Date of Filing: 14.12.2018
Date of Judgment: 07.12.2021
Mrs. Sashi Kala Basu, Hon’ble President
This complaint is filed by the complainant , Sri Parag Mukherjee, under section 12 of the C.P Act, 1986 against the O.Ps namely 1) The Divisional manager, United India Insurance Company Limited, 2) The Principal Officer, Heritage Health Insurance TPA Pvt. Ltd. 3) The Principal Officer, B.M Birla Heart Research Centre, alleging deficiency in service on their part.
The case of the complainant, in short, is that he has been maintaining mediclaim policy with the O.P no.1 bearing policy no. 0308002817P109101343 against the sum assured of Rs.7 lac for the period from 14.10.2017 to 13.10.2018. The petitioner was suffering from Cardiac pain on 12.3.2018. So, he was treated by one Dr. P.K Paul in his house who had conducted ECG and had prescribed certain medicines and had also advised several examination of the blood of the complainant. A sum of Rs. 6680/- was spent by the complainant in total on 12.3.2018 as pre-hospitalization expenses. On 12.3.2018 in the evening complainant was admitted at AMRI at Mukundapur where Angiogram and echo-cardiogram were done in respect of the heart of the complainant. An amount of Rs. 12,500/- was collected by the said AMRI hospital from the O.P no.2 being the agent of O.P no.1. On 13.3.2018 complainant was discharged from the said AMRI Hospital and after he was released from the said hospital, he was admitted into B.M Birla Heart Research Centre on the same date ,where he was admitted for his bypass surgery. On 15.3.2018 after receiving the amount of total PPN package money of Rs. 1,84,000/- in advance from the O.P no.2, the PO.P no.3 i.e B.M Birla Hospital shifted the complainant to the O.T for bypass surgery of the heart and the surgery was conducted. On 23.3.2018 complainant was discharged from the said B.M Birla Hospital. But the hospital authority demanded a further sum of Rs. 17,517/- which the complainant was compelled to pay. After discharge the complainant had to purchase medicines worth Rs. 2254/- , obtain the reports of blood examination and spent a sum of Rs. 960/- on 3.4.2018 and also had to pay a sum of Rs. 1484/- towards the post operative check up by Dr. Ratan Kumar Das. He also paid Rs. 2960/- for test. The said test was conducted by B.M Birla Heart Research Centre during post operative check up. He also had to spend Rs.500/- and Rs. 494/- on 4.5.2018 towards second post operative check up. Thus towards post hospital expenses complainant spent a sum of Rs. 11,965/- in total. By his letter dated 25.8.2018 complainant claimed the said total sum of Rs. 36, 162/- towards pre-hospitalization expenses, the balance amount of hospital expenses and for post hospitalization expenses. But the O.P Insurance Company paid only a sum of Rs. 16,659/- out of the said sum of Rs.36,162/- but has failed to pay the balance amount of Rs. 19,503/- . So, the present complaint has been filed by the complainant praying for directing the O.P no.1 to reimburse the said sum of Rs. 19,503/- , to pay compensation of Rs. 2 lac towards mental agony and to pay Rs. 1 Lac as damages towards deliberate deficiency in service.
Complainant has filed the relevant documents relating to the policy , the notice sent by the complainant and copy of medical bills and the prescriptions.
Only O.P no.1 has contested the case by filing written version, denying and disputing the allegations contending inter alia that O.P has already settled the claim under the said mediclaim policy and paid an amount of Rs. 1,84,000/- to the concerned hospital and also further paid Rs. 16,659/- after scrutinizing the claim papers. It is contended by the O. P no.1 that only a sum of Rs. 1800/- is due to be paid to the complainant under the policy which they are ready and willing to pay. The complainant is not entitled to the balance amount of Rs. 19,503/- prayed for by him, as the same are not covered under the policy. So, O.P has prayed for dismissing the case.
On perusal of the record it appears that the O.P nos. 2 and 3 did not take any step and thus case proceeded exparte against them.
Following points required determination:-
- Whether there has been deficiency in service on the part of the O.Ps?
- Whether the complainant is entitled to the relief as prayed for ?
Decision with reasons
Point nos. 1 & 2:
Both the points are taken up together for discussion in order to avoid repetition. Claim of the complainant that he is a mediclaim policy holder and that during the relevant period of treatment the policy was valid, has not been disputed by the O.P no.1. It is also not disputed that complainant underwent bypass surgery at B.M Birla Heart Research Centre on 15.3.2018 . Complainant has also filed the relevant documents that he was admitted at B.M Birla Heart Research Centre on 13.3.2018 and was discharged on 23.3.2018. O.P has also not disputed the expenses borne by the complainant towards pre-hospitalization a sum of Rs. 6680/-, Rs. 2,01,517/- at B.M Birla Hearts Research Centre , Rs. 12,500/- at AMRI towards hospitalization charges and Rs. 11,965/- towards post hospitalization expenses. It is also evident that O.P no.2 being agent of O.P no.1 has paid Rs.12,500/- at AMRI and Rs. 1,84,000/- at B.M Birla Heart Research Centre. O.P has also paid further sum of Rs.16,659/- after the complainant was discharged and made claim of Rs. 36,162/- in total ( Rs. 6680/- for pre-hospitalization charge, Rs. 17,517/- balance amount of hospitalization charge and Rs. 11,965/- for post hospitalization expenses). The documents filed by the complainant showing the visit of the doctor, purchase of medicines and pathological charges have also not been challenged by the O.P in its written version or during evidence. Only contention of the O.P is that out of Rs. 34,466/- O.P has already paid Rs. 16,659/- after necessary deductions. It may be pertinent to point out that complainant has claimed that O.P has malafidely stated the claim of the complainant as Rs. 34,416/- instead of Rs. 36,162/-. According to O.P some of the claim including the hospital charges are not payable under the terms and conditions of the said policy. But the O.P has not specified the amount which are not covered under the policy, as to whether it is for pre-hospitalization, hospitalization or post-hospitalization . Neither specific clause of the policy has been stated which excludes the amount claimed by the complainant. A vague statement has been made that as per terms of the policy , complainant is not entitled to the sum claimed by him. Absolutely no document has been filed by the O.P in support of its contention. On the other hand complainant has filed the copy of the policy ,wherefrom it appears that “Coverage” as stated in clause 1.2 includes Room, Boarding and Nursing expenses, I.C.U, Surgeon, Anesthetist, medical practitioner, specialist and consultant. It also provides that in case of major surgery it covers actual expenses incurred or 70% of sum assured. In this case sum assured is Rs. 7,00,000(Seven lakhs). As per clause 3.30 and 3.31 policy also covers pre-hospitalization and post-hospitalization medical expenses. The documents filed by the complainant are very categorical that pre-hospitalization expenses claimed by the complainant is towards the sum paid by him a day before his admission at B.M Birla Heart Research Centre (within 30 days as mentioned in clause 3.30 of the policy ) and post hospitalization expenses are of the sum paid by the complainant within 60 days as stated in clause 3.31 of the policy. It is not the case of the O.P that the sum claimed exceeds the limit as it is already highlighted above that O.P has made a vague and general denial. It is also evident that pre-hospitalization and post- hospitalization expenses claimed by the complainant relates to the by-pass surgery undergone by him. If that be so, then complainant is entitled to the sum of Rs. 19,503/- and also entitled to the compensation for harassment and mental agony suffered by him. An amount of Rs. 30, 000/- will be justified towards compensation .
Hence,
ORDERED
CC/671/2018 is allowed on contest against O.P no.1 and exparte against O.P no.2 but dismissed exparte against O.Pno.3.
O.P no.1 is directed to pay a sum of Rs. 19,503/- within sixty days from this date.
O.P no.1 is further directed to pay Rs. 30,000/- to the complainant as compensation within the aforesaid period of sixty(60) days in default of payment ,the entire sum shall carry interest @8% p.a till realization.
