Order No. 11 dt. 29/05/2019
The case of the complainants in brief is that Sri Debdutta Das, complainant no.2 while suffering from pain in the upper portion of his gum consulted Dr. Ranjan Rashmi Paul for treatment of pain on 29/09/2018. The said doctor advised the patient to take recourse to specific clinical and radiological test to investigate into the cause of the pain and from such test doctor detected the existence of a cyst in the upper jaw of the patient, which requires immediate surgery to alleviate pain in the gum. Accordingly complainant got admitted into ‘Life line diagnostic center cum nursing home at 4A, Wood Street, Kolkata – 700 016 on 26/10/2018 under the advice of Dr R.R. Paul who operated the cyst in the said nursing home and discharged the patient on 28/10/2018. Here it is to be mentioned that the complainants including the patient in this case undertook an insurance policy under the scheme “Family Health Optima Insurance Plan” for the family of the complainants vide policy no. P/191111/01/209/004434 for the period from 07/08/2018 to 06/08/2019 against insured amount of Rs.10 Lakh from M/s. Star Health and Allied Insurance Co. Ltd., 229/2, A.P.C. Road, Kolkata – 700 004. Therefore, complainant after getting treatment of surgery of the cyst submitted a claim of reimbursement of Rs.68,668.62 for the expense regarding doctor’s fee, cost of surgery, medicine and other incidental expenses before opt. no.1 who acknowledged the same on date. But opt. no.2 repudiated the claim on the ground that the complainant no.2 has undergone dental related treatment which cannot be considered as per exclusion clause no.4 of the said insurance policy on 26.11.2018. Finding no other alternative against the repudiation of the claim complaints lodged this complaint seeking direction upon the opt. to reimburse the Rs.68,668.62 along with compensation of Rs.2 Lakh including interest and litigation cost of Rs.50,000/-.
PR and TR shows notices have been served upon the opt. but in spite of receiving the notices ops. did not participated in the proceedings of this case. Therefore, the o.ps. are fixed ex parte in this case.
In order to prove the case the complainant sworn in an affidavit of evidence in support of the contention of the complaint and filed the documents in support of his claim including photocopies of the records of treatments and policy documents issued by the o.ps. Due to unchallenged testimony of the complainant there is no scope to disbelieve the submission of the complainant and therefore, it should be accepted and necessary order is to be passed accordingly.
Considering the submissions of the respective parties it is an undisputed fact that the complainant no.2 while suffering from pain in the upper portion of his gum consulted Dr. Ranjan Rashmi Paul on 29/09/2018. The doctor diagnosed disease and asked the patient to take recourse to specific clinical and radiological test to investigate into the cause of the pain and/or for confirmation of his estimation and from such tests doctor detected the existence of a cyst in the upper jaw of the patient. Accordingly, on the advice of the doctor complainant got admitted into ‘Life Line Diagnostic Center cum Nursing Home at 4A, Wood Street, Kolkata – 700 016 on 26/10/2018 and got operated the cyst in the said nursing home and discharged the patient on 28/10/2018. From the documents submitted by the complainants it is evident that complainant undertook an insurance policy under the scheme “Family Health Optima Insurance Plan” for the family of the complainants under policy no. P/191111/01/209/004434 for the period from 07/08/2018 to 06/08/2019 from M/s. Star Health and Allied Insurance Co. Ltd., 229/2, A.P.C. Road, Kolkata – 700 004. Therefore, complainant submitted a claim of reimbursement of Rs.68,668.62 for the expense for treatment of the cyst including doctor’s fee, cost of surgery, medicine and other incidental expenses before opt. no.1 who acknowledged the same on date. But opt. no.2 repudiated the claim on the ground that the complainant no.2 had undergone dental related treatment which could not be considered as per exclusion clause no.4 of the said insurance policy on 26.11.2018. Finding no other alternative against the repudiation of the claim complaints lodged this complaint .In the complaint petition complainant stated that surgery of the cyst in question is covered under clause no.2(ii) of the said policy and as such the complainant is entitled to get reimbursement of the entire amount. Ops. dealt the claim very negligent manner which leads to adoption of unfair trade practice by the o.ps. Against the submission of the claim o.ps. has observed the medical records and have revealed that the insured patient has undergone dental related treatment which cannot be considered as the said treatment is under the coverage of exclusion clause 4 under the phrase “dental treatment’’. But in the prescription dated 29/09/2018 Dr. R.R. Paul the treating doctor after examining the patient noted that complainant had no history of dental problem and such noting was made for exclusion of dental pain from the pain in the cyst in question for which the patient had to consult with the Dr. R.R. Paul. In the discharge certificate the treating doctor had not mentioned anywhere that it was a case of dental related surgery. With the above points in view we hold that there was deficiency in service together with unfair trade practice in dealing the reimbursement claim by the o.ps. Therefore, complainant is entitled to get relief.
Hence, ordered,
that the case no.22/2019 is allowed ex parte against the o.ps. The o.ps. are jointly and/or severally directed to pay the amount of Rs. 68,668.62/- (Rupees Sixty Eight Thousand Six Hundred Sixty Eight and Sixty Two Paisa only) as well as compensation of Rs.5,000/- (Rupees Five Thousand only) for harassment and mental agony and Rs.1,000/- (Rupees One Thousand only) for litigation cost within 30 days from the date of communication of this order, i.d. an interest @ 8% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.