DISTRICT CONSUMER DISPUTES REDRESSSAL FORUM

WEST TRIPURA : AGARTALA

 

 

CASE NO:  CC – 05  of   2018

 

 

Sri Haradhan Datta,

S/O- Lt. Jalandhar Datta,

Fakirbari Lane, Krishnanagar,

P.O. Agartala, P.S. West Agartala,

West Tripura- 799001. ….......…...Complainant.

 

 

         -VERSUS-

 

 

The Divisional Manager,

National Insurance Company Ltd.,

Divisional Office- Akhaura Road,

P.O. Agartala, P.S. West Agartala,

West Tripura- 799001. ......... Opposite Parties.

 

 

 

__________PRESENT__________

 

 SRI A. PAL,

PRESIDENT,

  DISTRICT CONSUMER 

 DISPUTES REDRESSAL FORUM,

      WEST TRIPURA, AGARTALA. 

 

SMT. DR. G. DEBNATH

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

SRI U. DAS

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

 

 

C o u n s e l

 

For the Complainant : Sri Anjan Kanti Pal,

  Advocate.

 

For the O.P. No. : Sri Sandip Datta Choudhury,

  Sri Bindu Pal,

  Advocates.

 

 

 

JUDGMENT   DELIVERED   ON:  26.06.2018.

 

J U D G M E N T

This case arises on the petition filed by one Haradan Datta. Petitioner's case in short is that he purchased Medi Claim Policy for period from 27.03.2017 to 26.03.2018. During the policy coverage period on 06.11.17, the wife of the complainant, Pratima Datta @ Pratima Baidhya suffered illness and admitted at Fortis Memorial Research Institute at Gurgaon, Haryana. Treated there  from 06.11.2017 to 07.11.2017. Total cost of treatment was Rs.49,720/-. With all necessary papers claimed the amount but the claim was denied by the O.P. Petitioner, therefore, claimed Rs.1,55,000/-. 

 

2. O.P. National Insurance Company Ltd. filed written statement denying the claim. It is contended that as per policy condition petitioner is not entitled to get expenses for hospital diagnostic and clinical examination. As complainant did not suffer major heart operation. There was no deficiency of service by O.P.

 

3. On the basis of contention raised by the petitioner and O.P. following points cropped up for determination:

(I) Whether the petitioner's wife suffered illness and cost of treatment is to borne by the Insurance company?

(II) Whether the petitioner is entitled to get the cost of treatment and compensation as claimed?

 

4. Petitioner side produced original Application, Insurance Policy, claim rejection letter, medical treatment documents, original authorization letter.

5. Petitioner also produced the statement on affidavit of one witness Haradhan Datta, authorized representative of Pratima Baidhya and also petitioner of this case. 

 

6. O.P. on the other hand produced the policy conditions certificate and also produced the statement on affidavit of Joydip Ghosh, Assistant Manager, National Insurance Company Ltd.

 

7. On the basis of all these documents and evidence we shall now determine the above points.

 

Findings and decision:

8. We have gone through the policy certificate and also terms and conditions as furnished by the O.P. The coverage is given for room charges and intensive care unit charges, nursing expenses, surgeon, anaesthetist, medical practitioner, consultants specialist's fees, Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines & drug diagnostic materials and X-ray, dialysis, chemotherapy cost of pacemaker, artificial limbs and similar expenses, ambulance charges. 

 

9. Assistant Manager of the National Insurance Company stated that as per exclusion clause, petitioner is not entitled to get cost of treatment as claimed. In the exclusion clause the existing disease and hospitalization for the purpose of diagnosis and evaluation, irrelevant investigations charges is written. Expenses incurred in the hospital for diagnosis, X-ray or laboratory examination or other diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury is written not covered. From the claim status of this terms and conditions it is clear that if any expenses is incurred for diagnosis which is not consistent nor incidental to the treatment of any ailment, sickness or any injury then petitioner is not entitled to get cost of that treatment. 

 

10. Haradan Datta petitioner stated that his wife was admitted at Fortis Memorial Research Institute and treated from 06.11.17 to 07.11.17 with complaint of heart disease. She was admitted in the hospital with the complains of dyspepsia & acidity, epigastria pain, weight loss, chest pain and vomiting. 

 

11. We have gone through the discharge summary, Endoscopy was done. Hernia with gastritis found. Colonoscopy was done which showed haemorrhoids and left sided ulcer. She was managed with antibiotics. CBC was also done. After this diagnosis medicine was prescribed by the doctors of the Fortis hospital.  Rs.22,600/- was paid for medical/ surgical procedure. Room rent Rs.4,500/- with drug consultation and investigation charges, total Rs.49,720/- was paid  as per the cash memo. There is nothing  in the report to support that treatment was not related to the diagnosis. From the medical report and the discharge summary it can not be said that investigation was irrelevant in consistence with the person's ailment found Heart disease was not diagnosed. Therefore, plea taken by the O.P. Insurance company for repudiating the claim appears to be unjust. 

 

12. We have gone through the repudiation letter and it was observed that clinical investigation was carried out and was not followed by active treatment. In every case operation may not be necessary. Medicine can help to heal the injury or disease. Therefore, we can not support the fact that treatment was not done as per diagnosis. Petitioner therefore, is entitled to get cost of expenses as per terms and conditions of the policy. O.P. Insurance company failed to provide the service by non payment. This is deficiency of service by the National Insurance company. Petitioner is entitled to get compensation for such deficiency of service. We therefore, direct O.P. National Insurance company to pay cost of expenses Rs.49,720/- and also pay Rs.10,000/- as compensation as Rs.5,000/- as litigation cost. Total Rs.64,720/-  is to be paid. Both the points are decided accordingly. 

 

13. In view of our above findings we direct the O.P. to pay Rs.64,720/- medical expenses, compensation and litigation cost to the petitioner within 2(two) months, if not paid it will carry interest @ 9% P.A.  

    Announced.

 

 

 

SRI A. PAL

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL FORUM,

WEST TRIPURA,  AGARTALA.

 

 

 

SMT. DR. G. DEBNATH,

MEMBER,

 DISTRICT CONSUMER DISPUTES 

REDRESSAL FORUM, 

WEST TRIPURA, AGARTALA SRI  U. DAS

MEMBER,

 DISTRICT CONSUMER DISPUTES 

REDRESSAL FORUM, 

WEST TRIPURA, AGARTALA