Judgment : Dt.11.12.2017

Balaka Chatterjee, Member

            This petition of complaint is filed under section 12 of C.P.Act by Sri Arijit Kanungo and Smt. Poly Kanungo alleging deficiency in service and unfair trade practice on the part of the opposite party Star Health & Allied Insurance Co. Ltd.

            Case of the Complainant in brief is that the Complainant No.1, Sri Arijit Kanungo entered into a medi-classic individual policy being policy No.P/191112/2009/000203 with the opposite party on 14.8.2008 for a joint coverage of Complainant No.1 and his mother Poly Kanungo, Complainant No.2. It is stated by the Complainant that since commencement of the said policy they have been paying the premium till date and the said policy has been being renewed every year and presently the same has been numbered as P/191112/01/2017/002510 with sum assured of Rs.1,50,000/- only for each of the Complainants and the same is valid till the midnight of 13.8.2017. It is further stated by the Complainant that the Complainant No.2 had undergone a blood test as to glucose fasting and glucose PP on 26.4.2017 and having had the report consulted her doctor namely Dr. P. Biswas on 26.4.2017, who, perusing the said test report, advised her “Urgent Hospitalization” and in accordance with the said advise of doctor, the Complainant No.2 was taken to a nursing home namely Mediview Nursing Home (P) Ltd. and was admitted there on 6.5.2017. It is also stated by the Complainant that although there was provision for cashless treatment in the said Insurance Policy but the OP insurer denied the request for authorization for cashless treatment without any cogent reason. The patient Complainant No.2 was discharged from the Nursing Home on 10.5.2017.

            It is stated by the Complainant that the bill amount of the said nursing home was Rs.27,915/- only including all the hospital charges and fees of the doctors. It is further stated by the Complainant that on 16.05.2017 the OP sent a letter to the Complainant No.1 asking him to submit all the documents mentioned therein within fifteen days from the date of discharge for reimbursement and in compliance, the Complainant No.1 submitted all the papers and documents as asked by the OP and the same was received on 20.5.2017 by the OP but, thereafter, the OP did not respond. Having no reply from the end of the insurer the Complainant served a letter dt.19.6.2017 on the OP. It is the specific allegation of the Complainant that subsequently by a letter dt.6.7.2017 the opposite party stated that the content of the letter dt.19.6.2017 is misconceived, mala fide, concocted and a product of after-thought and it was an attempt to justify the illegal acts which caused mental agony for which the OP is liable to compensate the Complainants to the tune of Rs.50,000/- along with Rs.27,915/- towards reimbursement of medical expenses. Accordingly, the Complainant has prayed for a direction upon OP to pay Rs.27,915/- as part of reimbursement of the Medical Bill, to pay Rs.50,000/- as compensation and to pay litigation cost.

            Notice was served upon the OP but OP did not turn up. So, the case was fixed for ex-parte hearing vide order No.6 dt.1.11.2017.

            The Complainant filed affidavit-in-chief along with photocopy of Medi Classic Individual Policy for the period from 14.00 on 14.8.2008 to Midnight of 13.8.2009, Medi Classic Individual Policy period of insurance 14.8.2016 to midnight of 13.8.2017, Blood Test reports d.t.26.4.2017, prescription dt.26.4.22017, receipts dt.10.5.2017and discharge certificate issued by Mediview Nursing Home (P) Ltd., reports on the bio-chemical examination dt.7.5.2017, letter dt.6.7.2017 issued by Star Health and Allied Insurance Co. Ltd. to Abhijit Sanyal, Advocate.

            In course of hearing Ld. Advocate for the Complainant stated that method/ procedure of treatment in exclusively Doctors’ discretion. Nobody can interfere in this matter.

Decision with reasons

            Having heard the submission made by the Ld. Advocate for the Complainant and on perusal of documents on record, it appears that the Complainant and his mother Complainant No.2, are under coverage of a Medi Classic Insurance Policy which is valid from 14.8.2016 to 13.8.2017. It further appears from the record that the Complainant No.2 admitted to a nursing home namely Mediview Nursing Home (P) Ltd. on 7.5.2017 and discharged therefrom on 10.5.2015. The Complainant No.1 has filed claim for disbursement of Rs.27,915/- towards cost of treatment to the OP insurer but the insurer vide letter dt.6.7.2017 repudiated the said claim. The Complainants have approached the Forum alleging unlawful repudiation of their claim by the OP. Now the moot point is whether the repudiation is justified. On perusal of letter dt.6.7.2017 vide which the OP repudiated the claim it appears that the OP has admitted that the insured patient was hospitalized on 6.5.2017 in Mediview Hospital (P) Ltd and raised a preauthorization request for availing cashless facility for treatment of Diabetes Mellitus with Hypertension but the same was denied stating that the patient had been investigated and orally treated and therefore, no active intervention (was occurred) for which admission (at the said hospital) was warranted and the same was communicated to the treating hospital vide letter dt.5.9.2017 and a copy of the same was given to the Complainant. The ground of repudiation of the claim is that the insured patient was treated with oral medication only and no active line of management was given to the insured patient and, therefore, the medical team of the OP is of opinion that the insured patient could have been treated as out-patient and hence the claim was repudiated and the same was informed to the Complainants vide letter dt.5.6.2017. However, as per terms of the policy the insurer is liable to pay for amount of expenses to the insured person for medical/surgical treatment upon advice of duly qualified physician/medical specialist/medical practitioner at any nursing home/ hospital in India which are enlisted by them as an inpatient upto the limits indicated but not exceeding the sum insured in aggregate.

            In the instant case, the insured admitted to hospital as per advice of Dr. P. Biswas MBBS (Cal) DIP, CAPD (CAL), General Physician and Cardiologist who advised by prescription dt.26.4.2017 for ‘urgent hospitalisation’. The OP did not dispute regarding medical qualification of the said physician nor did raise any question regarding recognition of the said nursing home wherefrom the insured received treatment but raised objection on the point of procedure/                        of treatment stating that the patient could have been treated as out-patient since she had been treated with oral medicine. The said objection as raised by the OP is contradictory to the terms of the policy as well as to practical approach since the patient had been hospitalized as per advice of a qualified medical practitioner and the patient had no scope for choice to be treated as out-patient. Hence, the ground for repudiation of the claim is not sustainable.

            In such view of the matter, we are of opinion that the Complainants are entitled to get the amount of Rs.27,915/- towards medical expenses from the OP. Further, the OP compelled the Complainants to file the instant case for getting their legitimate claim and as such the OP is liable to pay the cost of litigation. Considering the circumstances, we are not inclined to allow any compensation. In the result the petition succeeds in part.

            Hence,

ordered

            The CC/464/2017 and the same is allowed in part ex-parte with cost.

            The opposite party is directed to pay Rs.27,915/- to the Complainants within one month from this order on production of bill in original.                                          OP is further directed to pay Rs.7,500/- towards cost of litigation within above mentioned period. Failing which the entire amount shall carry interest @ 10% p.a. till realization.