p. in the written version contended interalia that on scrutiny of the claim documents it was seen that 61 years old complainant was admitted to the hospital for Lucentis Injection. The patient was admitted on 27-11-2012 and discharged on the same date within 24 hours of hospitalization ; that the claim is not admissible as per Clause 2.2.
3. Upon pleadings of both parties two points arose for determination :
i) Is there any deficiency in service on the part of the O.Ps. ?
ii) Whether the complainant is entitled to get any relief as prayed for ?
DECISION WITH REASONS :
4. Both the points are taken up together for consideration. Admittedly the complainant has a valid medi claim policy. The complainant submitted his claim on 26-12-2012 and again the supplementary bill was submitted on 03-01-2012 as the claim was not settled within 2 months from the date of submission. The plea of repudiation that the injection ( Injection Lucentis ) is administered in case of age related muscular degeneration and as such is to be disallowed in cases of ARMD as the procedure involved is within OPD protocol only, appears to be too fragile to merit acceptance. Likewise, the plea of the o.ps. that 24 hours hospitalization is must for obtaining the reimbursement is also bogus inasmuch as the complainant had to incur the expenditure as claimed. It appears from the record that the patient was 61 years on the date of admission to the hospital for Lucentis Injection and was discharged on the same date i.e., 27-11-2012. The observation during repudiation cannot be treated as expert opinion. The point of minimum stay in the hospital was not mentioned in the prospectus of any of the four policies purchased by the complainant since 2011 till 2014. It is just an attempt on the part of the o.ps. to mislead the Forum and at the same time the conduct of the o.ps. is clear manifest that they adopted unfair trade practice to a bonafide policy holder. Hand book issued by the o.p. no. 3 under the head line ‘Notice of claim’ only pinpoints – expenses on hospitalization for minimum period of 24 hours are admissible. This time limit is not applied to specific treatment.
5. There is no dispute that the complainant was treated by Dr. Partha Biswas, MBBS ( Hons.) Gold Medalist M.S. ( Opthalmology ) Fellow Sankara Netralaya Channai, at BB Eye Foundation. He is a highly qualified and renowned eye surgeon and is also an expert in the specific branch of medicine i.e., Opthalmology. This Dr. Biswas conducted the treatment of right eye of the complainant as an indoor patient by administration of Lucentis Injection. He thought it best that the treatment should be done in an O.T. only. It is well known advised that the this injection should be administered in an O.T. only. Since the expert of the same branch thought it best to release the patient within 24 hours, the expenditure incurred by the complainant cannot evaporate at the whims of the o.ps.
6. With respect to Clause 2.2. it is not be noted that the same is meant for the account holders / employees of the Oriental Bank of Commerce. The claim of the complainant is covered by the PNB Oriental Royal Medi Claim Policy.
Therefore, we are of the view that this is fit case where the prayer of the complainant shall be allowed. Both the points are accordingly disposed of.
Hence,
O R D E R E D
That the C. C. Case No. 413 of 2013 ( HDF 413 of 2013 ) be and the same is allowed on contest with costs against the O.P. nos. 1, 2 & 3 and dismissed without costs as against the o.p. no. 4.
The O.P. nos. 1, 2 & 3 be directed to settle the claim amount of Rs. 55,398/- and to pay the same to the complainant within 30 days from the date of this order together with 10% p.a. interest since the date of repudiation of the claim i.e., 11-06-2013 till full satisfaction.
The o.p. nos. 1, 2 & 3 do further pay a sum of Rs. 8,000/- to the complainant as compensation for causing mental pain and prolonged harassment and to pay Rs. 5,000/- for litigation costs.
The complainant is at liberty to put the decree into execution after expiry of the appeal period.
Supply the copies of the order to the parties, as per rule.
DICTATED & CORRECTED
BY ME.
( T.K. Bhattacharya )
President, C.D.R.F.,Howrah.
