F I N A L O R D E R/ JUDGEMENT
Shri Sibasis Sarkar, Ld. President.
The Complainant Shri Partha Chakraborty has filed the present petition of complaint under section 12 of the Consumer Protection Act, 1986, wherein he has stated that he is covered by joint Mediclaim Policy being Policy no. 512304/34/16/27/00000011 for the sum insured for Rs.2 lacs with the O.P/Insurance Company for the coverage period from 20.7.2016 to 19.7.2017. The said policy was first incepted on 20.7.1998 and the complainant has continued the policy without failing from the date of inception. During the period of coverage of the said policy the complainant had been admitted for his treatment in the Anandolok Hospital & Neuro Sciences Centre, Siliguri from 12.11.2016 to 18.11.2016 as indoor patient. After his discharge the complainant had submitted all the original documents and medical bills relating to his treatment for a sum of Rs. 1,38,329/- to the insurance company on 5.12.2016. On 9.1.2017 the O.P asked the complainant to provide additional information/documents for clarification. The complainant answered the query on 20.2.2017, but in spite of that the O.P did not settle the claim. The complainant also sent a letter on 1.9.2017 to the Nursing ome to to Home to supply the papers as asked for by the O.P, but the Nursing Home did not give any reply. Ultimately the complainant issued letter on 11.7.2017 and on 25.9.2017 requesting the O.P to settle the claim, but in vain. As a result, the complainant has been compelled to file the present case against the O.P praying for relief as per prayer of the petition of complaint.
The O.P The New India Assurance Company Ltd. is contesting the case by filing written version denying all the material allegations contending, inter alia, that the case is not maintainable in its present form and prayer. There is no cause of action for the present case. The O.P has admitted that the complainant is covered by joint Mediclaim Policy with the O.P. The O.P has also admitted that during the coverage of the policy, the complainant had been admitted for his treatment in the Anandolok Hospital &Neuro Sciences Centre, Siliguri on 12.11.2016 and he was under treatment as indoor patient upto 18.11.2016. The O.P. has also admitted that the complainant submitted all the original medical documents and the medical bills relating to his treatment to the O.P. The specific case of the O.P is that on perusal of the medical prescriptions and other documents relating to the treatment of the complainant, the O.P came to know that the complainant is a known alcoholic. It also appeared to the O.P that the complainant was medically treated for G.I bleeding esophageal varices and esophageal ulcer. According to the O.P, as per terms and conditions of the insurance policy mentioned in point no. 4.4.7 treatment of illness caused by the use of intoxicating drug/alcohol are excluded under the policy. The O.P suspected that the complainant being a known alcoholic, regular consumption of alcohol is the proximate cause of the illness of complainant for which he was treated. If it is found that the treatment of illness of the complainant was caused by the use of intoxicating alcohol, then the complainant is not entitled to get the claim, as prayed for. As such the O.P issued one letter to the complainant requesting him to obtain one certificate from the treating doctor that his illness was not caused by consumption of alcohol. But in spite of repeated request, the complainant failed to produce such additional information to the O.P and did not cooperate the O.P to settle the claim. As such the claim of the complainant could not be settled by the O.P for the negligence on the part of the complainant. There was no deficiency of service on the part of the O.P. Accordingly, the complainant is not entitled to get any relief as prayed for and the case is liable to be dismissed with cost.
Considering the rival pleadings of both the parties the following points have been framed.
POINTS FOR CONSIDERATION:-
- Was there any negligence on the part of the complainant ?
- Was the treatment of the complainant caused by the use of alcohol ?
- Was there any deficiency of service on the part of the O.P ?
- Is the complainant entitled to get any relief, as prayed for ?
- To what other relief or reliefs is the complainant entitled?
DECISION WITH REASONS:-
In the instant case neither the complainant, nor the O.P adduced any oral evidence. They also did not file any affidavit-in-chief. However, both the parties submitted before the Forum to pass Final Order/Judgment on the basis of the petition of complaint supported by affidavit along with the documents annexed therein and the written version supported by affidavit along with documents annexed therein treating them as their respective evidence on affidavit. Accordingly, we have carefully gone through the petition of complaint along with the documents annexed therein treating the same as evidence on affidavit on behalf of the complainant and the written version along with the documents annexed therein treating the same as evidence on affidavit on behalf of the O.P. We have also carefully perused the B.N.A filed by both the parties. We have also heard arguments of both the complainant as well as on behalf of the opposite party in full and at length.
POINT NO.1 :-
From the Xerox copy of the insurance policy being no.512304/34/16/27/00000011 filed by the complainant we find that the complainant is covered by joint mediclaim New India Ashakiran policy with the O.P for the sum insured of Rs. 2 lacs and the period of coverage was from 20.7.2016 to 19.7.2017. We also find that the said policy in the name of the complainant Partha Chakraborty was first incepted on and from 20.7.1998 . The policy is a continued one and is being renewed from year to year since the time of inception of the policy.The O.P in their written version did not deny the said fact. From the Xerox copy of Discharge certificate issued by Anandalok Hospital & Neuro Sciences Centre filed by the complainant, we find that the complainant was admitted in the said hospital on 12.11.2016 and was under the treatment of Dr. R.P. Ray(Gastro-enterologist).The complainant was treated in the said hospital as indoor patient and was discharged on 18.11.2016.From the said Discharge summarywe also find that the complainant was suffering from septicemia, G.I bleeding, esophageal varices, esophageal ulcer, umbilical hernia and anemia. The O.P did not deny about the treatment of the complainant in their written version.
The complainant in para-4 of his petition of complaint has stated that he had submitted all the original medical expenses bill incurred on account of his treatment on 5.12.2016, to the O.P/Insurance company claiming Rs. 1,38,329/-. From the Xerox copy of letter dated 9.1.2017 addressed to the complainant, issued by the Medicare T.P.A Services(I) Private Ltd. we find that the claim of the complainant has been registered as claim no. T120117101. From the said letter dated 9.1.2017 we also find that the Medicare T.P.A Services(I) Pvt. Ltd. has admitted that they have received the mediclaim documents submitted by the complainant and they have already processed all the documents which the complainant sent to them. From the said letter we also find that the T.P.A Services requested the complainant to provide underlying cause of G.I bleeding and esophageal varices by treating doctor in his letter-head. From the Xerox copy of letter dated 20.2.2017 the complainant informed the O.P that the treating doctor stated to them that everything is mentioned in the discharge certificate which contained all your queries.As such it is not possible to provide underlying cause of G.I bleeding and esophageal varices.From the other correspondences made by the insurance company, we find that the O.P requested the complainant to provide one certificate by the treating doctor about the actual cause of G.I bleeding, esophageal varices and esophageal ulcer in his own letter-head. But the complainant failed to produce such certificate to the O.P.From the Xerox copy of the letter dated 31.3.2017, issued by the O.P to Medicare T.P.A Services(I) Private Limited we find that they have stated that in their opinion, as per discharge certificate, the patient was known alcoholic.There is no mention of actual cause of G.I bleeding, esophageal varices and esophageal ulcer by the treating doctor.So, the claim lodged by the complainant is required to be rejected as per policy exclusion clause no.4.4.7.However, from the Xerox copy of letter dated 2.5.2017 issued by the O.P to the complainant, we find that the O.P again requested the complainant to file certificate to be issued
By the treating doctor in his own letter-head about the actual cause of G.I bleeding, esophageal varices and esophageal ulcer.The O.P also informed the complainant in the said letter that owing to non-receipt of the said certificate they are unable to process the claim further, therefore, the claim stands closed. It has also been mentioned that closing of the claim does not restrict the insured from submitting the said document/certificate to enable the O.P to re-open the case and proceed further. In spite of receiving the said letter the complainant did not submit doctor’s certificate from the treating doctor.
From condition no.5.7 of the New India Ashakiran Policy we find that it has been clearly mentioned that the insured person shall submit to the T.P.A all original bills, receipts and other documents upon which a claim is based and shall also give the T.P.A/Company such additional information and assistance, as the TPA/company may require.The term ‘’shall’’ certainly means must.Therefore, as per condition no. 5.7 the insurance company has the authority to call for additional information and assistance from the insured and it is mandatory for the insured to supply the said additional information and assist the company to settle the claim.In this case the insurance company demanded one certificate to be issued by the treating doctor in its own letter-head about the cause of illness of the insured/complainant as additional information. But the complainant failed to supply the said additional informationto the insurer/company and thereby violated the mandatory condition of the policy.Thus we have got no hesitation to hold that there was negligence on the part of the complainant himself.This point is thus decided against the complainant.
POINT NO.2 :-
From the copy of the discharge certificate filed by the complainant, we find that the complainant Partho Chakraborty was admitted at Anandoloke Hospital & Neuro Sciences on 12.11.2016 under Dr. R. P Ray and the complainant was medically treated as indoor patient in the said hospital upto 18.11.2016.From the said discharge certificate we also find that the complainant was a known alcoholic.There was history of blood-stained vomiting and passing tarry coloured stool from last two days. The complainant was suffering from Septicemia, G.I. bleeding, esophageal varices, esophageal ulcer, umbilical hernia, anemia.So, it is clear to us that due to the effect of esophageal varices and esophageal ulcer there was G.I bleeding. So, there was history of blood-stained vomiting and passing tarry coloured stool.From the copy of patients card filed by the complainant we find that the complainant visited Asian Institute of Gastro Enterlogy, Hyderabad on 23.11.2017 and was also medically treated by Dr. Mohan Ram Chandani. From the said patients card we also find that ultrasonography of the complainant was done in the said institute. From the report of ultrasonography of the said institute, wefind that the liver of the complainant decreased in size with irregular margins, parenchymal echo texture was altered. No IHBD. CBD was normal. Portal Vein was 40 mm. Spleen of the complainant was found increased in size(220 mm) and normal echo texture. As per findings of the consultant Radiologist the complainant had chronic liver disease with portal vein 14mm and splenomegaly Thus the symptoms mentioned in the Discharge certificate of Anandolok Hospital and ultrasound report conducted at Asian Institute of Gastro-enterlogy,Hyderabad clearly prove that the complainant was suffering from cirrhosis of liver.Now the question is what was the cause of such cirrhosis of liver.From the Xerox copy of doctors Order chart of Anandolok hospital in respect of the complainant we find that on 13.11.2016 the treating doctor namely, Dr. R.P. Ray has specifically mentioned during his treatment that the patient/complainant is suffering from alcoholic liver disease with upper G.I bleeding. So, as per opinion of the treating doctor, the complainant was admitted for treatment of alcoholic liver disease with upper G.I bleeding.Therefore, we have got no hesitation to hold that consumption of alcohol was the one and only one cause of cirrhosis of liver for which the complainant was suffering from and was admitted at Anandalok Hospital for his treatment. Accordingly, this point is also decided against the complainant.
POINT NO.3 :-
We have already found that the complainant was suffering from cirrhosis of liver.He was a known alcoholic and regular consumption of alcohol was the only cause of such liver disease for which he was admitted at Anandalok hospital for treatment. So, the O.P/insurance company had correctly suspected that the treatment of the complainant was caused by the use of alcohol.As such the O.P requested the complainant to supply one certificate fromthe treating doctor in his own letter-head about the cause of illness of the complainant as additional information. As per condition no.5.7 of the Ashakiran Policy condition it was obligatory upon the complainant to supply such certificate to assist the O.P for settlement of the claim. But the complainant did not supply the said document/certificate and thereby violated the mandatory condition being no.5.7 of Ashakiran Insurance policy.The complainant was found negligent in filing the said document.In the absence of such document, the complainant had rightly closed the claim of the complainant after giving liberty to the complainant for submitting the said additional information to enable the O.P to reopen the case and proceed further.Thus, there was no deficiency of service on the part of the O.P.
This point is thus decided in favour of the O.P.
POINT NOS. 4 AND 5 :-
In the facts and circumstances of the present case and in the light of our observations made above we have already found that the complainant was suffering from cirrhosis of liver and for the purpose of his treatment he was admitted at Anandolok hospital.We have also found that as per opinion of the treating doctor consumption of regular alcohol wasthe cause of such cirrhosis of liver for which the complainant was suffering from. The O.P rightly suspected that the illness of the complainant was caused by use of alcohol and accordingly the O.P requested the complainant to supply one certificate from the treating doctor in his own letter-head about the cause of illness of the complainant. But the complainant failed to produce such additional information to the O.P and thereby violated mandatory condition being no.5.7 of the Ashakiran Policy.The complainant had the opportunity to examine the treating doctor as a witness and to prove that consumption of alcohol was not the cause of his illness.But the complainant did not make such attempt.So, there was no deficiency of service on the part of the O.P. The complainant himself was found negligent in complying the request of the O.P. We have already found that as per opinion of the treating doctor, the complainant was suffering from alcoholic liver disease. So, the treatment of the complainant caused by the use of alcohol. As per clause no.4.4.7 of the Ashakiran policy the complainant is not entitled to get mediclaim for his treatment which was cause by the use of alcohol.As such the complainant is not entitled to get any relief, as prayed for and the case is liable to be dismissed.
As a result, the case fails.
Hence, it is
O R D E R E D :
that the Consumer Case No.49/2017 be and the same is dismissed on contest against the O.P. The parties do bear their own costs.
Let the original documents, if any, filed by the parties be returned on proper receipt.
Let a plain copy of this order be supplied free of cost to the parties on proper acknowledgement or be sent by speed post, in terms of Rule-5(10) of West Bengal Consumer Protection Rules, 1987 and the extra-set be returned to the parties on proper receipt.
