Ld. Advocate(s)
For Complainant: Rajdeep Majumder
For OP/OPs : Raj Kumar Mondal
Date of filing of the case :15.03.2022
Date of Disposal of the case : 16.08.2023
Final Order / Judgment dtd. 16.08.2023
Complainant above name filed the present complaint u/s 35 of C.P.Act 2019 against the aforesaid OPs praying for relief as per prayer. He alleged that complainant purchased one Policy from OP no. 1 and said policy was valid for the period from 29.09.2020 to 28.09.2021. During the validity of the said policy complainant was admitted in the nursing Home namely Hiramoni Memorial Hospital for his illness and was treated there and he was released on 24.09.2021. On 18.10.2021 complainant claimed medical expenditures amounting to Rs. 22,420/- from OP no. 1 and said claim was registered as claim no. NI-9-3341. He submitted necessary documents for getting claim amount and he also submitted documents on 08.12.2021 but OP no. 1 and 2 not yet paid the aforesaid amount in his favour.
Hence, the complainant filed this case.
Case is running ex-parte against OP no. 2 vide order dtd. 29.06.2022.
OP no. 1 contests the case by filing W/V and he denied the entire allegations lodged by the complainant.
He further stated that complainant was admitted at Hiramoni Memorial Hospital at Krishnagar and treated there for the period from 22.09.2021 to 24.09.2021 and he submitted the bill before them. He was asked to provide some documents and lastly the complainant submitted the same before them.
On perusal of those documents they found that complainant was treated at Hiramoni Memorial Hospital on 22.09.2021 and was discharged on 24.09.2021 with diagnosis of HTN, AWM. He could continue the said treatment as OPD patients.
Complainant violated the clause No. 51 of the policy and accordingly, he is not entitled to any amount.
TRIAL
During trial complainant filed affidavit-in-chief. OP filed interrogatories, Complainant filed answer. OP no. 1 filed affidavit-in-chief, complainant filed questionnaire and OP no. 1 gave answer.
DOCUMENTS
Complainant files certain documents under firisti:-
- Health card of Tapas Kr. Mitra( two copies original ).
- Collection receipt of National Insurance (five sheets original).
- Policy Sehedule of National Senior Citizen Mediclaim Policy ( five sheets Xerox.)
- Prescription of Dr. Jayanta Kr. Saha dtd. 22.09.2021.( one sheet Xerox)
- Receipt copy of Hiramoni Memorial Hospital dtd. 24.09.2021.( three sheet Xerox )
OP also produced certain documents under firisti:-
- 1. One copy of discharge certificate of HIRAMANI MEMORIAL HOSPITAL dtd. 24.09.2021.( original)
- Letter of NATIONAL INSURANCE COMPANY LIMITED addressed to Mr. Tapas Kr. Mitra issued by Branch Manager of National Insurance Company Limited dtd. 22.12.2021.( Xerox copy)
- A letter of SAFEWAY INSURANCE TPA PVT LTD dtd. 25.11.2021.( three Xerox copy ).
- Policy Schedule National Mediclaim Policy of National Insurance ( Four sheet original).
- National Insurance Company Limited ( two sheet Xerox)
BNA
Complainant filed BNA. OP filed BNA.
DECISION WITH REASONS
We have carefully gone through the petition of complaint filed by the complainant, W/V filed by OP, affidavit-in-chief filed by the complainant, affidavit-in-chief filed by the OP no. 1, BNA filed by the complainant and BNA filed by the OP no 1.
We have considered those documents.
On perusal of the affidavit-in-chief filed by the complainant we find that complainant corroborated the allegation mentioned in the petition of complainant. Similarly, OP no.1 corroborated the contention of his W/V. It is admitted position that complainant purchased one mediclaim policy from OP no. 1 and he time to time renewed the same.
On perusal of copy of renewal Policy we find that aforesaid mediclaim policy has renewed lastly for period from 29.09.2021 to 28.09.2022.
On perusal of the said documents we find that complainant started mediclaim policy in the year 2015 and same was valid till 24.09.2016. Complainnat time to time renewed same lastly the said policy renewed till 28.09.2022.
On perusal of the insurance policy dtd. 09.09.2020 we find that said policy was renewed for the period from 29.09.2020 to 28.09.2021.
On perusal of the health card we find that said card was issued in favour of the complainant for the period from 29.09.2020 to 28.09.2021.
On perusal of the copy of prescription of complainant dtd. 22.09.2021 we find that complainant was appeared before Dr. Jayanta Kumar Sara with some complications. On that time BP of the complainant was abnormally high. Doctor recorded the same as 189/160. No doubt aforesaid BP of the complainant was appeared abnormally high on that time. Said Doctor thoroughly examined him and advised some test and also advised to take admission in the ICU . As per said direction complainant took admission at Hiramani Memorial Hospital on 24.09.2021 at 6:29PM.
On perusal of copy of Medical Bill we find that complainant was admitted at Hiramani Memorial Hospital on 24.09.2021 at 6:20 PM and he was released there from 24.09.2021 at 3:11 Pm.
We also find that aforesaid Hospital issued a bill amounting to Rs. 22,420/- and complainant paid the same.
On perusal of the payment receipt dtd. 22.09.2021 we find that complainant by cash paid Rs. 22,420/-.
After released from the said Hospital complainant submitted all the necessary papers before the OP no. 1 and claimed the aforesaid amount.
During trial complainant produced those documents before this Commission.
On perusal of the original discharged certificate we find that at the time of discharge of complainant Doctor of the said Hospital advised some medicine. Aforesaid Hospital diagnosed, Respiratory distress, Swelling, palpitation, vertigo. They also found HTN, AWMI and Palpitation.
During hearing Ld. Adv for the OP no. 1 argued before this Commission that indoor treatment was not necessary and complainant could conduct his treatment as an OPD patients as there was no necessity for continuation of the treatment as indoor patient.
In reply Ld. Adv. for the complainant argued before this Commission that when a person suffers with health complication then he compelled to surrender before the Doctor and on that time he has no other alternative but to follow the direction of the Doctor. In the present case when complainant was suffering with serious complication relating to his health he went before Dr. Jayanta Kumar Saha and he advised for admission in ICU in the nursing home namely Hiramani Memoriala Hospital where said Doctor was attached. On that time complainant had no option to ignore the said direction of Doctor in the mediclaim. In the present case complainant rightly followed the direction of the Doctor. No one can raise any question over the decision of Doctor. Accordingly, the argument canvassed by OP no. 1 is not accepted.
OP no. 1 is not the medical expert. He has no authority to give any advice on the point of medical opinion.
So, it is clear before us that OP no. 1 has failed to assign any proper reason to refuse the claim of the complainant.
On perusal of record we find that complainant is a consumer and OP is service provider.
Having regard to the aforesaid discussion it is clear before us that complainant has able to established his grievance by sufficient documents beyond reasonable doubts.
Accordingly, we find that complainant is entitled to relief as per his prayer.
In the result present case succeeds.
Hence,
It is
Ordered
that the present case be and the same is allowed contest against the OP no.1 and allowed ex-parte against OP no. 2 with cost of Rs. 5,000/- to be paid by OP no.1 in favour of the complainant.
OP no.1 and 2 jointly or severally are directed to pay Rs.22,420/- in favour of the complainant within the 45 days from this date failing which aforesaid amount shall carry interest @9% per annum from this date to till the date of actual payment and complainant shall have liberty put this order into execution.
OP no. 1 and 2 jointly or severally are further directed to pay Rs. 20,000/- in favour of the complainant as compensation for his harassment, mental pain and agony within 45 days from this date failing which aforesaid amount shall carry interest @9% per annum from this date to till the date of actual payment and complainant shall have liberty put this order into execution.
Let a copy of this order be supplied to both the parties as free of cost.
Dictated & corrected by me
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PRESIDENT
(Shri DAMAN PROSAD BISWAS,) .................................................
PRESIDENT
(Shri DAMAN PROSAD BISWAS,)
We concur,
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MEMBER MEMBER
(NIROD BARAN ROY CHOWDHURY) (SMT MILLIKA SAMADDAR)
