Date of Filing : 27-02-2017 Date of Final Order : 26-03-2018
Sri Asish Kumar Senapati, President
This is an application u/s 12 of the C.P. Act, 1986.
One Debabrata Bakshi, since deceased, (hereinafter referred to as the Original Complainant) lodged the complaint against the Branch Manager, United India Insurance Co. and the Managing Director, MDINDIA Health Insurance TPA Pvt. Ltd., (hereinafter referred to as the O.Ps) alleging deficiency in service. Subsequently, the Complainant expired on 26.10.17 and his wife Smt. Amita Bakshi and his daughter Debodyuti Bakshi have been substituted in his place vide order dated 17.01.18.
The brief facts of the case is as follows:-
The original Complainant Debabrata Bakshi had a health Insurance policy viz. Individual Health Policy under the OP No.1 and the Policy was valid from 18.08.16 to 17.08.17. That the Complainant suddenly became ill in July, 2016 and after taking advice of the local Doctor, he went to Kolkata for better treatment. That on 26.08.16, the Complainant consulted Dr. Jayanta Mukherjee of ILS Hospital, Kolkata and he took admission as an indoor patient at Calcutta Heart Clinic & Hospital on 28.08.16 as the condition of the Complainant was not improved and he was there as indoor patient till 31.08.16. That Dr. Biplab Chanda diagnosed the cause of illness of the Complainant as Decompensate Cirrhosis of Liver Child-C, Non Bleeding Gr.II HE and accordingly, treated him at Calcutta Heart Clinic & Hospital from 28.08.16 to 31.08.16, On 31.08.16, the Complainant was shifted to Anandalok Hospital, Salt Lake, Kolkata under Dr. Goutam Das and Dr. Joy Mukherjee.
The Heart Clinic &Hospital received charge of Rs.39,236/- and issued Discharge Certificate along with a certificate assigning the diagnosis of disease. The original Complainant was an indoor patient in Anandalok Hospital from 03.08.16 to 05.09.16 and paid Rs.60,007/- and got payment receipt and discharge certificate. The treatment and period thereof were covered under the Insurance Policy, for which the original Complainant filed a claim for Insurance Policy to the tune of Rs.99,245/- before the OP No.1 which was duly received by the OP No.1 on 03.10.16. That on 25.11.16, the OP No.2 communicated the original Complainant by issuing a letter that his claim had been turned down on the ground mentioned in clause No.4.9 of the Insurance Policy and they had observed that the Complainant was admitted at Anandalok Hospital for alcohol liver disease and treatment related to chronic alcohol consumption was excluded from the scope of policy. That the Complainant was not a habitual drunker nor the disease was caused for habitual consumption of alcohol. The Complainant referred the matter to the OP No.1 but the OP No.1 clarified their stand by turning down the claim of the original Complainant on 15.12.16 by sending a letter. Thereafter, on 05.02.17, the original Complainant was again admitted at Dr. P.K. Saha Hospital Pvt. Ltd., Cooch Behar under Dr. Subhas Chandra Saha and he was there as indoor patient till 20.02.17 and paid Rs.79,728/- as the OP No.2 had repudiated the cashless claim of the original Complainant. That the original Complainant was examined by Dr. Jayanta Mukherjee on 26.08.16 and in reply to a question whether the Complainant consumed alcohol or not, the Complainant disclosed that he once in a while/occasionally at any party or social get-together consumed alcohol. The Doctor wrote down those answer at the right side of the prescription and the aforesaid answer was written as Ethanol Social which does not indicate that the Complainant was an habitual drunkard. The OPs had repudiated the claim of the Complainant without any valid reason. So, the O.Ps are liable for deficiency in service.
The original Complainant prayed for direction upon the OPs to supply the original documents and money receipts. The original Complainant also prayed for direction upon the OPs to pay the claim of Insurance policy amounting to Rs.1,78,971/-, compensation to the tune of Rs.2 lakh for mental pain, agony, harassment and emotional distress and Rs.25,000/- for deficiency in service and litigation cost.
The O.P. No.1 contested the case by filing W.V on 18.06.17 contending that the case is not maintainable. That the Claim of the original Complainant had been rightly repudiated in terms of clause 4.9 of the Policy. The O.P. No.1 prayed for dismissal of the Complainant with cost.
On the basis of above versions, the following points are framed for proper adjudication of the case.
POINTS FOR CONSIDERATION
- Are the Complainants a Consumer as per provision under Section 2(1)(d)(ii) of the C.P. Act, 1986?
- Has this Forum jurisdiction to entertain the instant complaint?
- Have the O.Ps any deficiency in service, as alleged by the Complainants?
- Whether the Complainants entitled to get any relief/reliefs, as prayed for?
DECISION WITH REASONS
Point No.1.
The Ld. Agent for the Complainants did not take part in the hearing of argument but he filed written argument on 19.02.18. It was stated in the written argument that the original Complainant was a consumer under the O.P. No.1 and his policy was valid from 18.08.16 to 17.08.17. In reply, the Ld. Agent for the OP No.1 submitted nothing on this point.
Admittedly, the original Complainant had valid health insurance policy during the period from 18.08.16 to 17.08.17 under the O.P. No.1 and the O.P. No.2 is an agent of the O.P. No.1. Therefore, the original Complainant hired the services of the OPs and he was a consumer under the OPs.
Point No.2.
The Complainants stated in their written argument that the original Complainant was treated at different hospitals/nursing homes during the period from 28.08.16 to 20.02.17 and cause of action arose within the territorial jurisdiction of this Forum.
In reply, the Ld. Agent for the OP No.1 stated nothing.
On a careful consideration, we find that this Forum has both pecuniary and territorial jurisdiction to entertain the complaint.
Point Nos.3 & 4.
Both the points are taken up together for the sake of convenience and to avoid repetition.
The Ld. Agent for the Complainants stated in their written argument dated 19.02.18 that the claim of the original Complainant amounting to Rs.99,243/- and Rs.79,728/- had been wrongly repudiated by the OPs on the ground that the patient was addicted to alcohol and as per policy clause 4.9, the claim was not paid. It was stated in the written argument that the original Complainant was not a habitual drunkard and his disease was not caused for habitual alcohol consumption and as such, the repudiation of the claim of the original Complainant was not justified. It was stated in the written argument that in reply to a question of Dr. Jayanta Mukherjee on 26.08.16 that the original Complainant disclosed that he once in a while/occasionally at any party or social get-together consumed alcohol and the answer had been written in the prescription as Ethanol Social which does not indicate that the original Complainant was a habitual drunker. The Complainants prayed for direction upon the OPs to pay the amount as mentioned in the complaint case.
In reply, the Ld. Agent for the O.P. No.1 submitted that the original Complainant had a health insurance policy during the period from 18.08.16 to 17.08.17 and as per condition No.2.2.b ii (g), treatment of hypertension was not covered under the policy and as per clause 4.9, intentional self injury and use of intoxication drugs/alcohol was not covered under the policy. He argued that it appeared from the prescription of Dr. Jayanta Mukherjee dated 29.08.16 filed by the Complainant (Annexure J) Ethanol-Social indicated that the Original Complainant was addicted to alcohol. He also drew our attention to the Triphasic CT Report of the Complainant dated 09.09.16 wherein it was stated in Impression: Liver Parenchymal disease with portal hypertension. He submitted that treatment of hypertension is not covered under the insurance policy as per clause 2.2 of the policy. He contended that the claim of the Complainant had rightly been repudiated by the OPs and the Complainant is not entitled to get any relief. He prayed for dismissal of the complaint with cost.
Admittedly, the original Complainant had a health insurance policy under the OP No.1 during the period from 18.08.16 to 17.08.17 and his treatment at ILS Hospital, Anandalok Hospital, Calcutta Heart Clinic Hospital and Dr. P.K. Saha Hospital Pvt. Ltd. was within the period covered under the policy. Now the point is whether the repudiation of the claim of the original Complainant is justified or not. Admittedly, Dr. Jayanta Mukherjee stated in his prescription dated 26.08.16 (Annexure J ) that the patient was addicted to Ethanol Social and the report of Asian Institute of Gastroenterology dated 09.09.16 revealed that the original Complainant had hypertension. The OPs have repudiated the claim of the original Complainant in terms of clause 2.2 and clause 4.9 of the Policy on the ground that the treatment of hypertension was not covered under the policy and the treatment for intentional self injury and use of intoxication drugs/alcohol is also not covered under the policy. It is true that there is no specific observation of any Doctor that the disease of the original Complainant was due to his addiction to alcohol but Dr. Jayanta Mukherjee has mentioned it in his prescription dated 26.08.16 that “addiction-Ethanol social”.
Considering the facts and circumstances, we find no irregularity/illegality in repudiating the claim of the original Complainant as per clause 2.2 and clause 4.9 of the insurance policy. We find that the Complainants have failed to establish deficiency in service on the part of the OPs. So, the Complainants are not entitled to get any relief in this case.
In the result, the complaint case fails.
Fees paid are correct.
Hence,
It is Ordered,
That the complaint case be and the same is hereby dismissed on contest against the O.P. No.1 without any cost and dismissed ex-parte against O.P. No.2 without cost.
Let plain copy of this Order be supplied to the parties concerned by hand/by Post forthwith, free of cost for information & necessary action. The copy of the Final Order will also be available in the following Website:
confonet.nic.in.
Dictated and corrected by me.
