Minakshi Chakraborty, Presiding Member.
Brief facts of the case of the complainant: This case has been filed U/s. 12 of the Consumer Protection Act, 1986 by the complainant stating that the complainant and his wife were insured by the mediclaim policy of the national India insurance Company Ltd. being policy no. 154400/48/14/850004154 from the 21.10.2014 to 20.10.2015 with a sum assured amount of Rs. 4,00,000/- (Rs. 2,00,000/- + Rs. 2,00,000/-) and extra bonus of Rs. 95,000/- each through the agent opposite party no. 2. On 5.9.2015 the complainant slept from the stair and broke his left hand and left side chest and suffering from “blunt injury chest” and visited doctor for treatment for the same and the doctor advised him to admit to a nursing home for treatment and he got admitted to Bagbazar Nursinghome, Chandanngore and after getting proper treatment on 9.9.2015 he was discharged from there.
On 23.9.2015 the complainant informed the said incident to the opposite party and raised his claim on 24.9.2015 of Rs. 15,631/- along with all necessary documents but on 20.11.2015 the opposite party rejected the claim and closed his claim by saying that the treatment of blunt trauma over chest resulting in pain administered to the patient does not support the need for hospitalization and the said treatment could have been availed on OPD basis. After hearing the same the doctor sent a letter to the opposite parties and challenged the remarks passed by them and then on 28.1.2016 the complainant sent a legal notice to the opposite parties.
Complainant filed the present petition praying direction upon the opposite party no. 1to pay a sum of Rs. 15,631/- with interest and to pay a sum of Rs. 75000/- due to deficiency in service and to pay a sum of Rs. 40,000/- due to mental agony and to pay a sum of Rs. 20,000/- for litigation cost and to pass any other order/ orders as deem fit and proper.
Brief facts of the case by the opposite parties: The opposite parties contest the case by filing written version denying inter-alia all the material allegations leveled against them and submit that the opposite party no. 1 had repudiated the claim as per Clause 4.19 of the Insurant Policy Contract to which both the parties are bound by and further on a perusal of the medical papers as has been provided by the complainant it is clear that during the period of hospitalization save and except for a few pathological testing and radiological testing no further active course of treatment was administered to the claimant. So, the complainant is not entitled to get any amount as prayed from the ops and the claim is merely made to get reimbursement from opposite party to which he is not entitled to as per the Insurance Policy Contract as has been referred to above.
Evidence adduced by both the parties
The complainant has filed evidence on affidavit which is nothing but replica of complaint petition and supports the averments of the complainant in the complaint petition and denial of the written version of the opposite parties.
Complainant and opposite parties have filed separate written notes of argument. The evidence on affidavit and written notes of argument of both sides are taken into consideration for passing final order.
Argument advanced by the Ld. advocates of the complainant and the opposite parties heard at length.
From the discussion hereinabove, we find the following issues/points for consideration.
Issues/points for consideration
- Whether the complainant is the consumer?
- Whether this commission 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 any relief?
DECISION WITH REASONS
Issue number 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(d) of the Consumer Protection Act 1986.
Issue number 2
Both the complainant and the opposite parties are residents/having their office addresses within the district of Hooghly. Considering the claim amount of complainant as per prayer of the petition of complainant it appears that those are not exceeding Rs. 20,00,000/-. So, this Commission has territorial as well as pecuniary jurisdiction to entertain the present case. This issue is thus disposed of.
Issue nos.3&4 :
Both the issues are taken up together for the sake of convenience.
Admittedly, the petitioner was insured by the mediclaim policy of the National Insurance company from 21/10/14 to 20/10/15. During the policy period on 5/9/15 the petitioner slept from the stair and broke his left hand and left side chest and was suffering from “blunt injury chest” for which he was admitted to a nursinghome as per advice of Dr. bhaskar Das and had been there from 5/9/15 to 9/9/15. The matter was informed to the insurance company on 23/9/15 and the petitioner claimed Rs. 15631/ which was repudiated by the insurance company( O.P-1) giving rise to the instant proceeding for various reliefs.
There is no denial of the fact that the petitioner was admitted in a nurshinghome and that the claim has been repudiated by the National Insurance Company (to be addressed as O.P-1 hereinafter).
The moot question to be solved by this commission is whether “blunt trauma over chest” can be said to be so serious as to make the petitioner entitled to claim reimbursement. On scrutiny of the record it appears that the O.P-1 has repudiated his claim as per condition number 4.19 of the subject policy and in support thereof the O.P-1 has filed a letter dated 20/11/15 addressed to the petitioner having reference no. 154400/mediclaim/2015 dated 20/11/2015. A perusal of the said letter reveals that condition no.4.19 makes the O.P-1 to state that the company shall not be liable ……..under policy in respect of any expenses incurred in connection with or in respect of admission at hospital or nurshinghome primarily for a diagnostic and evaluation purpose which can be carried out as out- patient procedure.
Now the question arises whether “blunt trauma over chest” can be said to be a just ground for mediclaim by the complainant. True it is that Dr. Bhaskar Das who made a treatment of the complainant during the period of his stay at nurshinghome is not a party to the proceeding ( which is also the say of the O.P-1), yet as the doctor advised medical treatment of the complainant in nurshinghome , he has found it as his duty to submit a letter addressed to O.P-1 which is dated 27/01/16 and also deposed as P.W-2. The letter in question has been seriously objected to by the O.Ps in their written argument on the ground that no treatment was made in the nurshinghome except some examinations and tests stating further in para 10 therein “ to get reimbursement with the tacit consent of the doctor he was admitted in the hospital…..in present day situation it becomes a common practice that patients are advised by the doctors to get admitted in a nurshinghome to give the former a chance to get the reimbursement of expenses incurred for investigation and evaluation.”
Keeping in mind the above contention of the O.Ps this commission is constrained to hold that if a doctor in a case like the present one thinks it wise to face such opposition, this commission appreciates his gesture. The letter dated 27/01/16 of the doctor deserves a careful consideration in this case which relates to blunt injury chest. Needless to say more about the letter in question but important to mark the Merck manual of chest trauma management for all injuries, doctor take measures to support breathing and circulation if necessary. People may be given oxygen (for example, by nasal prongs, by face mask, or through a breathing tube) and intravenous fluids or sometimes blood transfusions. People with severe chest injuries are admitted to the hospital. People may be given pain relievers (analgesics) to lessen pain. For some injuries, a tube must be inserted into the chest (thoracostomy or chest tube insertion- see Chest Tube insersion) to drain blood (in hemothorax) or air (in pneumothorax) from the chest. This procedure helps collapsed lungs reinflate. Insertion can usually be done using only local anesthesia. In treating the present complainant relating to his medical treatment the doctor has expressed his opinion “chest x-ray often requiring a repeat x-ray after 24 and 48 hours measuring oxygen saturation, pulse, BP and other vital signs are mandatory in treating a patient with blunt injury chest. A CT scan is sometimes required to exclude potentially serious injuries (as was in this patient where CT revealed bilateral pleural effusion-which is in reaction to the trauma incurred and could have grown to enormous proportion to compromise respiration and lead to death had he not been under my supervision at indoors. This at the same time specifies the injury to be something more than a minor trauma and justify his admission at indoors.” In fine, this commission holds that the statement of the doctor(P.W-2) has not been controverted by any cogent and reliable evidence as mere noting of clause 4.19 ipso facto does not seem to be acceptable to controvert the same and hence makes the petitioner entitled to get the benefit which he is entitled to get from O.P-1.
It appears that the statements have been submitted on behalf of both the O.Ps as is available from the record but O.P-2 is merely an agent and as such he does not appear to have any responsibility in connection with the financial benefit of the petitioner from his side.
Having regard to the submissions of both parties and also the documents filed by them alongwith materials referred to herein above this commission expresses its opinion that though keeping in mind the resolution of the O.P.No. 1 with reference to letter no. 154400/mediclaim/2015 dated 20/11/15 the petitioner has become entitled to mediclaim of Rs. 15631/ alongwith compensation and litigation cost.
Hence,
ordered
that the complaint case no. 37 of 2016 be and the same is decreed on contest against O.P No. 1 in part and stands dismissed against O.P.No.2.
The petitioner do get mediclaim of Rs 15631/ and also do get Rs. 15,000/ and Rs. 10000/ respectively towards compensation and litigation cost within 45 days from date otherwise complainant is given liberty to execute this order as per law.
In the event of nonpayment/ non compliance of the above noted direction the opposite party nos. 1 and 2 are also directed to pay and/ or deposit Rs. 5000/- in the Consumer Legal Aid Account of D.C.D.R.C., Hooghly which is to be utilized for the purpose of poor litigant public.
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
