IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
MURSHIDABAD AT BERHAMPORE.
CASE No.CC/14/2014
Date of Filing: 16.01.2014. Date of Final Order: 24.08.2016.
Complainant : Sujit Pramanik, S/O Late Ashoke Kumar Pramanik, 69/33/A, Ukilabad Road,
P.O.&P.S. Berhampore, Dist. Murshidabad.
-Vs-
Opposite Party: 1. The General Manager, The New India Assurance Co. Ltd.
P-163, VIP Road, Ultadanga, Kolkata-54.
2. The C.E.O. Medicare TPA Service(I) Pvt Ltd,
6, Bishop Lefroy Road, Kolkata-700020.
Present: Sri Anupam Bhattacharyya…....................... President.
Sri Samaresh Kumar Mitra ……………………..Member.
Smt. Pranati Ali ……….……………….……………. Member
FINAL ORDER
Sri Anupam Bhattacharyya, Presiding Member.
The instant complaint has been filed by the complainant u/s 12 of C. P. Act, 1986 praying for settlement of medi-claim for Rs.1,18,260.39 towards medical expenses incurred for treatment and compensation of rs.50,000/-
The complainant’s case, in brief, is that the complainant had a Mediclaim since 2010 having coverage of Rs.2 lacs each for self and for his wife and on 16.10.11 he sustained being fallen in the bathroom and on 17.10.11 he first attended before Dr. A. K. Bera, M.S. Ortho at Berhampore and ultimately he on 22.11.11 he was compelled to be admitted in Apollo Hospital at Chennai and was treated as indoor patient up to 27.11.11 spending Rs.1,18,260.39. But his claim submitted on 2.01.12 was repudiated by the OP No.1 with flimsy ground . Then, the complainant has filed the complaint. Hence, the instant complaint case.
The written version filed by the OP No.1-Insurance Company and OP No.2 , in brief, is that the impugned policy duration is less than two years and the policy has a waiting for PIVD and for that the claim is repudiated under Clause 4.3 of the policy There is no deficiency in service on the part of OPs. The claim is liable to be dismissed. Hence, the instant written version.
Considering the pleadings of both parties the following points have been fixed for the disposal of the dispute.
Points for consideration.
- Whether the complaint is barred by the law of estoppels, waiver and acquisance?
- Whether the case is barred by law of limitation?
- Whether there is any suppression of fact?
- Whether the complainant is entitled to get the relief as prayed for?
- To what other relief/reliefs the complainant is entitled to get?
Decision with reasons.
The instant complaint is for realization of medical expenses and compensation on the basis of medi-claim.
The complainant’s case, in brief, is that the complainant had a Medi-claim since 2010 having coverage of Rs.2 lacs each for self and for his wife and on 16.10.11 he sustained being fallen in the bathroom and on 17.10.11 he first attended before Dr. A. K. Bera, M.S. Ortho at Berhampore and ultimately he on 22.11.11 he was compelled to be admitted in Apollo Hospital at Chennai and was treated as indoor patient up to 27.11.11 spending Rs.1, 18,260.39. But his claim submitted on 2.01.12 was repudiated by the OP No.1 with flimsy ground inspite of submission of documents on 16.2.12 as per their demand by letter dt. 05.01.2012.
On the other hand the OPs’ case, in brief, is that the impugned policy duration is less than two years and the policy has a waiting for PIVD and for that the claim is repudiated under Clause 4.3 of the policy. There is no deficiency in service on the part of OPs.
To prove the case the complainant has adduced evidence supported by affidavit and has filed the relevant documents in support of his case including medical certificate dt. 29.01.12 mentioning that patient fallen in bathroom on 16.10.11 and sustained back pain.
On the other hand the OPs have filed written argument and relevant documents by firisti including Medi-claim policy 2007 of OP No.1 Insurance Co. and prescription of Dr. A. K. Bera dt. 02.11.11 and medical papers of Apollo Hospital at Chennai.
The OP’s main case is that the claim of the complainant of the instant case for the impugned policy was repudiated as per Clause 4.3.
Admittedly, the disease of the instant claim is Clause 16 under Clause 4.3 of the instant policy.
The period of duration for disease under Clause 16 provides prolapsed Inter Verterbral Disc unless arising from accident is two years.
From the above clause it is clear that if the disease arises as a result of accident then the duration of two years will not apply.
To come under the coverage of this policy the complainant’s case, is that suddenly he was fallen in the bath room on 16.10.11 as a result he sustained back pain and on 17.10.11 attended Dr. A.K. Bera , M.S. Ortho, Berhampore.
The Ld. Lawyer for the OP has advanced argument categorically challenging the alleged accident referring the all medical papers of Apollo Medical College & Hospital, Chennai and claimed petition of the complainant before the OP-Insurance Co. and the prescription of Dr. A. K. Bera, Berhampore dt. 2.11.11 and the same has been laid down in details in the written argument filed by the OP-Insurance Company.
There is no whisper about the history of such accident of falling in the bathroom on 16.11.11 causing such back pain.
To establish the case of accident the complainant has filed a medical certificate dt. 29.01.2012 under the letter head of Bone & Joint Clinic of Jeevan Deep where at the left margin there are printed names of two doctors 1. Dr. A. K. Bera and D. R. Sarkar but signature of doctor is illegible.
According to complaint case the complainant fell in the bathroom on 16.10.11 causing low back pain and attended to Dr. A. K. Bera on 17.10.11 and ultimately compelled him to be admitted in the Apollo Hospital at Chennai on 22.11.11 and discharged on 27.11.11 having surgery –Microdisecetomy L-4, L-5 and no history of pre-existing disease reveals from the Discharge Certificate of Apollo Hospital, Chennai but the complainant has failed to produce any prescription of Dr. A. K. Bera dt.17.10.11.
Where the OP has filed a prescription dt. 2.11.11 of Dr. A.K. Bera in favour of the complaint but there is no case as to fallen in the bathroom.
The C.P. Act is for protection of the consumers and this is an welfare legislation for the protection of the Consumers.
Also, this case under C.P. Act is a summary trial and strict proof by adducing evidence is not mandatory.
Admittedly, the complainant had under treatment of IVDP L-4, L-5 with Right Radiculopathy in the Apollo Hospital, Chennai having surery-Microdiscect L-5, L-5 being admitted on 22.11.11 and discharged on 27.11.11.
The medical paper of Apllo Hospital, Chennai submitted by the OP-Insurance Co, has not been challenged as manufactured one.
Considering the legislative approach of this particular Act and also considering the above facts and circumstance, we are of view that the principle of preponderance of probability is to be considered.
Considering the nature of treatment and surgery the certificate dt. 29.1.12 as to falling in the bathroom on 16.10.11 causing low back pain to the complaint cannot be ignored.
In the discharge certificate of Apollo Chennai in favour of the complainant there is nothing mentioned as to pre-existing any disease and cause of such disease.
Considering the above discussions we are of view that the treatment availed by the complainant including surgery in the Apollo Hospital at Chennai for the cause of falling in the bathroom i.e, for accident and for that accident the bar of two years duration is not applicable and as such the repudiation is bad and the complainant is entitled to get medi-claim policy.
Regarding the claim amount the complainant has simply mentioned the amount of claim as Rs.1, 18,260.39 in the claim application before OP-Insurance Company but he has not filed any vouchers or documents in support of such claim of medical expenses incurred for the said treatment in the Apollo Hospital at Chennai.
For absence of such documents we cannot ascertain the actual amount entitled by the complainant
But, we find that the complainant is entitled to get amount incurred towards medical expenses subject to production of the original vouchers and money receipts issued by the Apollo Hospital at Chennai and any other agency for the said treatment of the complainant.
Considering the above facts and circumstances the complaint is not entitled to get any compensation.
Hence,
Ordered
that the Consumer Complaint No. 14/2014 be and the same is allowed on contest in part.
The OP –Insurance Company Ltd is directed to ascertain the claim and make payment to the complainant, the cost incurred by the complainant for the said treatment within 2(two) months from the date of getting the original vouchers and money receipts issued by the Apollo Hospital and any other agencies.
The complainant is directed to submit the original vouchers and money receipts to the office of the OP-Insurance Company as early as possible.
Let a plain copy of this order be made available and be supplied free of cost, to each of the parties on contest in person, Ld. Advocate/Agent on record, by hand under proper acknowledgment / be sent forthwith under ordinary post to the concerned parties as per rules, for information and necessary action.
Member Member President
