DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA :  AGARTALA

 

CASE   NO:   CC- 60 of 2021.

 

1. Shri Arindam Ghosh, Principal Insurer and 

father of the Claimant Petitioner.  

Miss Sayantika Ghosh,

D/O. Shri Arindam Ghosh,

Ramnagar Road No.2, P.O.-Ramnagar,

Dist. -West Tripura, Agartala- 799002,…..…..................Complainant.

(Represented by her father Shri Arindam Ghosh)

 

-VERSUS-

 

   (1) The Divisional Manager, 

Oriental Insurance Company Limited.

H.G. Basak Road, P.O.-Agartala,

Dist.- West Tripura, Pin-799001..................................Opposite Party.

 

    __________PRESENT__________

 

 SRI GOUTAM DEBNATH

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

DR (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

  WEST TRIPURA,  AGARTALA.

 

SRI SAMIR  GUPTA

MEMBER,

  DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA. 

 

C O U N S E L

 

For the Complainant : Sri Bhupal Chandra Biswas,

  Advocate. 

For the O.P. : Sri Prahlad Kumar Debnath,

   Advocate. 

 

FINAL ORDER  DELIVERED  ON:18/04/2023.

F I N A L     O R D E R

1. The Complainant Miss Sayantika Ghosh alongwith her father Sri Arindam Ghosh had Health Insurance Policy with the O.P. The Complainant felt ill on 14/08/2020 as she became unconscious in washroom. She was shifted to ILS Hospital, Agartala at 4.15 P.M. She was released on 16/08/2020. Her father duly intimated the O.P. The Medi Assist on 18/12/2020 asked for documents by sending one e-mail and all documents were sent accordingly. But the claim was neither settled nor her original medical documents were returned. Hence, this claim for Rs. 1,73,273/-.   

2. The O.P. in W.O. pleaded inter alia that the Complainant has failed to submit the required medical papers under Group Health Insurance Policy coverage, i.e., letter of Need for hospitalisation by treating physician to the Medi Assist Insurance TPA Pvt. Ltd. As per the E-mail dated 09/10/2020 within 10 days and Claim Form Part-B, Prenumbered paid receipt as sought by E-mail dated 14/01/2021, 21/01/2021, 29/01/2021 for which the claim was not admissible in the course of law. Accordingly, TPA management by E-mail dated 23/02/2021 sought for claim closure approval and finding no alternative the O.P. Insurance Company on 01/03/2021 issued Pre-Repudiation Letter(without pre-judice) giving one more opportunity to submit the Claim Form Part-B and Pre-numbered paid receipt of Rs.70,000/- paid on 30/09/2020 within 2 weeks and the said letter was also received by the Complainant on 02/03/2021 putting his signature thereon. The response letter dated 05/03/2021 and 15/03/2021 of the Complainant are avoiding to the proper requirements and then as per Clause 1.0, Description 4,13, the Denial of letter is prepared as the claim is not admissible in view of Expenses for investigation/treatment irrelevant to the disease. However in their additional W.O. in Para No. 3 the O.P. pleaded that Sayantika, the patient suffered from anxiety Neurosis is psychiatric disorder which is excluded from the scope of the policy hence, the claim stands repudiated under Clause 4.9 of the policy. 

3. Both the parties submitted at evidence on affidavit alongwith documents. 

On the basis of arguments, pleading and evidence the following points emerge for description of decision:

    (i). Whether claim of the medical reimbursement for Sayantika Ghosh is admissible under the terms and condition of the Policy?   

      (ii).  Whether the O.P. is guilty of deficiency in service?       

5. All the points are taken up together for discussion and decision. 

DECISION AND REASONS FOR DECISION:-

6. One certificate in the name of Sayantika Ghosh submitted showing that she was admitted in ILS Hospital, Agartala with breathing difficulty etc. with PCOD with hypothyroidism. Her condition could not be managed in OPD. As such the need for admission in hospital has been proved.  

Copy of Discharge Summary shows that the patient suffered from Anxiety Neurosis polycystic Ovarian disease – Hypothyroidism with Complaints of breathing for 3 days, Tingling sensation in lower limb for 3 days and Amenorhea for 3 months. The patient was admitted on 14/08/2020 and was discharged on 16/08/2020.

In order to find out whether the above mentioned medical conditions are outside the purview of the medical policy we beneficially look at the policy clause 4.9 as pleaded by the O.P. in their additional written objection and clause 4.2(ii) and 4.9 read as follows: 

          4.2 – The expenses on treatment of following ailments / diseases / surgeries, if contracted and /or manifested after inception of first policy(subject to continuity being maintained), are not payable during the waiting period specified below:

        (ii) (Polycystic ovarian diseases).    

  4.9 – Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the Hospitalised period. 

      Thus as per the discharge summary the patient was not only suffering from Polycystic Ovarian disease which is excluded under clause 4.2(ii) but also suffered from anxiety Neurosis and Hypothyroidism which are not excluded under clause 4.2(ii). Further the patient was not admitted only for evaluation / diagnostic purposes and not followed by active treatment. The discharge summary proves active treatment. Hence, clause 4.9 is also not applicable.                     

9. In view of the discussion above both the points are decided in affirmative in favour of the Complainant. 

                In the result it is ordered that the O.P. had no reason to repudiate the claim and as such guilty of deficiency in service. Hence, the O.P. shall pay to the Complainant the total bill amount of Rs.52,573/- as per the final bill raised by the Hospital. In addition to that the O.P. shall pay compensation for Rs.30,000/- to the Complainant for deficiency of service which is inclusive of litigation cost. Both these amount shall be paid within 30 days from today otherwise these amount shall carry interest @ 7.5% P.A. with effect from 30/07/2021 i.e. the day of filing the complaint till the date of actual payment. 

 Announced.

 

SRI  GOUTAM DEBNATH

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA

 

 

DR (SMT)  BINDU  PAL

MEMBER, 

DISTRICT CONSUMER DISPUTES 

REDRESSAL COMMISSION, 

WEST TRIPURA,  AGARTALA

 

 

 

SRI SAMIR  GUPTA

MEMBER,

 DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA.