This appeal is referred against the final order delivered by Ld. DCDRF, Siliguri dated 30/3/2016 in reference to CC no. 12/S/2014. The fact of the case in nutshell is that the respondent Pramod Agarwal has purchased a Happy Family floater insurance policy (silver plan) with oriental insurance company bearing policy no. 313205/48/2013/1598. He was admitted for illness in Medanta Global Health private Limited on 20/8/2013 at 16.42 hours where he was undergone medical check up along with coronary angiography. He was discharged from the said Hospital on 21/8/2013 at 13/19 hours. Thereafter he submitted a claim before the Insurance Company for his expenses which he has incurred for such treatment to the tune of rupees 41,000. The insurance company has repudiated the claim on the ground that as per terms and condition of clause no. 4.11, the complainant was not entitled to get such reimbursement of medical expenses as he was not hospitalized for treatment of any specific ailments. Then the complainant registered a consumer complaint where the Oriental Insurance Company as Op had contested the case and contended inter alia that the claim of the complainant was not sustainable in accordance with the provisions of clause 4.11 in the insurance policy. Ld. Forum after recording evidences and after hearing the both sides, has delivered the final order which is challenged before this Commission in appeal on the ground that the order of Ld. Forum was not sustainable in law and was liable to be set aside. The appeal was admitted in due course and the notice upon the respondent P Agarwal was served notice, who has contested the appeal through his Ld. Advocate S Mitruka. The appellant is represented here in this Commission, through Ld. Mr. B Maitra. The appeal was heard in presence of Ld. Advocate of both sides.

Decision with reasons,

Admitted position is that one P Agarwal has purchased the Happy Family floater Insurance policy from Oriental Insurance Company by making payment of premium to the company in due course and thereafter he was admitted at Medanta Global Health private Limited on 20/8/2013 where his routine health checkup was conducted along with Coronary Angiography.

Thereafter he furnished the claim application before the insurance company for medical reimbursement amounting to rupees 41,000 and the said claim application was repudiated on the part of the insurance company on the ground that the complainant was not hospitalized with any complicating health problem. He was admitted there only for the routine medical tests under his own fashion and the investigation like Coronary Angiography could be done only as OPD patients and for the reason, the claim was repudiated by the insurance company under clause 4.11 of the insurance policy.

Ld. advocate of the appellant submits that according to section clause 4.11 “any expenses incurred at hospital or Nursing home. Primarily for evolution/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period could not be re-imbursed”

He further submits that the medical documents which was furnished by the complainant never has shown any illness or disease he was suffering at that point of time and he has availed the health check up package which is called Medanta executive whole-body checkup.

He further argued that Ld. Forum in the judgment observed that discharge certificate and discharge summary issued by the Medanta Global Health private Limited, has shown the recommendation of some medicines for the treatment of the patient but the said discharge summary which was produced by the complainant/respondent did not show any medicine was prescribed for him for his treatment of any ailment. He was simply advised to take some tabulates like Aspirin and Anti acidity which did not suggest that he was suffering any acute ailment. Ld. Advocate of the respondent at the time of his turn during the course of his argument mentioned that the medical papers which has produced by the complainant clearly speaks that he took admission in the said hospital Medanta Global Health private Limited, due to pain in chest and stomach and others part of the body and he was treated there under the care of Dr. Pravin Chanda, a renowned cardiologist.

Ld. Advocate further submits that he at first was diagnosed of heart problem on 19/8/2013 while he was treated by dr. Rakesh Kumar Tandon as OPD patient at PS Research Institute at New Delhi, and thereafter he came back to Siliguri for doing normal routine works and then he endured some pains in his chest and respiratory problem and for that reason, he went to Medanta Global Health private Limited for treatment and checkup where coronary angiography was held on 20/8/2013. Now the question is whether the complainant P Agarwal was suffering any ailment during his stay at Siliguri till 20/8/2013. During the course of evidence some questionnaires was furnished on the part of the appellants. In question no. 5 the complainant was asked whether he had consulted with any doctor of Siliguri for his illness/complication, in reply to the said question the answer was negative.

In question no. 6 it was asked by the Insurance company whether the complainant was advised by any doctor to go to Medanta Global Health private Limited for his treatment, in reply he says that Dr. Tandon has advised him to go to Medanta Global Health private Limited. The document submitted by the complainant speaks that he went to Dr. Rakesh Kumar Tender at T S researching Institute on 19/08/2013 at New Delhi. And he visited Medanta on 20/8/2013 that meant just on the next day. The Medanta is also located at New Delhi. So, there is crystal clear from the medical evidences that the patient was suffering in uneasiness for his chest pain and he went to a cardiologist who referred coronary angiography and health check-up at Medanta and for that reason he was admitted at Medanta on 20/8/2013 and after health check-up and coronary angiography he was discharged on 21/08/2013. So the view of the commission is that though the complainant had no serious ailment for hospitalization but under the advice of Dr. Tandor he had to take admission at Medanta for coronary angiography and health checkup and for that reason he had to incur medical expenses to the tune of rupees 41000/- and such amount has rightly claimed by him. The insurance company only on the advice of Dr. V Mittal has repudiated the claim where Dr. Mittal has not come before Ld. Forum to say that the said investigation of the complainant could be done on an OPD basis. The claim of the respondent was justified one and insurance company repudiated the claim on the Advice of Mr.  Dr. Mittal which was nothing but misguide the insurance company and insurance company had no serious fault in this regard as the Company had to rely upon the advice of Dr. Mittal. So, the award for rupees 41,000 for reimbursement of medical cost incurred by the complainant, is very much genuine one. On the other hand, the harassment cost rupees 44,000 appears to be excessive one as because the insurance company had no serious fault on their part and such amount as cost of harassment to the tune of rupees 44,000 should be reduced to rupees 20,000 and the litigation cost awarded in favour of the complainant/respondent of rupees 10,000 is appreciating one and order of the Ld. Forum should be effected from the date of delivery of the copy of judgment of this Commission to the appellant.

Thus, the appeal is hereby disposed of touching all the disputes.

Hence, it is,

Ordered,

That the appeal be and same is hereby dismissed on contest without cost, subject to modification of the award delivered by the Ld. DCDRF, Siliguri. The order of Ld. Forum to be modified as follows: -

The appellant/OP is directed to pay rupees 41,000 as medical cost. Rupees 20,000 towards compensation for negligence and deficiency of service and rupees 10,000 as litigation cost to the complainant/respondent within 30 days form the date of receiving the copy of this appeal failing which 9 per cent per annuum will be carried on over the entire amount Rs. 71000/-.

Let a copy of this order be sent to the concern Forum and also to be supplied to the parties free of cost.