Ld. Advocate(s)
For Complainant: Debraj Das
For OP/OPs :Rajkumar Mandal
Date of filing of the case :21.12.2020
Date of Disposal of the case :21.03.2024
Final Order / Judgment dtd.21.03.2024
The pith and substance of the case of the complainant is that the complainant Radheshyam Poddar purchased one Mediclaim being policy no.030401/48/13/97/00001341 from the OP No.1 Branch Manager United India Insurance Company for the complainant and his wife for Rs.2,00,000/- for the period 03.01.2014 to 02.01.2015 with monthly premium of Rs.5,733/-. The complainant due to chest pain was admitted at Majumder Millennium Nursing Home and Reliable Diagnostic Centre Private Limited for his treatment . On diagnosis with General Anxiety disorder he was admitted to nursing home from 29.10.2014 to 31.10.2014 and incurred medical expenses for Rs.6696/-. Thereafter, the complainant informed the said matter to the OP NO.1 and raised claim along with original documents on 02.12.2014. The OP No.2 Medicare TPA Services Private Limited and OP No.1 rejected the claim of the complainant on 11.02.2015 under signature of authorised signatory Dr. Shibaji Dutta registration no.18262-A on the ground ailment for which hospitalisation took place can be treated on an OPD basis and does not warrant hospitalisation . Hence, the claim is not payable . Since then the complainant made several correspondences and RTI application dated 08.04.2016 to the Manager of OP No.1 Kalyani Branch where medical policy was registered. On query regarding Professional Medical Qualification of Dr. Shibaji Dutta , reply was given by the OP No.1 company but the reply was not convincing so he preferred an appeal to the 1st appellate authority but he bypassed the information. Thereafter the complainant submitted another RTI application on 30.07.2018 to the Director Health Services about genuineness of registration no. of Dr. Shibaji Dutta. In reply the complainant was informed by the OP No.3 Director, West Bengal Medical Council that the said registration no. of Dr. Shibaji Dutta is fake and it is registered in the name of Dr. Priyonath Sil who is aged about 100 years. So, the rejection of the insurance claim was done by a fake doctor which is unfair trade practice and deficiency in service by OP No.1&2. Subsequently, the complainant received one letter on 03.07.2019 regarding verification of registration no.18262-A wherein it was disclosed that the doctor and his registration were fake so, the present case is filed. The cause action arose on 18.07.2019 and on subsequent dates. The complainant , therefore, prepared an award for Rs. 6696/- towards actual medi-claim, Rs.4,50,000/- for harassment and mental pain and agony and litigation cost of Rs.25,000/-.
The OP No.2 Branch Manager Medicare TPA services Private Limited and OP No.3 the Registrar West Bengal Medical Council preferred not to contest the case and as such the case is decided to be heard ex-parte against OP No.2&3 vide order no.13 dated 08.03.2022. The OP No.1 Branch Manager United India Insurance Company Limited contested the case by filing W/V wherein they denied the major allegation. The OP No.1 challenged the case on the ground that the present case is barred by limitation and bad for defect of parties. The OP NO.1 denied the other allegation against him. The positive defence case of OP No.1 is that OP NO.1 issued an insurance policy being policy no. 030401/48/13/97/00001341 for the period 03.01.2014 to 02.01.2015 in favour of the complainant subject to terms and conditions of the policy. Insurance policy is a bilateral document and both the parties must follow the terms and conditions of the policy. Under clause 3.23 of the said policy medically necessary treatment is defined as any treatment tests medication or stay in hospital or part of a stay in hospital which is required for the medical management of the illness or injury suffered by the insured and must have been prescribed by the medical practitioner. In the instant case complainant did not comply with the terms and conditions of clause 3.23 of the policy conditions under the clause 3.17 of the insurance policy, illness means sickness or a disease or a pathological condition leading to the impairment or claim physiology function which manifests itself during the policy period of required medical treatment . As per claim settlement procedure OP NO.1 is the proper authority to settle the claim as per terms and conditions limitations and exception to the policy. OP No.2 is mere an enquiry authority. OP No.1 rightly and legally rejected the claim of the complainant . There was no deficiency in service or any negligence on the part of the OP No.1. So, the OP No.1 claimed that the case is liable to be dismissed with cost.
The conflicting pleadings of the parties demand for ascertainment of the following points for proper adjudication of the case.
Points for Determination
Point No.1.
Whether the present case is maintainable in its present form and prayer.
Point No.2.
Whether the complainant is entitled to get the relief as prayed for.
Point No.3.
To what other relief if any the complainant is entitled to get.
Decision with Reasons
Point No.1.
The OP No.1 challenged the case as not maintainable on the ground that it is bad for defect of parties and barred by limitation.
Although, the aforesaid two points are taken up by the OP NO.1 yet in course of argument Ld. Defence Counsel did not advance any argument as to why it is bad for defect of parties or barred by limitation. However, having perused the pleadings of the parties and the materials in the case record, the Commission comes to the finding that the case has been filed against the appropriate opposite parties . The cause of action claimed to have arisen on 18.07.2019 and the case is filed on 21.12.2020. Accordingly, it is filed well within the limitation period under C.P Act. Both the parties reside within the territorial jurisdiction of this Commission. The amounts of relief claim also falls within the pecuniary jurisdiction of this Commission.
Accordingly, the case is not barred by any provisions of law and it is legally maintainable.
Point no.1 is therefore, decided positively in favour of the complainant.
Point No.2&3.
Both the points are closely interlinked with each other and as such these are taken up together for brevity and convenience of discussion.
It is admitted fact that the complainant produced one insurance policy from the OP No.1 being policy no. 030401/48/13/97/00001341.
The complainant in order to substantiate the case proved the documents as per the list filed by the complainant. The following documents stand proved in course of trial of this case on behalf of the complainant.
Annexure-A is the insurance policy bearing no. 030401/48/13/97/00001341 for the period 03.01.2014 to 02.01.2015 in the name of insured Radheshyam Poddar through agent Tapas Chowdhury.
Annexure-B is the treatment slip with Majumder Millennium Nursing Home and Reliable Diagnostic Centre Private Limited dated 30.10.2014 as annexure B1 to B16. B16 is the particular of expenses incurred for Rs.6621/-.
Annexure-C is the Insurance Claim Form dated 02.12.2014.
Annexure-D is the claim repudiation letter dated 11.02.2015.
Annexure-E is the photo copy of RTI application to the OP No.1 company by the complainant dated 08.04.2016.
Annexure-F is the letter of replied by OP No.1 to the complainant dated 26.05.2016.
Annexure-G is the letter /RTI application by the complainant to the Director of Health Services dated 03.07.2018.
Annexure-H is the reply by S.P.S.R.C Government of West Bengal to the complainant dated 18.07.2019.
Annexure-I is the letter by the OP No.3 West Bengal Medical Council to the S.P.S.R.C dated 03..07.2019.
Annexure-J is the complaint letter to C.A Bureau , Nadia dated 06.12.2019.
The Complainant categorically alleged that after medical treatment he submitted his claim on 02.12.2014 along with original treatment and expenses bills but it was repudiated by the OP No.2 on the ground that the ailment can be treated on an OPD basis and does not warrant hospitalisation.
The OP No.2 Medicare TPA services did not contest the case and it was heard ex-parte against them.
It is further allegation of the complainant that the Dr. Shibaji Dutta the medical adviser of the Insurance Company attached with said TPA is a fake doctor as per information obtained from the Director of Health Services . So, the repudiation of claim is unfair for which he suffered harassment and mental pain and agony due to the deficiency in service by the OPs .
The OP No.1 through their W/V claimed that the complainant did not comply with the terms and conditions of clause 3.23 of the policy conditions. The OP No.1 further claimed that as per clause 3.17 illness means sickness or a disease or biological condition leading to the impairment or normal physiology function should manifests itself during the policy period and required medical treatment .
On perusal of clause 3.23 it transpires that medically necessary treatment means any treatment medication or stay in hospital which is required for the medical management or illness and must have been prescribed by medical practitioner. Annexure-B is the treatment sheet of the complainant who was medically treated at Millennium Nursing Home and diagnostic centre. The complainant was medically treated by Dr. T.K. Dutta of the said hospital and undergone diagnostic test and investigation by Dr. Uday Kumar Ghosh M.D and Dr. N. Mistry M.B.B.S D.M.R.D.
The OP No.1 did not cross-examine the complainant regarding the genuineness of his medical treatment in the said hospital. However, in regard to other questionnaires by the OP No.1 the complainant categorically discarded it.
The complainant very effectively answered against question no.4 in explanation to clause 3.23 of the insurance policy. The complainant categorically stated inter-alia that he sought information through his RTI application. On 15.05.2023 “Now I like to know the degree of illness (u/s .3.17) and necessary time moment for medical management (u/s3.23) when the policy holder like me should approach to Hospital/Nursing Home for admission if no medical practitioner available at the time of need outside the nursing home.” Similarly against question no.7 the complainant specifically answered in cross-examination about under which condition he was compelled to be admitted at the Nursing Home .
Question No.8 relates to elements for which hospitalisation took place can be treated on an OPD basis. The complainant specifically answer that he was not satisfied with the answer given by the TPA and he preferred appeal to the appellate authority.
The complainant further replied that the Branch Manager Insurance Company is non-medical person recommended repudiation of claim on the basis of the observation of the doctor of TPA who appears to be fake and committed fraudulent practice. As such where the head of panel of doctors of TPA appears to be fake his repudiation is not valid and bad in law.
The said TPA did not come forward to discard the view and specific claim of the complainant in as much as the case is being heard ex-parte against the OP No.2 Medicare TPA Services.
It further appears that the OP No.1 stated that as per claim settlement procedure insurance company OP No.1 is the proper authority to settle the claim as per terms and conditions.
If that be so, then how the OP NO.1 could repudiate the claim on the basis of assessment by a fake doctor. Doctor of OP No.2 who is at all not a doctor as per the report of the Director Health Services. So, continuation made in para-15 of the W/V of the OP No.1 tantamounts to admission of fact and allegations made by the complainant, so the OP No.1 cannot escape from the vicarious liability. In fact in the instant case the OP NO.2 acted as an agent of OP No.1. And as such OP No.1 should be held liable as principal for the act of his agent OP No.2.
Ld. Senior Defence Counsel argued that Medical Officer should advise for admission but LIC is liable to the beneficiary only. The OP NO.1 just sought for the opinion from the TPA. The opinion through TPA is duly approved by the IRDA and as such OP No.1 should not be liable.
The argument is not acceptable in as much as it is accepted that the investigation about the claim of insured should be conducted by a genuine doctor. If the investigating authority consist of some members of fake persons then the principal cannot escape the liability.
The complainant rightly made TPA party to this case.
The complainant argued that there is an unholy nexus between the OP NO.1&2 and as such his claim was repudiated.
The case record shows that the complainant obtained information from the appropriate authority to ascertain that the authority who repudiated the claim is actually not a valid doctor.
That apart the medical documents proved by the complainant as Annexure-A to I suggest that the complainant was medically treated for his genuine disease and as such his claim for medical expenses is duly supported by the documents.
It further appears from the case record that the complainant by his letter dated 08.04.2016 Annexure-E wanted information regarding admissible illness for medi-claim . He also wanted to know the genuineness of the said Dr. Shibaji Dutta.
The OP NO.1 against the said letter replied that the professional medical qualification cannot be furnished. So, when a question is raised as to the genuineness of a doctor the OP NO.1 company ought to have enquired into the details of the said doctor before repudiation of the claim or in the alternative they could have made an independent inquiry as to the genuineness of the claim of the complainant. But in the instant case the OP NO.1 repudiated the claim very casually without reasonable ground.
The aforesaid misdeeds on the part of the OP NO.1&2 tantamounts to deficiency in service and as such both the OP NO.1&2 are jointly and severally liable for the harassment, mental pain and agony suffered by the complainant.
In the back drop of the aforesaid discussion and observation made hereinabove the Commission comes to the finding that the complainant successfully proved the case against the OPs upto the hilt.
Accordingly, point no.2&3 are answered in affirmative in favour of the complainant.
Consequently, the complaint case succeeds on contest with cost.
Hence,
It is
Ordered
that the complaint case no.CC/241/2020 be and the same is allowed on contest against OP No.1 and ex-parte against OP No.2 &3 with cost of Rs.10,000/- (Rupees ten thousand). The complainant Radheshyam Poddar do get an award for sum of Rs.6,696/- (Rupees six thousand six hundred ninety six) against the OPs towards actual medical expenses Rs.2,00,000/- (Rupees two lakhs) towards compensation for harassment and mental pain and agony and Rs.10,000/- (Rupees ten thousand) towards cost of litigation. The OP No.1&2 are jointly and severally liable for the payment of the said award money within 30 days from the date of passing the final order failing which the entire award money shall carry an interest @8% p.a till the date of its realisation.
All Interim Applications (I.A) stand disposed of accordingly.
D.A to note in the trial register.
The case is accordingly disposed of.
Let a copy of this final order be supplied to both the parties at 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)
