Case No. CC/01/2020
COMPLAINANT :1. Miss Anindita Sarkar,
D/O. Sri Ritesh Sarkar,
Of-111/Gait Road,
P.O. Krishnagar,
P.S. Kotwali,
Dist. Nadia, Pin-741101.
V-E-R-S-U-S
OPPOSITE PARTIES / 1.Branch Manager,
National Insurance Company Ltd,
17, M.M. Ghosh Street, P.O. Krishnagar,
P.S. Kotwali, Dist. Nadia, Pin-741101.
2. Manager,
National Insurance Company Limited,
Having its registered of Head-Office,
3-Middleton Street, Kolkata – 700071.
3. Manager,
Safeway Insurance TPA Pvt. Limited,
815, Vishwa Sadan, District Centre, Janak Puri,
New Delhi, Pin-110058.
Ld. Advocate(s)
For Complainant: Pradip Banerjee
For OP/OPs : Dilip Kumar Ray
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Date of filing of the case :08.01.2020
Date of Disposal of the case :12.10.2023
Final Order / Judgment dtd.12.10.2023
Disputes relating to Mediclaim of complaint and its refusal by the OP led this complainant to lodge this case against the OP. The concise fact of the dispute is that the complainant Anindita Sarkar and her father Ritesh Sarkar, Mother Sima Sarkar and Sister Rina Sarkar are covered with an insurance policy registered with the OP National Insurance Company Limited being policy no.154001501810000972 valid from 25.03.2019 to 24.03.2020. The complainant fell down at her house on 22.07.2018 at 4:00 P.M and sustained injury in the left knee. Thereafter, the complainant was medically treated by Dr. Debasis Chatterjee on and from 23.07.2018. On 30.03.2019 the said doctor advised the complainant to undergo surgical operation. Accordingly, the complainant was admitted to Tulip Nursing Home Pvt. Limited on 04.04.2019 at 16:25 P.M. and discharged from the Nursing Home on 07.04.2019. The said Nursing Home charged Rs.65,000/- through the bill dated 07.04.2019 for the said medical treatment which the Ld. Complainant duly paid. The complainant actually spent Rs.74,856/- for the said operation, medicine and various examinations. Thereafter, the complainant submitted mediclaim with the OP along with 37 documents on 20.05.2019 for a total claim of Rs.74,856/-. But the OP without any intimation deposited Rs.44,094/- in the account of the complainant. So, the complainant wanted explanation from the OP regarding less payment but they did not reply. Hence this case is filed. The cause of action of the present case arose on 20.05.2019 and on subsequent date till the filing of this case. The complainant further prayed for an award for Rs.30,762/- being the balance amount, Rs.50,000/- towards compensation and litigation cost.
The OP contested the case by filing W/V wherein denied the major allegations. The OP challenged the case on the ground that the case is not maintainable . The positive defence case in brief is that complainant sustained the alleged injury on 22.07.2018. He was taken to Dr. Debasis Chatterjee on 23.07.2018 and the doctor advised to undergo an operation on 05.04.2019. The complainant covered a Parivar Mediclaim policy valid from 25.03.2019 to 24.03.2020. After injury and advised by the doctor to operate his knee, the complainant adopted the policy on that date. But the OP National Insurance Company Limited after proper calculation allowed the amount of Rs.44,094/- as per clause 3.29 of Parivar Mediclaim policy. The reasonable and customary charges means the charges for services or supplies , which are the standard charges for the specific provider and consisting of all the provisional charges in the Geographical area in identical or as the similar service taking into account the nature of the illness/injury involved. At the time of issuing the policy the complainant was informed regarding the cashless hospital network whereas
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with the better treatment facility their package rate for the same injury is much lesser than the amount claimed by the insured. If the complainant approached, for any other PPN hospital in the same localities then the cost would have been much higher. The OP prayed for rejection of the complaint case and dismissal thereof.
The disputed questions involved led this Commission to set forth following points for determination.
Points for Determination:
- Whether the case is maintainable in its present form and prayer.
- Whether the complainant is entitled to get the relief prayed for.
- To what other relief if any the complainant is entitled to get.
Decision With Reasons
Point No.1
The OP challenged the maintainability of the case in their W/V but in course of argument Learned Defence Council could not advance anything as to the maintainability of the case. It is the admitted position that the complainant purchased an insurance policy from the OP, so the relation between the complainant and the OP is just like purchaser and seller. Both the parties reside within the territorial jurisdiction of this Commission and the relief claimed by the complainant is well within the pecuniary jurisdiction of this Commission.
So, the complaint case is not bared by any provision of law.
Point No.1 is accordingly decided in favour of the complainant.
Point no.2 and 3
Both the points are taken up together for brevity and convenience of discussion.
As per pleadings of the OP in para 8 of the W/V, it is the admitted fact that the complainant covered a Parivar Medical Policy valid from 25.03.2019 to 24.03.2020. As per the pleadings and the documents the complainant undergone operation on 05.04.2019 , as per the advise of Dr. Debasis Chatterjee.
The defence plea is that the complainant after getting advise from the doctor to operate his knee adopted the policy on that date.
The said defence plea is not justified by cogent and succinct evidence that in order to get the Mediclaim only the complainant purchased the policy. In fact the doctor advised him for operation on 05.04.2019 but the complainant purchased the medical policy much ahead prior to the operation, that is on 25.03.2019.
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It is also important to consider that since the complainant fulfilled the main criteria for registering the policy so the OP registered the policy in the name of the complainant and other family members..
The complainant proved the following documents in order to strengthen her claim and establish the case. The copies of document filed by the complainant disclosed that the complainant incurred expenses for medical treatment in annexure-1. Delivery report of Theism Ultra Sound Centre dated 27.03.2019 referred by Dr. Debasis Chatterjee for Rs.2,800/- stands also proved.
Annexure-2 is the receipt issued by Dr. Debasis Chatterjee for Rs.400/-.
Annexure-3 is the Safeway Insurance TPA Pvt. Ltd. receipt regarding additional information in the name of the patient Anindita Sarkar. As per the said additional information slip dated 17.06.2019 the claim raised is for Rs.74,856/- for the period from 04.04.2019 to 07.04.2019.
Annexure-4 is the intimation of operation of the complainant to the Branch Manager NIC, Krishnagar dated 02.04.2019.
Annexure-5 is the self declaration certificate regarding the said injury given by the complainant Anindita Sarkar.
Annexure-6 is the medical bill of Tulip Nursing Home for the period from 04.04.2019 to 07.04.2019.
Annexure-7 is the acknowledgement receipt of Tulip Nursing Home.
Annexure-8 is the Tax Invoice of medicines of Ousadh Ghar dated 15.05.2019 and 07.04.2019.
Annexure-9 is the claim form of the complainant for Health Insurance Policy dated 18.05.2019.
Annexure-10 is the prescription of Dr. Debasis Chatterjee dated 30.03.2019.
Annexure-11 is the claim form of Health Insurance Policy.
Having perused all the medical documents it stands proved that the complainant Anindita Sarkar was medically treated by Dr. Debasis Chatterjee and incurred medical expenses for her treatment as stated in the complaint. It stands further proved that the complainant incurred medical expenses for her own treatment.
The OP proved some documents like insurance policy details. Learned Defence Council drew the attention of this Commission in regard to the sub limits to the coverage. As per the said document the insured is entitled to get room charges, medical practitioner’s fees and other expenses.
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The amount claimed by the complainant clearly comes within the purview of the coverage sub limits as stated in the said policy. After perusing the said document of coverage it is found that a sum of Rs.44,200/- is fixed for Arthroscopic surgery.
It is also important to consider that different expenses are allowed for fracture or knee replacement amounting to Rs.71,500/-. Therefore , although the knee of the complainant need not be replaced yet the complainant incurred the medical expenses for surgery also is covered under the heading orthopaedics of the said policy.
Learned Defence Council further argued drawing the attention of the Commission on a document of the OP company NIC to the effect that some of the reputed hospitals namely Amri Hospital, Peerless Hospital, R.N. Tagore Surgical Hospital, Fortis Hospital, R.N. Tagore Cardiac Hospital, Apollo Hospital Calcutta, Ruby General Hospital Kolkata etc. After perusing the said document it is found that there is nothing mentioned in the said document that an insured patient will not be entitled to get the mediclaim beyond the said hospital named in that document.
It is the discretion of insurer patient as to where he will be easily medical treated.. In other words if a serious patient of Krishnagar requires immediate medical treatment he is not supposed to have sufficient time to go to the hospital as named in the document. For a speedy medical treatment he should first be medically treated at Krishnagar and if the said doctor refers him for better treatment in Kolkata then only he may choose for treatment in any of those hospitals in Kolkata.
The claim statement come discharge voucher of the OP clearly depicts that the amount claimed is Rs.74,856/- but the amount paid is Rs.44,094/- in the said discharge voucher. The break up are not sufficiently mentioned. Actually this amount appears to have been paid for Arthroscopic surgery. But the complainant proved the different documents including the bill of the Tulip Nursing Home, bill of Theism Ultra Sound Centre. Thus the complainant had duly proved under which head the said total amount of Rs.74,856/- was incurred.
Ld. Advocate for the complainant argued that the OP whimsically paid the said sum of Rs.44,094/- against which the complainant raised objection . So the complainant is entitled to get the balance amount of Rs.30,762/-.
The OP could not justify the ground for not paying the entire amount incurred by the complainant for her medical expenses and surgery.
Ld. Advocate for the complainant referred to a case law reported in 2005(I) CPJ 288 wherein it was held that full claim of medical expenses was not allowed as per old scheme. Execution of discharge voucher not
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always deprive insurer from preferring claim for deficiency in service. No estoppels against legally sustainable and rightful insurance claim. Company liable to pay balance amount with interest.
The case law in relied on.
Ld. Advocate for the complainant also referred to another case law reported in 2018 (II) CPJ 19 (SC) in which it was held that speciality hospitals are established for treatment of specified ailments and services of doctors specialised in discipline are available by patient only to insure proper required and safe treatment. Right to medical claim cannot be denied merely because name of hospital is not included. Authorities are bound to ensure as to whether the claimant had actually taken treatment supported by records duly certified by doctors/hospital concerned. The said case law squarely applied here.
Thus having assessed the entire evidence of both the parties and on the basis of the observation made here in above this Commission is of the firm view that denial of total mediclaim by the OP to the complainant has caused deficiency in service to the complainant as well as harassment to him which should be compensated in terms of money.
Accordingly, Point number 2 and 3 are answered in favour of the complainant .
In the result the complaint case succeeds on contest with cost.
Hence,
It is
Ordered
that the complaint Case No.CC/01/2020 be and the same is allowed on contest against OP NO.1 & 2 and ex-parte against OP NO.3 with cost of Rs.5,000/- (Rupees five thousand) to the complainant. The complainant do get an award for a sum of Rs.74,856/- (Rupees seventy four thousand eight hundred fifty six) against the OP NO.1 & 2 as the actual amount of medical expenses, Rs.20,000/- (Rupees Twenty thousand) towards deficiency in service, harassment and mental pain and agony. OP NO.1 & 2 are directed to pay Rs.55,762/- (Rupees fifty five thousand seven hundred sixty two) to the complainant within 30 days from the date of passing the final order failing which the entire award money shall carry an interest at the rate of 8% per annum from the date of final order till the date of its realisation.
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OP NO.1 & 2 are jointly and severally responsible for payment of the said award money.
D.A. to note in the trial register.
The case is finally disposed of.
Let a copy of this final order be supplied to both the parties as free of costs.
Dictated & corrected by me
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PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,) ................ ..........................................
PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,)
I concur,
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MEMBER
(NIROD BARAN ROY CHOWDHURY)
