DIST. CONSUMER  DISPUTES  REDRESAL  COMMISSION

NORTH 24 Pgs., BARASAT.

C.C. No. 75/2018

Date of Filing:                      Date of Admission:             Date of Disposal:

                  13.02.2018                                    22.02.2018                              30.05.2023

P R E S E N T                       :-         Smt. Monisha Shaw …………………. Member.

                                                :-         Sri.  Abhijit Basu      …………………. Member.

            JUDGMENT/FINAL ORDER

This complaint is filed by the Complainant U/s 12 of the Consumer Protection Act, 1986 (as amended up to date) alleging deficiency in service as well as unfair trade practice against the OPs as the OPs did not take any step to redress his grievance till filing of this complaint.

The brief fact of the complaint is that the Complainant, Sri Jnanabrata Ganguly subscribed to one BOI National Swasthya Bima Policy being the primary beneficiary along with his wife Smt. Pranati Ganguly who is also covered under this said policy. The O.P. No. 1 and 2 have issued the said policy to the Complainant being No. 10080048148500003341, valid upto 26/03/2016 and 100800501510001216 valid up to 26/03/2017 after being totally satisfied with the application made by the Complainant and on acceptance of premium. The said insurance policies were valid 27^th March, 2015 to 26^th March, 2016 and 27^th March, 2016 to 26^th March, 2017. The said insured Pranati Ganguly, W/o Jnanabrata Ganguly was admitted to Christian Medical College, Vellore on 16^th March, 2016 for treating of her ailments (she admitted to the Christian Medical College, Vellore during the validity of the said insurance policies).

The Complainant further stated that after thorough investigation and full satisfaction as regards the nature of ailments of the said Pranati Ganguly was being admitted as an Indoor Patient and the Complainant stated that it is entirely incumbent or direction of the hospital authorities to admit a patient depending upon the gravity of the case and ailments. The said Pranati Ganguly W/o the Complainant admitted to Christian Medical College, Vellore under Department of Geriatrics with Chief Complaint of three episodes of GTCS since November, 2015, Dysuria and Urinary incontinence for 7 to 10 days and loose tools for 3 days. Again, Pranati Ganguly was admitted on 16^th March, 2016 at CMC, Vellore under Department of Geriatrics and was discharged on 28^th March, 2016 all diagnosed with several serious ailments which are recorded in details in the discharge certificates of the said CMC, Vellore.

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The Complainant further stated that it has defrayed a sum of Rs. 1,48,025/- towards hospitalization charges for the period of 16^th March, 2016 to 28^th March, 2016 and the Complainant wanted to reimbursement of that expenses i.e. Rs. 1,48,025/- from O.P. No. 3 and 4. As per Complainant’s version the O.P No. 4 assured to process the claim speedily and also the O.P. No. 4 required the original documents from the Complainant and the dispatched the same. The O.P. No. 1 and 2 arbitrarily and whimsically refuted the genuine and bonafide claim of the Complainant vide letter dated 7^th October, 2016 denying the claim as policy exclusion 4.13, which read as follows, “hospitalization for the purpose of diagnosis and evaluation, irrelevant investigation charges” and wrongfully and unlawfully refuted the claim of the Complainant with mala fide intension. As per Complainant the O.P. No. 1 and 2 constitutes gross deficiency of service and it is an unfair trade practice. The Complainant received the certificate and email Dr. Mathews, Professor, Head of the Department of Geriatrics, Christian Medical College, Vellore and forwarded the same to the Opposite Party No. 1 and 2 vide letter dated 28/11/2016 and the Opposite Party No. 1 and 2 on received of the said certificate from the said doctor about the said treatment vide email dated 19/12/2017 refuted the claim with a reckless and irresponsible observation that “patient is a chronic case of GTCS and was admitted for this episode only for proper evaluation purpose. Hence, we are unable to consider the said reimbursement claim…..”.

            Having no other alternative the Complainant sent a legal notice through his Ld. Advocate dated 12/05/2017 and filed this case on 13/02/2018.

From the record it is evident that though the O.P no. 3&4 received the notice on 30.06.2018 and 29.07.2019 respectively but did not turn up and not appeared before this Commission so the case do run exparte against the O.P no.3 from 12.12.2018 and also against O.P no.4 from 10.12.2019.

O.P. No. 1 and 2 received the notice on 29/06/2018 and they have filed the W/V on 05/07/2018. In the W/V they stated and admitted that the Complainant is a policy holder being no. 100800/48/14/8500003341 and the patient Smt. Pranati Ganguly was finally diagnosis convulsions, not elsewhere classified, other Ceribrovascular diseases, essential hypertension, disorders of lipoprotein metabolism and other Lipidaemias, Gonarthrosis (arthritis of knee) and admitted Christian Medical College, Vellore. They also submitted that the insured Complainant over the period and submitted numerous claim. . . . . . . . . . . (to be copied later)

The claim details which have already been settled total 07 claims up to the current policy period out of which 03 claims are of Policy No. 10080/48/14/8500003341.

The O.P. No. 1 and 2 also submitted that the patient is basically suffering with UTI, LRTI, status epilepticus, old ischemic, CVA, Pelvic Rami and Conacrvative as well as surgical procedures are being provided in those hospitalization cases and Opposite Party No. 1 and 2 already approved as per the policy condition. The Complainant beg to submit that reimbursement of hospitalization expenses under claim no. 12610555 was considered for denial under policy 10080/48/14/8500003341.

On scrutiny of the claim documents, TPA observed that the claim is not admissible in view of the policy because since 27/03/2014 the Complainant is a diagnosed case of Acute delirium, SEIZURE disordered, CVA, HTN, Dyslipidemia, B/L OA Knee. As per documents provided by the Complainant it is admitted that the patient / Complainant could have been managed on OPD / Day care basis and also hence denied as per exclusion 4.13 and since the claim does not fall within the perview of the policy terms and conditions and it was repudiated letter dated 07/10/2016 issued by Divisional Manager.

The O.Ps also stated that hospitalization for the purpose of diagnosis and evaluation, irrelevant investigation charges, all expenses incurred at hospital primarily for diagnostic, X-ray or a laboratory examination or for other diagnostic studies not consistent or with or nor incidental to the diagnosis and treatment of positive existence or presence of any alignment sickness or injury, for which confinement is required at a hospital.

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As per version of the O.P. No. 1 and 2 the Complainants beg to submit that TPA vide its letter dated 31/05/2016 advised tie insured to provide doctor prescription showing for admission mentioning with presenting clinical condition furnished mote over discharge summary also silent. They also submitted that the bill was submitted by the Complainant as room rent of Rs. 71,500/-, investigation of Rs. 39,675/-, pharmacy of Rs. 16,153/-, Miscellaneous of Rs. 7,792/-.

That insured submitted complete documents along with reimbursement of expenses incurred for Rs. 1,48,025/- and the claim file was reviewed by TPA based on the submitted documents. It was recommended for repudiation under clause 4.13 National Medical Policy and letter dated 07/10/2016 was issued to the Complainant since as per submitted documents, it appears that “No active treatment has been given and treated only with oral medicine. Another point is that during hospitalization only for investigation and evaluation are done since the above said reason are not payable as per clause 4.13 of NIC policy condition”.

They also submitted in respect of no active line of any treatment or for any other case no insured can get mediclaim policy and in this regard Hon’ble N.C.D.R.C passed in C.P.R., 2013 (4) pages 165 observed the policy that policy condition shall be followed by the Forum and no examination or relaxation can be made on the ground of equity for violating the terms and conditions of the policy, Complainant is entitled to get any relief. So the repudiation is justified and for which the Complainant is not entitled to get any relief. It is also decided by the Hon’ble Supreme Court that parties shall be guided by the terms and conditions of the policy and there is no question of giving any extra relief to the insured on the ground of equity or etc. and further it is already decided by the Hon’ble Apex Court in 1966 3  SCR   500 constitution bench that the duty of the Court is to interpret the words in which contract is expressed by the parties because it is not for the Court to make a new contract. However, reasonable, if the parties have not made it themselves or moreover in the present case we have gathered that O.P. applied their mind by applying the terms and conditions of the policy after consideration of the medical report and discharge summary as produced by the Complainant and there is no deficiency on the part of the O.P and it was repudiated after considering the documents by applying judicial mind.

The O.Ps also submitted that the Complainant has no cause of action and the Complaint is not maintainable both in facts and law since the loss is not covered by the terms and conditions of the mediclaim policy and falls under the Exclusion clause 4.13.

The O.P prayed for dismissal the petition of complaint in limini under section 26 of said consumer protection Act, 1986 as there is no deficiency in service on the part of the O.P 1 & 2, the petitioners herein repudiating the claim after proper application of mind in good faith on the basis of TPA’S recommendation since as per discharge summary, there is no Active line of treatment done and this can be possible to do OPD basis.

Having no other alternative, the Complainant lodged this case on 25/07/2019 before this Commission, D.C.D.R.C., Barasat, North 24 Parganas for his proper redressal.

Prayer of the Complainants:-

1. To forthwith honour the claim and pay your petitioner reimbursement of Rs. 1,48,025/- along with interest @12% from the date of filing the claim.
2. To pay the Complainant a sum of Rs. 2,00,00/- for causing mental pain, anxiety, trauma and tremendous harassment causing serious irreparable damage to mental health of the Complainant.
3. To pay Rs. 1,00,000/- towards litigation cost.

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4. For other relief or reliefs.
5. Pass any other order / orders as the Ld. District Commission may deemed fit and proper in the fact and circumstances of the case.

Following issued were framed for the purpose of decision:-

1. Whether the complaint is maintainable or not?
2. Whether the Complainant is entitled to get relief / reliefs in this case.

Decision with reasons:-

Considering the facts and circumstances as well as nature and character of this case all the points are interlinked to each other and as such all the points are taken up together for consideration for the sake of brevity and convenience.

On perusal of the materials along with the supporting affidavit related to documents available in the case record as well as hearing of argument by the Ld. Advocate for the Complainant, BNA filed by the both sides. It is revealed from the record that the Complainant is a policy holder of the National Insurance Company of the OP no. 1 & 2.

Here the status of the OP no.1to4 are service provider and the Complainant being a customer of the OP no.1to4, so the Complainant becomes a consumer as per Consumer Protection Act, 2019. The Complainant residing at – 11/A, Nimchand Karar Street, Ariadaha, Police Station – Belghoria, Kolkata – 700057, District North 24 Parganas and the claimed amount does not exceed the pecuniary limit of this Commission. Therefore, this Commission has ample jurisdiction to try this case.

The Complainant filed all documents which was supplied by the CMC, Vellore as per written Version filed by O.P. No. 1 and 2 the O.Ps admitted that insured submitted complete documents along with filed a claim from seeking reimbursement of expenses incurred for Rs. 1,48,025/- and the claim filed was reviewed by TPA and the TPA repudiated under clause 4.13. It is admitted fact that the treating doctor Mr. Prasad Mathew who advised to admit her is very much efficient. The relevant paper issued by the CMC, Vellore and it was submitted by the Complainant to the insured company. The mentioned paper is in the case record.

We have perused the complaint as well as Examination-in-Chief and all documents from Christian Medical College Vellore filed by the Complainant. We have perused the copy of the money receipt along with copy of the certificate which was provided by the Christian Medical College Vellore, discharge certificate from Christian Medical College Vellore and admission order from Christian Medical College Vellore and other documents filed by the Complainant. It is admitted fact that the Complainant admitted on 16.03.2016 and discharged from that hospital i,e Christian Medical College Vellore on 28.03.2016.

The discussed points bear positive results. As such we are of the view that the Complainant is entitled to receive his claimed amount with interest and he is also entitled to other relief/reliefs and that will be reflected in the ordering portion. There is gross negligence in the part of the O.Ps.

Thus all the points are disposed of accordingly.

Hence, for ends of justice:

It is Ordered

That the instant case being no.CC-75/2018 be and the same is allowed against the OP No. 1 to 2 and exparte against the O.P no. 3&4.

The O.Ps are directed to pay to the Complainant, Sri Jnanabrata Ganguly as decreetal amount of Rs.1,48,025/- with 6% interest within 03 (three) months from the date of this

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judgment. The Complainant also do get a decree of Rs.5,000/- as compensation and litigation cost of Rs.3,000/-, failing which the Complainant do get the decree with another  6% interest on the total decreetal amount from the date of filing of this case till realisation.

In default the Complainant is at liberty to put this decree into execution according to law.

Let plain copy of this order be given to the parties free of cost as per the CPR, 2005.

Dictated & Corrected by

           Member                                                                                                                                    

           Member                                                                                            Member