Presented by:
Minakshi Chakraborty, Presiding Member.
BRIEF FACTS OF THE CASE:
Complainant files this case under section 12 of the Consumer Protection Act, 1986. As per the complaint, the complainant made a national mediclaim policy under the O.ps. being Policy No.153500501610002954 under National Insurance Company Limited at 22, G. T. Road (S), Howrah-711101. The O.ps. after observing all formality issued the policy in favour of the complainant and the policy covers an amount of Rs.2,00,000/- and the complainant and his family i.e. sons, daughter and wife are entitled to the benefit under the policy. The complainant craves leave of this Commission to point out the scope of the mediclaim which includes the diseases involved in the present case in hand. The O.ps do not raise any dispute regarding the issuing of medical policy and coverage of claim under the mediclaim policy and that the complainant is defaulted in depositing premium or that the mediclaim policy was not valid on the date of the incident when the complainant’s wife was hospitalized.
As per submission of the complainant, the documents submitted by the complainant namely Insurance Policy clearly shows that the existence of valid and binding medical policy was there which is also annexed with the W/V of the O.p. no.1.
According to the complainant, he visited Dr. Sushil Das on 27/11/2017 in connection with liver complain, abdominal pain and others allied problems of his wife and the said doctor prescribed medicine and directed the patient to make investigation CECT (W) abdomen, lower G.I. Endoscopy, consultation with Gastroenterologist, admission SOS at CMRI, Kolkata under the Doctor Anirban Chatterjee and he advised to admit the patient on 04/12/2017 under his care in CMRI, Kolkata.
As per submission of the complainant, the consistence advice of doctors will clearly show that there is sufficient ground and reason for admission of the patient under medical advice.
Complainant repeatedly requested the O.ps. to pay the mediclaim policy amount but the O.ps. failed and neglected to reimburse the said amount in favour of the complainant by raising some dispute and thereby refusing to pay the medicalim policy amount in favour of the complainant.
Ultimately having no other alternative the complainant filed the instant case with a prayer to direct the O.p.no.1 to reimburse the hospitalization claim amount of Rs.60,696/- and Rs.14,521/- post hospitalization in favour of the complainant in connection with the insurance policy no.153500501610002954 and compensation of Rs.50,000/- and litigation cost of Rs.10,000/- with other reliefs.
DEFENCE CASE:
The O.p.no.1 submitted the written version denying inter-alia all material allegations against him. The specific case of the O.P is that, it is a settled principal of law held by the Hon’ble Apex Court as well as Hon’ble National Commission that constitution of the policy bond which is the basis of the contract of insurance is question of law and it is true and correct interpretation would give the Consumer Forum to pronounce upon the deficiency in service. The O.p.no.1 clearly expressed that no treatment has been made by the complainant but a few investigations were made during Hospitalization.
As per submission of the O.p. no.1, the patient was admitted on 04/12/2017 and discharged on 09/12/2017. As per discharge summary which has been submitted by the complainant himself, the reason for admission has been mentioned as
“Known case fatty liver with normal UGIE and colonoscopy admitted with complaints of on and off abdominal bloating water brush and globes sensation.
Patient admitted for further management.
From the above it can be construed that this was known case of liver and was admitted only for further management which can be done as an outdoor patient also.
Further the significant Physical and other finds are also below:
Temp – 98F.
HR – 78 mm
RR – 18/mm BP – 110/70 mm if HG
i.e. All the above are normal.
The treatment done in the hospital reveals the following :
Patient was seen by Psychiatrist Dr. S. Mitra and his advices followed. Eye checkup was done and glasses prescribed.
The above confirms that there was no specific line of treatment and the admission was done for “Management of known fatty liver of health checkup” which can be managed in Outdoor Patient Department and hospitalization is not justified.
Since treatment under OPD is no covered under the policy, the claim was rejected and repudiation letter dated 06/02/2018 issued to the insured. Post hospitalization claim is payable only when the original claim is payable. On receipt of the repudiation letter, the insured requested to return the original documents of treatment and the same was returned accordingly, so as per submission of O.p. no.1 there is no deficiency of service and the O.p. no.1 states that the complainant is not entitled to reimbursement or to get any reliefs as prayed for.
Evidence on record
The complainant and O.p. no.1 have filed their respective evidence on affidavit, questionnaire and reply accordingly. Both sides their B.N.A. which are nothing but replica of complaint, written version and supports the averments of their respective petitions.
Argument highlighted by the ld. Lawyers of the complainant and O.p. no.1
Both the complainant and O.p. no.1 have filed separate written notes of argument. As per BNA the evidence on affidavit and written notes of argument of both sides shall have to be taken into consideration for disposal of the instant proceeding.
Heard argument of complainant and O.p. no.1 at length. In course of argument Ld. Lawyer of complainant and O.p. no.1 have given emphasis on evidence and documents produced by the parties.
From the discussion hereinabove, we find the following issues/points for consideration.
Issues/points for consideration
- Whether the complainant is the consumer?
- Whether this Forum has territorial/pecuniary jurisdiction to entertain the case?
- Whether there is any deficiency of service on the part of the opposite parties?
- Whether the complainant is entitled to get relief?
DECISION WITH REASONS
Issue no.1:
In the light of the discussion hereinabove and from the materials on record, it transpires that the complainant is a Consumer as provided by the spirit of Section 2(1)(d) of the Consumer Protection Act, 1986.The point is thus answered in the affirmative.
Issue no.2:
As both the parties have their address within the district of Howrah and the claims do not exceed the pecuniary limit of this commission, so as per section 11 of the Consumer Protection Act 1986, this commission has territorial as well as pecuniary jurisdiction to entertain the instant complaint case. This point thus disposed of accordingly.
ISSUE 3& 4
The case is running ex-parte against O.p. no.2 vide order no.8 dated 01/10/2018.
As per submission of the complainant, his wife underwent treatment at CMRI for fatty liver with normal UGIE disease. She was admitted to hospital on 04/12/2017 and was discharged on 09/12/2017. The medical papers of discharge summary of CMRI alongwith all test reports and doctors prescription are being annexed by the complainant with the complaint petition. Various investigation took place during admission for which huge expenditure was incurred by the present complainant for which the complainant submitted the policy claim form claiming the amount of Rs.60,696/- as he has a mediclaim policy in the name of his wife with National Insurance being policy no………The complainant vide its letter dated 06/02/2018 categorically stated that the claim has been rejected by National Insurance Company with a remark that “ we regret to inform you that your above reported claim has been rejected by the concerned TPA because of the following reasons….since the deceases/illness does not warrant hospitalization and treatment could have been done as an OPD patient even though it was converted into hospitalization for more than 24 hours. Therefore, we are not able to entertain the claim which may be kindly noted”. Though the complainant had paid the premium for the same. The complainant has filed the claim form and also the letter dated 06/02/2018 as annexure. Another letter dated 10/01/2018 has been filed by the complainant wherefrom it is found that National Insurance has clearly written that the claim is not admissible as per terms and conditions of the policy since the deceases/illness does not warrant hospitalization and treatment could have been done as an OPD patient even though it was converted into hospitalization for more than 24 hours. Rejection reason was written as “Hospitalization was not justified could have been treated on OPD basis”. Therefore the claim is recommended for rejection. In the written version submitted by O.p. no.1 in paragraph no.9 it has been stated that, it is a settled principal of law held by the Hon’ble Apex Court as well as Hon’ble National Commission that constitution of the policy bond which is the basis of the contract of insurance is question of law and it is true and correct interpretation would give the Consumer Forum to pronounce upon the deficiency in service, moreso as per submission of O.p. no.1 no treatment has been made but a few investigations were made during hospitalization for which the O.p.-Company repudiated the claim of the complainant. Certain questions were put by O.p. no.1 the answer of which by the complainant are not very clear. AT the time of scanning or scrutinizing the documents submitted by the complainant this Commission finds one prescription dated 27/11/2017 where it has been clearly written that “ SOS at CMRI”. No specific direction was given by the doctor for immediate hospitalization. In the discharge summary also the reason for admission was “known case of fatty liver with normal UGIE and colonoscopy admitted with complaints of on and off abdominal bloater……”. No serious decease was diagnosed for which admitted was recommended by the doctor. O.p. no.1 has further submitted the NMP prospector where, in point no.4 it is categorically stated certain conditions which are excluded from claiming the mediclaim. In point no.4.19 it has been specifically stated that “diagnostic and evaluation purpose where such diagnosis and evaluation can be carried out as outpatient procedure and the condition of the patient does not require hospitalization in that case the company shall not be liable to make any payment under the policy in respect of expenses incurred by the insurer”.
No papers have been filed by the complainant wherefrom the Commission may come to the point that the doctor has advice for immediate hospitalization for treatment, rather the papers submitted by the complainant are only proof that certain tests have been done by the CMRI. No papers have been submitted or produced by the complainant to show that any kind of treatment has been done by the hospital to within those 6 days. The complainant has miserably failed to prove his case.
Both the issues are thus disposed of.
Hence,
O R D E R E D
That the Complaint case no 92 of 2018 be and the same is dismissed on contest against O.p. no.1 and dismissed ex-parte against O.p. no.2. No order is passed as to cost.
Let a plain copy of this order be supplied free of cost to the parties/their ld. Advocates/Agents on record by hand under proper acknowledgement/ sent by ordinary post for information and necessary action.
The Final Order will be available in the following website The word file is drafted and corrected by me.
(Minakshi Chakraborty)
Member
D.C.D.R.C., Howrah
