West Bengal

Paschim Midnapore

CC/177/2016

Sri Sachindra Nath Misra - Complainant(s)

Versus

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

17 Aug 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

     Bibekananda Pramanik, President,

     Pulak Kumar Singha, Member

and

   Sagarika Sarkar, Member. 

 

Complaint Case No.177/2016

 

Sri Sachindra Nath Misra, S/113, Mitra Compound, Midnapore

P.O. & P.S.-Midnapore, District-Paschim Medinipur..………..……Complainant.

Vs.

1. The Divisional Manager, National Insurance Co. Ltd., Midnapore Division, Station Road, Midnapore, Dist-Paschim Medinipur
2. The Manager, H.O., C.R.M.D., National Insurance  Co. Ltd., 3, Middleton Street, Kolkata-700071
3. The Manager, Rothshield Health Care, T.P.A. Service Pvt. Ltd., 5A & B, Chowringhee Lane, Flat No. 1(C), 4^th Floor, Kolkata-700016.....……….….Opp. Parties.

                                                     

                For the Complainant   :                      Self

                For the O.P.                 : Mr. Mirza Md. Galib Chowdhury, Advocate.

 

Decided on:17/08/2017

                               

ORDER

            Pulak Kumar Singha, Member : 

 

                    Complainant files  this case u/s 12 of the C.P. Act, 1986.

  In short the case of the complainant is that the complainant purchased mediclaim policy for his entire family members on 06/03/2002 vide policy no.150301/48/2001/8501448 which has been continued upto 2017 by way of time to time  paid policy premium and the complainant also earned cumulative bonus for every year.

                                                                                                                                                               Contd……………P/2

 

( 2 )

 On 30/01/2016 wife of the complainant went to  surgical OPD at Midnapore Meeical College for  painful serious injury on the Right hand thumb.  Due non availability of bed of said Hospital Smt. Smriti Bhattacharya Misra was admitted in the Shivam Laparoscopic Institute, Midnapore for better treatment and she was operated thereon on 30/01/2016 and  discharge on 31/01/2016. Complainant had to pay Rs.5,700/- for such operation including medicine. Complainant submitted claim reimbursement from the O.P. and submitted required documents but O.P. no.1  repudiated the claim as such operation was done in OPD, so, O.P. decline the claim as No Claim. The complainant appeared before this Forum for getting   relief as per prayer of complaint.

O.P. no.1 contested the case by filing written objection denying the allegations stating interalia that the claim is not maintainable, the compensation amount of Rs.99,950/- with interest is excessive, arbitrary and without basis. Since the  treatment of alilment PARONYCHIA  was done under local anesthesia which in an out patient procedure and under policy condition  exclusion clause no.4.18, OPD  treatment is not cover under the policy. This  O.P. prayed for rejection of claim.  

In spite of duly service of summons upon O.P. no.2 & 3, none appeared and  contested the case on behalf of  O.P. no.2 & 3.  So, the case is heard ex-parte against O.P. no.2 & 3.

                                                  Points for decision

1. Is the claim is maintainable ?
2. Are the opposite parties deficient in service ?
3. Is the complainant entitled to get the relief ?    

                   

Decision with reasons

      For the sake of convenience and brevity, all the above points are taken up together for consideration.

     We have perused the complaint, documents, evidence and considered the written arguments by the parties, it appears that it is admitted fact, the family members of complainant are the policy holders under Health Scheme of mediclaim policy of O.P. company. Complainant purchased mediclaim policy on 05/03/2002 and such policy continued by way of renewal by paying time to time  policy premium and said policy is valid from 12/03/2016 to 11/03/2017.

    Smt. Smriti Bhattacharya Misra, wife of the complainant having the mediclaim policy holder of O.P., vide policy no.153800/48/15/8500002371, sum assured Rs.3,50,000/-

                                                                                                                                                       Contd……………P/3

 

                                                                                                   ( 3 )

valid for the period from 12/03/2016 to 11/03/2017. The wife of the complainant on 30/01/2016 went to Midnapore Medical College for painful serious injury on her  Right hand thumb for treatment but due to  non-availability  of bed she could not get admission  thereon. On that day she went to Sibham Laparoscopic Institute, Midnapore for treatment, where she had to  admit and her operation  on the right hand thumb was done on 30/01/2016 and  she  was discharge on  31/01/2016.  It appears from the discharge certificate,  medical expenditure bill etc.  we find that Smt. Smriti Bhattacharya Misra  was admitted on 30/01/2016 under Dr. T.K. Biswas (MS) on  bed no.L-I and  discharge on 31/01/2016 with advice of medicine and taking post operative measures.  It also reveals from the documents that insured was treated on said institute (Hospital) as indoor patient.  Complainant to prove his case adduced evidence by filing examination-in-chief with affidavit and tender himself as witness on oath and also filed  documents which  are marked exhibits. O.P. also adduced evidence and submitted blank policy Jacket which is marked as exhibit-A.

     Complainant submits that first policy was issued for the period on 06/03/2002 to 05/03/2003 where there is no existence of clause 4.18  in terms  and condition  of the said policy and OPW-I,   Asstt. Manager of O.P. also admits the submission in his cross-examination. Such policy is continued from time to time  by paying policy premium. OPW-1 stated that previous policy now charged as National mediclaim Policy, so terms and condition of the new policy has been changed. But complainant denied said statement of OPW-1 as he remained the policy since in the year 2003  by paying regular premium but O.P.  never intimated him regarding the charge of old policy terms and condition. We find from the  policy jacket of national mediclaim policy clause 4.18, it  is mentioned outpatient department treatment (OPD treatment) is in the  exclusion clause of New  mediclaim policy. It is fact that complainants’ wife submitted claim reimbursement to the O.P. under New policy period. As per version of O.P. that they are not liable to pay in expenses in connection  with or in respect of outpatient department treatment as, such treatment is an OPD procedure, there is no need to admission at Hospital or nursing home.

      It is fact that in a surgical case patient can not choose whether her treatment can be at outdoor or indoor patient. Such  option can only depends upon  the doctor, who examine the patient, being a doctor (MS) has medical skill in respect of surgical, so he can only  the person who decided whether such type of  injury can be operated in OPD or as indoor  patient. Doctor never depends upon the patient choice as there is involved responsibility and liability of doctor. So, it cannot be said that such injury of insured can be held at OPD. In the instance case insured was admitted as indoor patient operated and

                                                                                                                                                          Contd……………P/4

 

                                                                                             ( 4 )

treated according to the advice of doctor who being a surgeon who has enough medical skill. So, clause 4.18 in the terms and condition of policy is not applicable in the instance case.  In view of the above discussion and we think this case is well maintainable in law and O.Ps. have deficiency in rendering service by repudiating the claim of the complainant for such complainant has been suffering mental pain and  harassment. So, the complainant is entitled to get relief as prayed for.     

                            Hence, it is,

                                                     Ordered,

                                that the complaint case be and the same is allowed on contest against O.Ps. with cost.

 O.P.no.1 & 2 are directed to pay jointly or severally of Rs.5,700/- with interest @9% p.a. from February, 2016 to the complainant within one month from the date of this order. 

O.P. no.1 & 2 are  further directed to pay compensation of Rs.5,000/- to the complainant within stipulated period. 

Failure to comply the order O.Ps. shall be liable to pay Rs.2,000/- per month to the Legal Aid Fund of this Forum as penal cost.

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

             Dictated and Corrected by me

                       Sd/- P.K. Singha                             Sd/- S. Sarkar                       Sd/-B. Pramanik.

                            Member                                           Member                                 President

                                                                                                                               District Forum

                                                                                                                            Paschim Medinipur