DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KOLKATA, UNIT-II

8B, Nelie Sengupta Sarani, 7^th floor, Kolkata – 700 087

C.C. No.66 of 2012 

Date of filing                                          Date of Admission                                   Date of Order

Complainant :

Mr. Manas Pal, 8/C, Maharshi Devendra Road, Bank of Baroda Building, Top Floor, Kolkata – 700 007.

    Vs.

Opposite Parties :

1)    The Divisional Manager, The National Insurance Co. Ltd., 3, Middleton Street, P.S. Shakespeare Sarani, Kolkata – 700 071.

2)    The Manager, National Insurance Building, 5, N.S. Road, Royal Insurance Building, 1^st Floor, Division-XII, Kolkata – 70 001.

3)    Heritage Health TPA Pvt. Ltd., 2, Hare Street, Nicco House (5^th Floor), Kolkata – 700 001., P.S. Hare Street.

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          Before : HON’BLE PRESIDENT   :   SHRI B. MUKHOPADHYAY

ORDER

Order No.                 .

Shri B. Mukhopadhyay, President.   

This is an application u/s.12 of the C.P. Act, 1986.

            In short, the present complainant is a Mediclaim Policy holder of the OPs1 and 2 what have been renewed for last several years and lastly the policy was under the name and heading “Health Plus Medical Expenses Policy” which was obtained on payment of premium of Rs.1,821/- on 29-06-2010 having policy No.10200/48/10/8500001002, with valid insured period from 29-06-2010 to 28-06-2011, and the said policy covers the risk of the medical treatment cost etc. for the complainant and his wife Smt. Susmita Pal, and sum assured is Rs.1 lakh for each policy holder.

            During subsistence of the valid period of the present policy complainant fell seriously ill and was examined by Dr. S.S. Gupta who examined him and advised for urgent admission for treatment for which he was admitted at TRA General Hospital on 11-11-2010 under the care of Dr. S.S. Gupta where the doctor diagnosed for treatment for Jaundice, concur vertices treatment.  After thorough treatment patient was discharged on 02-12-2010 and after discharge from the hospital complainant submitted claim in respect of the reimbursement of the medical expenditure for an amount of Rs.47,331/- on 27-01-2011.

            But OP TPA vide letter dated 28-05-2011 repudiated the claim of the complainant with following observation “as per discharge record of TRA General Hospital, dated 02-12-2010 the patient has been suffering from Jaundice”  and as per discharge record of TRA General Hospital it is evident that the patient stayed at Nursing Home for rest so this treatment is treated as domiciliary treatment which is not accepted as per insurance norms hence, their medical doctors opined that the claim was not admissible and was repudiated as standard mediclaim policy.

            Being aggrieved by the said repudiation complainant raised protest and wrote a letter on 08-04-2011 for reconsideration but that matter failed for which the present complaint is filed for relief and redressal.

            On the other hand, the OPs1 and 2 by filing written version have submitted that the TPA after proper consideration of the entire material i.e. treatment sheet, discharge certificate etc. issued by the TRA General Hospital considered that it was a domiciliary treatment and for which alleged claim was repudiated by the Board of Doctors of TPA and for which the complainant is not entitled to any further relief and present complaint is evasive one and for which the same should be dismissed.

Decision with Reasons

Fact remains in this case TPA did not appear though notice was served but OPs1 and 2 by appearing before this Forum and at the time of argument submitted that they have no other submission on the ground that the TPA rejected it.  The OP1 and OP2 on the basis of the material relied upon that and for which further argument is not required and that is the final submission of the OPs1 and 2 as it is a domiciliary treatment but such a treatment cannot be enjoyed at hospital or nursing home.

            After considering the argument for the Ld. Lawyer OPs 1 and 2 and also their written version it is undisputed fact that complainant was suffering from Jaundice admittedly he was admitted at TRA General Hospital for 21 days with effect from 11-11-2010 to 02-12-2010 and claim was in respect of Rs.47,339/-.  Now, question is how and what circumstances, OPs repudiated that claim.  Most probably the insurance companies are suffering from such sort of jaundice that they are not in a position to entertain any mediclaim of any insured and probably the OPs are not aware of the sufferings of the disease Jaundice and now-a-days different type of Jaundice cannot be treated by adopting domiciliary treatment but patient must be kept in the hospital or nursing home for time to time check up by the doctors and time to time treatment and invariably Dr. S.S. Gupta realized that it is not possible to give relief the patient who has been suffering from Jaundice by keeping him at home so admitted her to hospital.  Complainant himself did not admit him by paying money but as per advice of the doctor he was admitted.  Truth is that he was treated for 21 days at Hospital and, thereafter, was discharged.  The doctor did not opine for domiciliary treatment when gravity of Jaundice was of such a nature that it should be controlled first by keeping the patient under constant proper observation.  This medical treatment procedure was criticized by the Insurance Company.  Then it is clear these OPs are here and there for repudiating the claim but only for collecting the premiums per year by alluring the customers and it is no doubt unfair trade practice on the part of the OPs.

            Another factor is that the doctor who treated the present complainant was not examined by the TPA doctors there is no challenge that complainant had not been suffering from Jaundice but only their plea is such sort of disease(Jaundice) can be cured by adopting conservative treatment (domiciliary treatment).  Then invariably we can say without any hesitation that the insurance company shall have to take charge of treatment of Jaundice and place their customers who have been suffering from Jaundice and take charge of their treatment and if they cannot take charge of treatment of their customers who are suffering from Jaundice in that case they shall have to pay the entire bill amount but the adopted method as taken by the OP in most of the cases including this case is completely an act of adopting unfair trade practice and for which they should be penalized at first for repudiating claim falsely without any substance.

            A reasonable and prudent man can say without hesitation that Jaundice is of different nature and their classifications cannot be determined by the family members and generally anyone who is suffering from Jaundice, are advised for admission to hospital or nursing home for observation and determination of the classification of the Jaundice and nature of Jaundice and impact of the body system because Jaundice is a very dangerous disease of a human body.  It may cause death even within 48 hours giving no chance for treatment but insurance company claimed that jaundice can be cured by adopting domiciliary treatment what is sufficient then we can say without any hesitation OPs are suffering from such disease repudiation of claim and for that purpose invariably the judicial system or the tribunal or the forum is fit to recover them from such disease whatever it may be enter defence of the OPs is false and fabricated for repudiation and only for dishonouring the claim but the complainant for good ground is entitled to get entire amount of his treatment cost of Rs.47,339/- from the OPs 1 and 2 and also compensation for harassing the present complainant a lot and litigation cost.

            Accordingly, complaint succeeds.

Hence,

Ordered

That the complaint be and the same is allowed on contest against the OPs1 and 2 with a cost of Rs.10,000/-(Rupees Ten thousand only) and same is allowed with ex parte against OP3 with a cost of Rs.5,000/- (Rupees Five thousand only).  OPs1 and 2 are hereby directed to pay the complainant claimed amount Rs.47,339/-(Rupees Forty seven thousand three hundred thirty nine only) and also compensation for Rs.15,000/- and for harassing the complainant in such a fashion and for disallowing the claim actually by adopting unfair trade practice by them and also their agent TPA OP3.

            OPs1,2 and 3 are hereby directed to pay a sum of Rs.5,000/-(Rupees Five thousand only) each for adopting unfair trade practice for repudiating such mediclaim of the complainant and also often mediclaim policy holders in such a manner by casually rejecting the claim and only to check the above habit and to control their such disease “repudiation of claim” this penalty is imposed as punitive damages and it shall be paid by them respectively to the State Consumer Welfare Fund.

            OPs are directed jointly and severally to comply the order strictly within one month from the date of this order by satisfying the entire claim of the complainant and by depositing the punitive damages on SCWF failing which for each months delay OPs1 and 2 shall have to pay a penal interest @Rs.2,500/- (at the rate of Rupees two thousand five hundred only) and if it is collected it shall be deposited to SCWF even after that if it is found that OPs are deliberately disobeying the Forum’s order in that case penal action u/s.27 of the C.P. Act, shall be taken against them for which they shall be liable.