West Bengal

Dakshin Dinajpur

CC/62/2018

Sri Partha Pratim Kundu, S/O- Late Dhirendra Nath Kundu - Complainant(s)

Versus

The Branch Manager, National Insurance Company Ltd., Balurghat Branch - Opp.Party(s)

Mintu Das

20 Jun 2019

ORDER

The case of the complainant in brief are that the complainant purchased a hospitalization and domiciliary hospitalization insurance policy of Rs 3,00,000/- for his family i.e. for himself his wife and two daughters from the Op No.1 in the year 2004 and the said policy was renewed year to year and lastly the complainant renewed the policy on 31.03.2017 by paying the yearly premium of Rs.4,845/- for the said year. The OP No.1 issued policy cover note vide policy No. 150703/48/16/8500002566 in favour of the compliant as pre terms of the said policy the Op No.1 will pay  of 1% of sum assured per day as room plus nursing charges i.e. Rs.3000/- per day, consultant, surgeon and Anesthetist fees 25% of sum assured i.e. Rs. 75,000/- max and O.T charges  50% of sum assured, i.e. Rs.1,50,000/- max.

            The daughter of the complainant Paramita Kundu was admitted at Dishari Health Point Pvt. Ltd. Mokdumpur,  Malda on 23.08.2017 for operation of appendix and gall stone and she was discharged on 26.08.2017. The said Nursing home authority charged total bill of Rs 51,605 for the said operation out of which Rs,30,000/- was charged for surgical team, Rs.6,500./- was charged for operation theater and Rs. 3,900/- (Rs.1,300/- per day x3) was charged for cabin bed. The OP no.1 at the time of payment of the said bill paid only Rs.43,205/- and without any reasonable excuse illegally deducted Rs.900/- from the Bed/Nursing charges, Rs.5000/- from the Surgical Charges and Rs.2,500/- from O.T charges and due to that reason the complainant had to pay Rs.8400/- personally from his own pocket at the time of release of his daughter from the said nursing home.

           

            The complainant had written to the Op no.1 on different occasions for payment of the said deducted amount of Rs. 8,400/- but the Op did not pay the claim amount to the complainant. Hence this case.

            Notice was served upon the Op no.1 and 2 through this Forum and Op no. 1 and 2 entered appearance and contested the case by filing two separate written versions wherein the material averments made in the complainant are denied and it has been contended inter alia that the instant case is not maintainable. It has been admitted by the Ops that the complainant was a policy holder under the Op no.1 and the insurance policy was valid at the time of occurrence. It has been further admitted by the Ops that the complainant claimed a sum of Rs. 51,605/- for the treatment cost of his daughter and recovered a sum of Rs. 43,205/- from the Op No.1. It has been contended by the Op no.1 that TPA i.e. Op No-2 herein is the authority to calculate the amount according to the terms and condition of the policy and being advised by the TPA, the Op no. 1 paid Rs, 43,205/-  after deducting the claim amount of Rs. 8,400/- and if the party claims that he had received less amount then TPA is bound to clarify the same to the party and not the Op no.1.

            Op No.2  has further contended that according to tariff  the room charge of single AC room will be Rs.1000/ per day but from the final bill it has been found that Dishari Health Point  took Rs.1,300/- per day which is execs of Rs. 900/- for three days  and as such Rs. 900/- was deducted against bed charges from the final bill. As per tariff Surgical charges for Laparoscopy cholecystectomy  is Rs.16000/- to 18000/- and for Laparoscopy Appendectomy is Rs. 16000/- to 18000/-, if operation is done in the same hospitalization under the same OT and anesthesia, then first surgery will be 100% and for 2^nd surgery 50% payable but the nursing home claim Rs.30,000/-  as per final bill and for which Rs.5000/- has been deduced. As per final bill O.T charges is Rs.6500/- but as per tariff O.T charges for major operation is of  Rs.3,500/- to 4000/- hence O.T charges of Rs.2500/- has been deducted from Rs.6500/-.  The cost of O.T gas plus Oxygen and monitoring is Rs. 3000/- and post monitoring is of Rs. 500/- which is actually part of the O.T. And in view of USG findings and as per tariff rate all deduction done are in order. It has been further contended by the Op- 2 that Dishari nursing home took Rs.8400/- in excess from the party against tariff and Dishari is liable to refund the said amount to the complainant.

            In this case the complainant has filed examination in chief supported by affidavit and certain documents i.e.

1. Photo copy of policy
2. Final Bill of Dishari Health Point Pvt. Ltd.
3. Final Authorization Letter of N.I.C Ltd.
4. Money Receipt of Dishari Health Point Pvt. Ltd.
5. Prayer Before B.M. of N.I.C, Dt. 17.10.17
6. Prayer before B.M. of N.I.C dt. 6.4.18

The Op no.1 and 2 on the other hand prayed for treating the written version filed by the Ops as deposition in chief. No document is submitted on the side of the Ops.

            Points for discussion

1. Whether the complainant is a consumer within the meaning of Section 2 (I) (d) of the Consumer Protection Act 1986?
2. Whether there is any deficiency in service on the part of OPs?
3. Is the complainant entitled to get relief/reliefs as prayed for?

DECISION  WITH  REASONS

Point No.1

            This issue is not disputed by the Ld. Advocate of the OPs during his course of argument. However, after going through the entire facts and circumstances of the case with regard to the materials and evidence of the parties on record this Forum is of the view that the complainant is a consumer within the meaning of Section 2 (I) (d) of the consumer Protection Act 1986.

Point No. 2 and 3

            These two issues are taken up together for discussion for the sake of brevity and convenience. It is admitted position that the complainant was a policy holder under the OP No.1 and the said insurance policy was valid at the relevant time of occurrence. It is also admitted position that the complainant claimed a sum of Rs. 51,605/- from the OP No.1 being charged by the Dishari Health Point Pvt. Ldt. for operation/ treatment of the daughter of the complainant but the OP No.1 paid only Rs. 43,205/- and deducted a sum of Rs. 8400/- against the final bill of the nursing home.  

            This is the specific case of the complainant that the Op-1 illegally deducted the said amount without any reasonable ground and due to that reason the complainant had to pay Rs. 8,400/- to the nursing home personally from his won pocket at the time of release of his daughter, accordingly the complainant has filed the instant case for realization of said amount Rs. 8,400/- and other relief. In this case the complainant has submitted his evidence supported by affidavit and certain documents by firisti. On perusal of the final bill issued by nursing authority it appears that nursing home charged Rs. 51,605/- for the said operation and accordingly issued a bill   showing that Rs. 30,000/- was charged for surgical team Rs. 6500/- was charged for operation theater and Rs. 3900/- i.e. (Rs.1,300/- per days x3) was charged for cabin bed. But final authorization letter issued by OP no.1 addressed to the medical director of  Dishari Health Point Pvt. Ltd. Mokdumpur, Malda West Bengal shows that Op no.1 deducted Rs.900/- against bed/nursing charges Rs. 5000/- against Surgical charges anbd Rs. 2,500/-against OT charges and thus deducted total Rs. 8400/- against the total claim of Rs. 51,605/- of the nursing home. On scrutiny of the final authorization letter we find that as per terms of the policy Op no.1 will pay Room + Nursing charges  1% of sum insured (per day)   i.e. Rs. 3000/-,  consultant, surgeon , anesthesias fees 25% of sum insured i.e. Rs. 75000/- max   and OT charges   50%of sum insured  i.e. Rs. 1,50,000/.

 OP no. 1 claimed that TPA is the authority to determine/ calculate the amount to be paid to the party according to the terms and conditions of the policy and being advised by TPA (Op-2) the OP No-1 paid the total amount of Rs. 43,205/- after deducting Rs. 8400/- from the claimed amount. The OP-2  further claimed that as per tariff and agreement  between Op-2 and the nursing home the room charge of single AC room will be Rs. 1000/- per day but Dishari Nursing home took Rs. 1300/- per day which is excess of Rs. 900/- for 3 days and so, Rs. 900/- is deducted against bed charge.  OP-2 further claimed that the Nursing home took Rs. 30,000/- for surgical charges violating the tariff agreement and as such Rs. 5000/- was deducted against surgical charges from the final bill and Rs. 2500/- was deducted against O.T charges of Rs. 6500/- claimed by the Nursing home and thus total Rs. 8400/- was deducted from the final bill of the Nursing home as the said amount was illegally claimed by the nursing home from the party.  

Now the question is whether the Op-1 can deduct the amount of Rs.8400/- from the total amount of Rs. 51,605/- as per advise of TPA when it appears that as per terms and condition of the policy Op-1 will pay room plus Nursing charges  1% of sum assured per day i.e. Rs. 3000/- per day and consultant, Surgeon, anesthesias fees  25% of sum assured i.e. Rs. 75,000/- and OT charges  50% of sum assured I.e. Rs.1,50,000/- to the complainant. Here Nursing home charged Rs. 1.300/- for cabin bed per day and Rs. 30,000/- for surgical team and Rs. 6500/- for OT charges and other miscellaneous charges i.e. total Rs. 51,605/- which is less than the amount entitled by the complainant from the OP No.1 as per terms and condition of the policy. Ops claimed that Nursing home in violation of tariff took Rs. 8,400/- as excess amount from the complainant. If that be so, the Op-2 could take action against nursing home for violation of the tariff and agreement made between the parties.  But instead of doing that the Ops deducted the aforesaid amount of Rs.8,400/- and forced the complainant to pay the said amount to the nursing home from his own pocket. On perusal of the entire materials, evidence and documents supplied by the parties we find that the Op-1 insurer has illegally deducted the amount of Rs.8400/- from the claimed amount of Rs. 51,605/- without showing any cogent reason and also in violation of the terms and condition of the policy and due to such acts of the Ops the complainant had to sustain loss of Rs. 8400/- and suffer mental pain and agony without having any fault on his part. The OP-2 though claimed that as per tariff and agreement nursing home should take room charge of single AC room of Rs. 1000/- per day and other charges i.e. O.T anesthesias, surgical charges etc much less then the amount claimed in the bill but in this regard neither  tariff nor any document  submitted from the side of the Ops. Mere statement made in the written version is not sufficient to establish the defense case. If the nursing home violates the tariff the Ops could take action against them but instead of doing so Ops illegally deducted Rs. 8,400/- and thus forced the complainant to pay the said amount to the nursing home from his own pocket.  It is clear from the acts and conduct of the Ops that there is negligence and deficiency in service on their part for which complainant suffered financial loss, harassment and mental agony. So complainant is entitled a sum of Rs. 8,400/- and further Rs.6000/- for harassment, mental agony, sufferings etc and further a sum of Rs. 4000/- towards litigation cost from the opposite parties.

In the result the case succeeds in part.     

 

Hence, it is

                                                O R D E R E D

 

                        That the CC No.62 of 2018 be and the same  is decreed on contest with cost against the Op-1 and Op-2.

Op-1 and Op-2 are jointly and severally directed to pay an amount of Rs. 8400/- to the complainant by issuing an account payee chaque in his favour within 45 days from the date of passing of this order.

Op-1 and Op-2 are jointly and severally directed to pay a sum of Rs. 6000/- to the complainant for harassment, sufferings and mental agony caused to the complainant within 45 days from the date of passing of this order.

Op-1 and Op -2 are further directed to pay jointly and severally a sum of Rs 4000/- to the complainant towards litigation cost failing which the entire awarded amount will bear interest  10% till the full realization of the amount.

Ops are directed to pay the total awarded amount of Rs. 18,400/- to the complainant within the stipulated period in default compliant has liberty to realize the amount by filing execution case.

 

            Let a plain copy of this order be supplied to the parties forthwith free of cost.