IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
MURSHIDABAD AT BERHAMPORE.
CASE No.CC /100/2013
Date of Filing: 16.08.2013. Date of Final Order: 28.07.2015.
Complainant: Ashoke Kumar Jain, 16/3, Babul Bonal Rload, P.O. Berhampore,
Dist. Murshidabad. Pin 742101.
Vs
Opposite Party: 1. Sr. Branch Manager, United India Insurance Co. Ltd, 3/20/A, K.K. Banerjee
Road, 1st floor, P.O. Berhampore, Dist. Murshidabad. Pin 742101.
2. Heritage Health TPA Pvt.Ltd. Nicco House, 2, Hare Steet, Kolkata-700001.
Present: Sri Anupam Bhattacharyya ………………….President.
Sri Samaresh Kumar Mitra ……………………..Member.
FINAL ORDER
Sri Anupam Bhattacharyya, Presiding Member.
The instant complainant has been filed by the complainant u/s 12 of C.P. Act, 1986 praying for payment of medical expenses for Rs.6512/- plus Rs.5000/- towards compensation from OPs.
The complainant’s case, in brief, is that the complaint along with his wife Mrs Madhu Jain had Health Insurance Policy valid up to 26.8.13 for the sum insured was Rs.1, 50,000/- each. Mr. Madhu Jain was admitted at CMRI, Kolkata on 19.4.13 as per advice of Dr. Anirban Bhaduri for treatment of left side Hemifacial Spasm and the complainant paid Rs.6512 in cash. Previously Madhu Jain, wife of complainant was admitted on 15.7.11 in the same CMRI for same treatment when she got cashless facility of Rs.6500/- and paid balance amount of Rs.387/- in cash. The complaint sent claim letter dt. 22.4.13 to OP No.2 along with original documents. OP No.1 replied on 21.5.13 rejecting the claim on the ground that the claim does not come within the purview of the policy. The complainant further wrote to head office and sent copy to regional and branch office on 13.06.2013 but in vain. Then, the complainant was compelled to file the instant complaint. Hence, the instant complaint.
The written version filed by the OP, in brief, is that as per Policy Condition (Clause 2.3) the Insured is not entitled to get any amount if he or she is not admitted in Hospital for more than consecutive 24 hours. But such rule will not be applied for some specific treatments as mentioned in Clause 2.3. But in certain cases with prior approval of TPA the insured can get benefit. The complainant never took the prior approval from the TPA regarding the operation for which the period of admission is less than 24 years. No prior notice was given to the Insurance Company. Moreover, intimation and approval are not identical one. There is no deficiency of service on the part of this Opposite Party. There is no laches on the part of the Opposite Party. So, the complainant is not entitled to get any compensation. The complaint should be rejected with cost.
Considering the pleadings of both parties the following points have been framed for disposal of the case.
POINTS FOR DECISION
- Whether the case is maintainable as per law and fact?
- Whether the case is barred by law of limitation or not?
- Whether the complainant has any locus sandi to file the present case?
- Whether the complainant is entitled to get any relief as prayed for?
- To what other relief/reliefs the complainant may get?
Decision with reasons
Point Nos. 1 to 6.
All the points are taken up together for the sake of convenience.
The instant complaint has been filed by the complainant for payment of medical expenses for Rs.6512/- plus Rs. 5000/- towards compensation.
The complainant’s case is that as per valid medical Mrs. Madhu Jain was admitted in CMRI hospital at Kolkata for left Hemifacial Spasm as per advice of doctor and deposited cash Rs.6,512/- and claimed payment of such cash of Rs.6512/- but repudiated the claim illegally where she got cashless facility for the same treatment in the same hospital on 15.7.11.
On the other hand the OP’s case is that as per Policy the complainant’s wife was admitted in the hospital for less than 24 hours and there is no prior approval for TPA for getting the benefit for the specific treatment as mentioned in clause 2.3.
To prove the complainant’s case the complainant has adduced relevant documents by firisti.
On the other the OP has filed the original policy showing in Para 3.2 showing the list of specific treatment where the time limit for 24 hours is not applicable.
The complainant has not filed any such document showing that the treatment will come under this Clause 3.2 and there was no document filed by the complainant showing prior approval.
Rather , it is clear from the list of treatment mentioned in clause 3.2 in the original policy that in that list there is no such treatment for hemifiial spasm and as such we can safely conclude that the impugned treatment being admitted in the hospital for not more than 24 hours, will not come under this policy.
Further, as per objection raised by the OP, the complainant has not filed any documents showing prior approval obtained by the complainant from TPA.
Regarding the strong argument advanced by the Ld. lawyer for the complainant as to cashless facilities as well as getting the benefit of the policy for the same treatment on earlier occasion on 15.7.11 though admitted for less than 24 hours in the same hospital, it is palpably clear from the document filed by the complainant himself in this case that there was prior approval which is the proviso of this clause 2.3 of the policy.
Considering the material on record as discussed above, we have no other alternative but to conclude that the claim of the complainant is not coming under the purview of the medi-claim policy and as such the complainant is not entitled to get any relief.
On the basis of the above discussion, all those points are disposed of against the complainant and as such the complaint is liable to be dismissed.
Hence,
ORDERED
that the Consumer Complaint No. 100/2013 be and the same is hereby dismissed on contest.
There will be no order as to cost.
Let a plain copy of this order be made available and be supplied free of cost, to each of the parties on contest in person, Ld. Advocate/Agent on record, by hand under proper acknowledgment / be sent forthwith under ordinary post to the concerned parties as per rules, for information and necessary action.
Member, President,
District Consumer Disputes District Consumer Disputes
Redressal Forum, Murshidabad. Redressal Forum, Murshidabad.
