In  the  Court  of  the

Consumer Disputes Redressal Forum, Unit -I, Kolkata,

8B, Nelie Sengupta Sarani, Kolkata-700087.

CDF/Unit-I/Case No.380/2010

1)                   Sri Sambhunath Chakraborty,

A/15, Poddarnagar, (No-2),

P.G.H. Shah Road, Kolkata-700032.                                                       ---------- Complainant

---Versus---

1)                   Chairman, The New India Insurance Co. Ltd.,

87, M.G. Road, Mumbai-400 001.

2)                   The Divisional Manager, The New India Insurance Co. Ltd.,

18/2, Gariahat Road, Kolkata-700019.

3)                   E-Meditek (TPA) Services Ltd.,

Room No.5, Shantiniketan Buildings,

8, Camac Street, Kolkata-700019.

4)                   Dr. Bipla Saha, E-Meditek (TPA) Services Ltd.,

Room No.5, Shantiniketan Buildings,

8, Camac Street, Kolkata-700019.                                                          ---------- Opposite Parties

Present :           Sri Sankar Nath Das, President.

                        Smt. Sharmi Basu, Member

Order No.    21   Dated  31/12/2012.

            The petition of complaint has been filed by the complainant Sambhunath Chakrabati against the o.ps. The New India Assurance Co. Ltd. and others. The case of the complainant in short is that complainant purchased mediclaim policy from o.p. nos.1and 2 which commenced on and from 7.5.1997 and renewed with continuous insurance cover on payment of requisite premiums and o.p. no.2 issued the policy certificate bearing no.610600/34/09/11/00000476 having sum assured Rs.1 lakh for the relevant year 2009-2010. On 17.7.09 from noon complainant had been suffering from stomach pain and thereafter in the midnight he was taken to Sri Arabindo Seva Kendra (SASK) with symptoms of vomiting, nausea, respiratory problems and chest pain. Considering serious condition and as per advice of attending doctors of SASK the complainant was admitted there at 12-01 a.m. on 18.7.09 for necessary treatment under Dr. Soumitra Roy, MD (Cal), MRCP (UK), FRCP (Edin) a cardiologist.

            On admission routine investigations including ECG of the complainant were conducted which relevant anemia, renal impairment and hypokalemia. ECG revealed ST-T changes with frequent Ectopics, Traponin-I was negative and cardiac enzymes WNL. Dr. P. Das (Nephrologists) was consulted. Complainant also developed hyperkalemia which was corrected in ICU and thereafter, he was shifted to general ward after his condition stabilized. The complainant was treated as indoor patient at SASK for interalia, LVF, Dyseletgrolytemia, Hypertension and Chronic Obstructive Pulmonary Disease etc. and finally discharged on 23.7.09 at 11-32 a.m.

            Complainant submitted a claim of Rs.32,949/- on account of hospitalization expenses by a prescribed claim form supported by original relevant documents, bills and vouchers with the o.p. no.3 (TPA) and agent of o.p. nos.1 and 2. O.p. no.3 received the said claim form on 4.9.09 bearing claim no.577015. O.p. no.4 on behalf of o.p. no.3 by a letter no.EMSL/REJ/112009/00059224 dt.16.11.09 repudiated the claim of the complainant with the observation “As per discharge summary patient admitted with H/O taking analgesic for dental pain. So as per Cl. No.4.4.5 & 4.4.6 of the N.I.A.C. the claim is hereby rejected”.

            Being aggrieved by and dissatisfied with the said letter of repudiation the complainant referred the matter to Dr. Soumitra Roy, MD (Cal), MRCP (UK), FRCP (Edin) and eminent  Cardiologist attached to SASK who treated the complainant, for his opinion. Dr. Roy considering the relevant documents and reports opined and issued a certificate dt.9.12.09 stating that “Mr. Sambhu Chakraborti (complainant) had been admitted under me at SASK on 18.7.09 with acute LVF and dyselectrolytemia. He also h ad D.M. Hypertension COPD and gastritis which are secondary disease”. Dr. Roy also certified that LVF of the complainant was treated and he was discharged on a stable condition on 23.7.09. Dr. Roy opined further that the complainant took paracetamol for dental pain before admission, but paracetamol is an analgesic and not an NSAID and so it cannot cause gastritis.

            After obtaining expert opinion complainant filed a letter of appeal against the letter of repudiation before o.p. no.2 in terms of clause 13 of the policy condition on 15.2.09 and copy of the same was received by o.p. no.3 on 24.3.10. The certificate issued by Dr. Soumitra Roy was submitted with the said letter of appeal with o.p. nos.2 and 3. Complainant also stated therein that in Col No.3 of the claim form the nature of disease was inadvertently written “Severe epigastric pain”. The actual disease for which he was admitted and treated in the hospital was ‘Acute LVF and Dyselectrolytemia with  DM/HTN and COPD. Complainant by the said letter of appeal requested o.p. nos.2 and 3 to reconsider the letter of repudiation and allow the claim at an early date.

            O.p. no.3 repudiated the claim only on the ground that “patient admitted with H/O taking analgestic for dental pain. So, as per Cl. 4.5.5. and 4.4.6 of the NIAC the claim is rejected”. Hence the case was filed by complainant with the prayer contained in the petition of complaint.

            O.p. no.2 had entered his appearance in this case by filing w/v and denied all the material allegations labeled against him as well as justifying the repudiation of the claim of the complainant and prayed for dismissal of the case. O.p. nos.1, 3 and 4 did not contest the case by filing w/v despite receipt of valid service of notice and matter was heard ex parte against o.p. nos.1, 3 and 4.

Decision with reasons:-

            We have gone through the pleadings of the parties, evidence and documents in particular. It is admitted fact that complainant had a mediclaim policy with o.p. nos.1 and 2 and assured sum of Rs.1 lakh for the year 2009-10. Further we find that complainant started suffering from various ailments on and from 17.7.09 and admitted on 18.7.09 for treatment at Sri Arabindo Seva Kendra (SASK) and subsequently complainant submitted claim of Rs.32,949/-, but o.p. nos.1 and 2 (insurer) repudiated the claim of the complainant as it was a dental pain and on being dissatisfied complainant submitted a certificate from Dr Soumitra Roy on 9.12.09 which speaks that the patient/complainant was admitted under him SASK on 18.7.09 with acute LVF and Dyselectrolytemia and complainant also had D.M. Hypertension, COPD and Gastritis which are secondary dieses. The said certificate further discloses that complainant was treated for LVF.

            In view of the above findings and on perusal of the entire materials on record we are of the view that the repudiation cannot be construed as a justified repudiation and we do not find any reason for such repudiation of the claim of the complainant which caused much mental agony and harassment and thus we are of the opinion that o.p. nos.1 and 2 are liable for deficiency while rendering service and complainant is entitled to relief.

            Hence, ordered,

            That the case is allowed on contest against o.p. no.2 and ex parte against o.p. no.1 with cost of Rs.20,000/- (Rupees twenty thousand) only and ex parte without cost against o.p. n os.3 and 4. O.p. nos.1 and are jointly and/or severally directed to pay a sum of Rs.32,949/- (Rupees thirty two thousand nine hundred forty nine) only being the claim amount and are further directed to pay compensation of Rs.50,000/- (Rupees fifty thousand) only for harassment and mental agony and litigation cost of Rs.10,000/- (Rupees ten thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 9% shall accrue over the entire sum due to the credit of the complainant till full realization.

            Supply certified copy of this order to the parties free of cost.