West Bengal

Paschim Midnapore

CC/169/2015

Sri Basudeb Pal - Complainant(s)

Versus

The Devisional Manager, National Insurance Co.Ltd. - Opp.Party(s)

Swapan kumar Bhattacherjee

06 May 2016

ORDER

 

                                                           DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

and 

Kapot Chattopadhyay, Member.

   

Complaint Case No.169 /2015

                                                        

                                                                           Sri Basudeb Pal…………..….……Complainant.

  Versus

 

                        1) The Divisional Manager, National Insurance Co. Ltd.,

                        2) The Chairman, National Insurance Co. Ltd.,

                        3) Rothsfield (TPA) Service Ltd……......…..Opp. Parties.

 

              For the Complainant: Mr.  Swapan Kumar Bhattacherjee, Advocate.

              For the O.P.               : Mr. Anath Bandhu Ghosh, Advocate.

 

Decided on: -06/05/2016

                               

ORDER

                          Bibekananda Pramanik, President – Facts of the case, in brief, is that the complainant is a resident of Keranitola, Medinipur town within the jurisdiction of this Forum.  He is a bona fide policy holder under the opposite party no.1 and the name of the said policy is “Varistha Mediclaim For Senior Citizen” having policy no.153800/48/14/8500001248. In the said policy, there are two terms/head of assured sum i.e. Medical Sum Insured and Critical Sum Insured. The insured sum for Medical Sum Insured is for Rs.1,00,000/- and for Critical Sum Insured is for Rs.2,00,000/-.  The complainant purchased the said policy through opposite party no.2 and he is running his said policy from the year 2008. In the first part of this year 2015, the complainant felt respiratory problem and he was diagnosed by several doctors in Medinipur as well as at Kolkata and at last it was detected by the doctor of “We Care Nursing Home and

Contd………………..P/2

 

 

( 2 )

 

Diagnostic Centre” that the complainant was suffering from complete heart block, hypertension etc.  Being advised by the doctor of that nursing home, the complainant was admitted for treatment and a pacemaker was installed in the chest of the complainant and he incurred a sum of Rs.1,70,000/- only  for the cost of that pacemaker out of his total cost of  Rs.2,26,000/-.  After discharge from the nursing home, the complainant submitted claim form with all documents regarding the expenses of treatment to the opposite party no.2 through it’s TPA.  After considering all documents, the opposite party no.3 issued a cheque of Rs.70,425/-  only to the complainant as final settlement against his total expenses of Rs.2,26,000/- out of which a sum or Rs.23,831/-  as pacemaker charge.  Being dissatisfied with such settlement, the complainant submitted a written representation on 03/09/2015 to the Chairman/Managing Director, National Insurance Co. Ltd. i.e. opposite party no.2.  On 24/09/2015, a reply notice was given to the complainant which is not correct.  As per “Varistha Mediclaim For Senior Citizen” policy,  the complainant is entitled to full cost of pacemaker but the opposite parties are very much reluctant to settle  the actual claim of the complainant.  Hence the complaint, praying for directing the opposite parties to pay Rs.1,46,169/- only as rest cost of the pacemaker and for a sum of Rs.50,000/- as litigation cost.

                      Opposite party no.3 received the notice of this case but in spite of receipt of notice, opposite party no.3 did not appear to contest this case for which the case was ordered to heard ex parte against opposite party no.3.

                  The opposite party nos.1&2 have contested this case by filling a joint written statement.

                   Denying and disputing the case of the complainant, it is the specific case of the opposite party nos.1&2 that process of the claim, submitted by the complainant, was started by them and after process of claim on the basis of documents submitted by the complainant, opposite party nos.1&2 settled the claim at Rs.70,425/- and the said amount was sent to the complainant by issuance of a cheque against bill of Rs.2,26,000/- following the policy terms and condition and barring inadmissible expenses.  There was deduction of Rs.1,55,575/- from the claim amount following Section-II of  Varishtha Mediclaim Policy as because the permanent pacemaker implantation and or heart block is not considered as critical illness  as per terms and conditions of the said policy.  It is therefore stated that there is no deficiency in service from the side of the opposite parties and the complainant is not entitled to the reliefs, as prayed for.

Point for decision

                      Is the complainant entitled to get the reliefs, as sought for?   

Contd………………..P/3

 

 

( 3 )

                   

Decision with reasons

In this case, neither the complainant nor the opposite party adduced any sort of evidence either oral or documentary but they have relied upon some documents,  so filed by them.

Admittedly, the complainant obtained a policy named “Varistha Mediclaim for Senior Citizen” from the opposite party-Insurance Company having policy no.153800/48/14/8500001248.  It is not denied and disputed that the complainant felt respiratory problem and as per advice of the doctor,  he was admitted in “We Care Nursing Home and Diagnostic Centre” and a pacemaker was implanted in his chest.  According to the complainant, he had to incur a sum of Rs.1,70,000/- for the cost of that pacemaker out of total cost of Rs.2,26,000/-.  Admittedly, after discharge from the nursing home, the complainant submitted claim form with all relevant documents before the opposite patty no.2 and after considering all documents, opposite party issued a cheque of Rs.70,425/- to the complainant as final settlement of his claim under that policy against total claim of Rs.2,26,000/- out of which a sum of Rs.23,831/- was allowed as  pacemaker implant charge.  Being dissatisfied with such settlement, the complainant has filed this case and has prayed for directing the opposite parties to pay Rs.1,46,169/-  only as remaining cost price of the pacemaker.  As against this, opposite parties case, as it appears from the written objection, that there was deduction of Rs.1,55,575/- from the claim amount of Rs.2,26,000/- as because the  permanent pacemaker implantation and or heart block is not considered as critical illness as provided under Section - II as per terms and conditions of the said policy.  From the policy in question, as submitted by the complainant in this case, we find that admittedly there are two heads of sum assured i.e. one for Medical Sum Insured of Rs.1,00,000/- and Critical Sum Insured of Rs.2,00,000/-.  From the policy terms and conditions,  as submitted by the opposite party-Insurance Company, we find that Section-II defines  the critical illness cover and from that Section –II  we find that implantation of pacemaker is not included in the said definition in the category of critical illness.  So under the said head of critical illness coverage of Rs.2,00,000/-, the complainant is not entitled to get reimbursement of implantation of pacemaker under that head.  Now we come to the other head of the policy i.e. medical sum insured of Rs.1,00,000/-.  From the policy terms and conditions, we find from Section 1.0 that the insured is entitled to the cost of pacemaker under that head of medical sum assured of Rs.1,00,000/-.   Here in this case, we find that out of total settlement of Rs.70,425/- a sum of Rs.23,831/- was allowed by the opposite party-Insurance Company as pacemaker implant charge.  We find from the terms and conditions of the policy in Section- I that the cost of pacemaker is admissible under this scheme and there is no limit of

Contd………………..P/4

 

 

( 4 )

 

such payment of cost of pacemaker.  Since under the said head of medical sum assured, the complainant is entitled to get Rs.1,00,000/- as sum assured,  so the opposite party-Insurance Company was not justified in allowing Rs.23,831/- only towards the cost of pacemaker.  From the TAX INVOICE of purchase of pacemaker, we find that the complainant had to incur a sum of Rs.1,70,000/- towards  purchasing of pacemaker.  But the opposite party-Insurance Company has allowed only 23,831/- as implantation charge of pacemaker out of the total settlement of Rs.70,425/-.Since the insure under that head covers a sum of Rs.1,00,000/- so the complainant is entitled to get the entire insured amount of Rs.1,00,000/- for his medical expenses including the cost of pacemaker but the opposite party-Insurance Company has allowed only Rs.70,425/-.  We are therefore of the view that the complainant is entitled to the remaining sum of Rs.29,575/-/- under that head of the policy.  Consequently the petition of complaint is allowed in part.

                                                  Hence, it is,

                                                     Ordered,

                                                      that the complaint case no.169/2015  is allowed in part on contest with cost.   Opposite parties are directed to pay a sum of Rs.29,575/- as balance payment under that head of policy to the complainant along with interest @9% p.a. from the date of filing of this complaint and to pay a  sum of Rs.5,000/- as compensation and Rs.2000/- as litigation cost to the complainant within a month from this date of order.

                               Let plain copy of this order be given to the parties free of cost.

                 Dictated & corrected by me

                                Sd/-                                    Sd/-                                                Sd/-

                           President                              Member                                         President

                                                                                                                          District Forum

                                                                                                                       Paschim Medinipur