Order-15.

Date-29/03/2018.

         Smt. Sangita Paul, Member.

            The Complainant’s case, in brief, is that complainant is mediclaimpolicy holder under the O.Ps. for more than few years. The name of the policy is Senior Citizens Red Carpet Insurnce Policy being No.P/700002/01/2017/068325. The said policy is to cover for health for the period from 26/01/2017 to 25/01/2018 and sum insured amount is Rs.5,00,000/-. During the policy period complainant fell ill in the first week of December-2016 and as such she went to Doctor for her treatment. During prognosis Dr. Dutta had noted some symtoms what he suspected  and therefore he advised for some pathological tests to ensure the disease  and for proper treatment. According to the advice of the Doctor she took medicines and did all pathological tests and it was diagnosed that serum potassium and serum sodium were not proper. Treatment on the basis of prescription dated 16/05/2017 did not give proper reliefto complainant and complainant subsequently went to Kothari Medical Centre for treatment and after diagnosis the treating Doctor admitted her on that day i.e. on 20/05/2017 for treatmet and discharged complainant on 26/05/2017. It was clear from the discharge summery that complainant was suffering from weakness and lethargy for five days, diabetis mellitus, hypertension. After thorough treatment of complainant the Doctor finally diagnosed Diabetis, Hyperkalemia and Hypertension, but she never suffered from Gouty Arthritis  as suspected by the first Doctor Ranjit Dutta. As complainant made an application for cashless treatment before the O.P.-1 during admission at Kothari Medical Centre, has been approved by O.P.-1 vide letter dated 21/05/2017. But unfortunately the insurance company did not reimburse the treatment expenditure claimed by complainant. Complainant incurred expenditure for an amount of Rs.99,470/- which has been paid to the Kothari medical centre at the time of discharge. Complainant also lodged claim before the insurance company for reimbursement. The insurance company repudiated the claim amount vide letter dated 24/05/2017 on the ground of insufficient documents relating to Gouty Arthritis, whether it was first diagnosed or any previous treatment record. Complainant came to know that as per query of O.P.-3 that the patient with the disease of increase of potassium for few days is completely wrong. The Doctor certified that the patient had no knowledge of gouty arthritis, it came out after investigation. So the statement of O.P.-3 that the patient was suffering from arthritis is totally wrong After getting such false information complainant wrote O.P.-1 to consider his claim on the basis of the discharge certificate of Dr. Anil Malhotra. But the O.P.-1 did not settle the claim. Complainant submits that in collusion with the insurance company O.Ps.-1 and 2 submitted such baseless information. Complainant is deprived of having her legitimate claim. O.P.-1 received relevant documents relating to the treatment and claim form, but O.P.-1 did not settle the claim and repudiated the same in spite of several reminders. Hence complainant prays for issuance of notice upon the O.Ps. for their appearance and show cause, also prays for directing the O.Ps.-1 and 2 to pay and settle the claim amout of Rs.99,470/- along with interest  at the rate of 18 percent p.a. from the date of claim till payment, for directing O.Ps.-1 and 2  to pay compensation of Rs.15,000/- for mental agony and harassment and for paying litigation cost of Rs.10,000/-.

            In the written version O.Ps.-1 and 2 state that each allegation made in the complaint is frivolous and vexatious  and the same is liable to be dismissed. Complainant is guilty of suppression of medical facts and mis-representation. Coplainant is a policy holder since 26/01/2016 to 25/01/2017 and 26/01/2017 to 25/01/2018. The said mediclaim policy is subject to certain conditions, exclusions and complainant was admitted to Kothari Medical Centre from 20/05/2017 to 26/05/2017 for treatment of diabetes, hyperkalemia, hypertension. As per documents of 09/12/2016 and 13/01/2017 complainant has gouty arthritis. As a result, claim was repudiated on 24/05/2017. The insured has not furnished the required documents. So her claim has been repudiated u/s-4 of the policy. Complainant is unable to establish deficiency in service on the side of the O.Ps.two letters, one dated 24/05/2017 and another on 08/07/2017 clearly repudiated the cashless claim of complainant. Complainant should have disclosed the material facts  regarding health. So complainant is not entitled to any relief as prayed for.

            O.P.-3 Dr. Ranjit Dutta states that the present complainant is not maintainable in law and liable to be dismissed. Complainant does not disclose any cause of action against the proformaO.P. Complainant has not submitted any prescription of O.P.-3. ProformaO.P.-3 prescribed gouty arthritis. It is not stated that the diagnosis is not correct. No relief is sought against O.P.-3. Some treating Doctors  have made contradictory statements. But the treatment of O.P.-3 is devoid of any error.

            ProformaO.P.-4 states that there is no specific  allegation of complainant against proformaO.P.-4. Complainant has specific claim against O.Ps.-1 and 2. The insurance company who is illegally repudiated  thebonafide claim of complainant. Complainant is aggrieved by deficiency of service of insurance company. Complainant has no allegation against Kothari Medical Centre, O.P.-4. O.P.-4 is not complainant’s insurer. There is no contractual relationship between complainant and O.P.-4 regading insurance service. O.P.-4 renders treatment to the patients. O.P.-4 in no way related to the disbursement of claim. No charge of meical negligence has been revealed against O.P.-4. HenceO.P.-4 is not entitled to disburse any relief to complainant.

Decision with Reasons

We have perused the documents on record i.e. complaint petition, written versions of O.Ps.-1 to 4, letter of repudiation copies of e-mail conversations, claim form, discharge summary and other documents lying on record. It appears that complainant has a mediclaim policy. The name of the policy is Senior Citizens Red Carpet policy being No.P/700002/01/2017/06-8325 for the period 26/01/2017 to 25/01/2018 and sum insured amount is Rs.5,00,000/-. Complainant fell ill in the month of December-2016. She went to Doctor. After medical test it was revealed that serum potassium and serum sodium were not proper. Medication did not yield satisfactory result, we went to Kothari Medical centre. Complainant was admitted to Kothari Medical Centre on 20/05/2017 and discharged on 26/05/2017. From discharge summery it was revealed that complainant was suffering from weakness, lethargy, diabetis mellitus, hyper kalemia and hypertension, but she never suffered from gouty arthritis suspected by O.P.-3, Dr. Ranjit Dutta. After admission complainant applied for cashless treatment through Kothari Medical centre. But unfortunately the insurance company did not disburse the claim of complainant. The amount of expenditure was Rs.99,470/-. Her claim was repudiated on the ground of insufficient documents relating to gouty arthritis. In the language of O.P. she has not furnished required documents. In the absence of those documents they are unable to process her claim, so they are repudiating  the claim. The insurance company informed through a letter dated 08/07/2017. In the papers of senior citizens red carpet insurance policy it is mentioned that the company will pay to the insured persons the amount of expenses as are reasonably and necessarily incurred up to the limits indicated. Medical practitioner, consultants, specialist fees are subject to a maximum of 25 percent of the sum insured per hospitalization. The case of the complainant is a bit different for the reasons unknown to complainant. Complainant did not get any hospitalization expenditure. Complainant is entitled to get specialist fees to a maximum of 25 percent of sum insured per hospitalization. Complainant did not get a single penny from the insurance company. In the pre-authorization request form, complainant mentioned that she has diabetis and hypertension. In the discharge summery of Kothari Medical Centre it was mentioned by the Doctor that she had diabetic diet according to diet chart, check B.P. regularly and keep records, hypoglycemia awareness and remedial measures explained.No where in the discharge summary the treating doctor Dr. Anil Malhotra explained that she has no gouty arthritis. As patient / complainant is not suffering from gouty arthritis  the submission of required documents regarding gouty arthritis does not arise. In an e-mail dated 07/07/2017 complainant wanted to know regarding reimbursement through e-mail. Complainant submitted all relevant documents regarding treatment but O.Ps.-1 and 2 want more documents.Complainant had nothing to submitbecause all original documents have been submitted by complainant. Now O.Ps. are trying not to disburse the claim of complainant. At the time of buying the policy the insurance company declares  that they are ready to disburse the claim of complainant. Complainant clearly mentioned her disease. After that complainant got opportunity to buy the medicaimpolicy . Now they are showing multiple reasons to repudiate the claim. O.Ps.-1 and 2 are depriving complainant of her legitimate claim. Hence the case constitutes deficiency of service and unfair trade practice. Complainant fell victim in the hands of O.Ps.-1 and 2. There is no claim against O.P.-4 the treating doctor of Kothari Medical Centre.

            In the result, complaint succeeds.

Hence,

Ordered

That the case be and the same is allowed on contest against O.Ps.-1 and 2with a cost of Rs.10,000/-.

            O.Ps.-1 and 2 are directed to reimburse the medical expense of the complainant of Rs.99,470/- with 9 percent interest p.a. within one month from the date of this order.

            O.Ps.-1 and 2 are directed to pay an amount of Rs.10,000/- as compensation for causing harassment and mental agony to complainant within the stipulated period.

            O.Ps.-1 and 2 are directed to pay Rs.5,000/- for adopting unfair trade practice. If collected it shall be deposited to the Dist. Forum.

Failure to comply with the order will entitle the complainant to put the order into execution under appropriate provision inC.P. Act.

Order-16.

Date-11/06/2018.

Record is put up on prayer of the Opposite Parties Nos.1 and 2 – Star Health and Allied Insurance Co. Ltd. A petition is filed for the Opposite Parties No. 1 and 2 stating therein that the JDrs. have paid the decreetal dues to the Complianant in compliance of the judgement  dated 29.03.2018 passed by this Forum by sending a Demand Draft for Rs.1,25,651/- bearing no.538659 dated 17.04.2018 drawn on HDFC Bank, Kolkata to Mrs. Manjulika Dasgupta, the Complainant in the instant case towards full and final satisfaction of the award through DTDC Courier. Now the O.P. Nos.1 and 2 tender one Demand Draft for Rs.5,000/- bearing no.867118 dated 20.04.2018 drawn on Indian Bank issued in favour of “President, DCDRF, Kolkata Unit – II” for payment of penalty for adopting unfair trade practice in terms of order dated 29.03.2018 passed by this Forum, with the prayer for acceptance of the same.

                        Perused the petition filed for the Opposite Parties Nos.1 and 2. Seen the judgement dated 29.03.2018 passed by this Forum in CC/305/2017. Considered.

                        Let the amount of Rs.5,000/-(Rupees Five Thousand) Only as aforesaid be accepted and office to deposit the same to the concerned bank account.