Dt. of filing : 31/01/2019
Dt. of Judgement : 22/02/2021
Mrs. Sashi Kala Basu, Hon’ble President
This consumer complaint is filed by the Complainant namely Maahrunnessa Kaneez under Section 12 of the Consumer Protection Act, 1986 against the Opposite Parties (referred as OPs hereafter) namely 1) The Manager, Royal Sundram General Insurance Co. Ltd., Millenium City Information Technology Park, Unit No.T-2-2A, Salt Lake, Kolkata-700091, 2) The Manager, Paramount Health Services & Insurance TPA Pvt. Ltd and 3) Royal Sundram General Insurance Co. Ltd., Vishranthi Melaram Towers no.2/319, Chennai-600097 alleging deficiency in service on their part.
Case of the Complainant in short is that Complainant is a holder of mediclaim policy under Royal Sundram General Insurance Co. Ltd., being Policy No.PLB000358000100. Complainant was admitted in Kothari Medical Centre twice on 16/10/2018 and on 24/10/2018 for infusion of iron injection as per advice of the concerned medical practitioner under “Day-Care Treatment” and she was discharged on the same day. A total sum of Rs.3,946/- only for both days towards medical expenses was borne by the petitioner. But when she wrote to the Opposite Party for its reimbursement on 10/11/2018 Opposite Party paid no heed. However on 29/11/2018 and 30/11/2018 by two letters Complainant was told that her claims were not payable and hence rejected due to “OPD treatment”. Again Complainant sent a letter on 8/12/2018 stating that it was a “Day Care treatment” and not “OPD”. But again on 14/1/2019 Opposite Party replied the same that the claim was not maintainable. Hence, the present case for directing the Opposite Parties to pay Rs.3,946/- along with interest @ 18% p.a., to pay compensation of Rs.20,000/- and litigation cost of Rs.10,000/- .
Complainant has annexed with the complaint copy of Insurance Certificate, Copy of the prescription of the Doctors, Bills, Claim Form, Letters of repudiation, Mails sent and the copy of the terms of the policy.
Opposite Party Nos. 1 & 3 have contested the case by filing the written version contending specifically that panel of Doctors of TPA Services disapprove the claim of the Complainant as the Complainant received the treatment only on OPD basis. So the Complainant is not entitled to the relief as prayed and thus they have prayed for dismissal of the case.
Opposite Party No.2 did not take any step and thus the case proceeded ex-parte against Opposite Party No.2.
During the course of the trial both parties have filed their respective affidavit-in-chief followed by filing of questionnaire and reply thereto and ultimately written argument has been filed by both the parties.
So the following points require determination:
- Whether there has been unfair trade practice on the part of the Opposite Parties?
- Whether the Complainant is entitled to the relief as prayed for?
Decision with reasons
Both the points are taken up together for a comprehensive discussion.
Complainant has claimed that she is holder of mediclaim policy and she was treated in Kothari Medical Centre on 16/10/2018 and 24/10/2018 for which she had to bear expenses of Rs.3,946/-. According to the Complainant she was admitted in the Kothari Medical Centre and as per advice of the concerned medical practitioner she was treated as “Day Care Treatment” and in terms of clause 3.4 of Section 3 of the policy, she is entitled to the reimbursement of the said medical bill. However Opposite Parties have contended that the Complainant was treated as a OPD patient and thus as per the same clause being 3.4 of Section 3 of the policy she is not entitled to any reimbursement. So, the dispute in this case is restricted to, whether the Complainant was admitted and treated as “Day Care Treatment” or whether she treated on “OPD” basis.
Clause 3.4 of Section 3 of the policy reads as follows:
“We will cover Medical Expenses of an Insured Person in case of Medically Necessary Day Care Treatment or Surgery that require less than 24 hours Hospitalisation due to advancement in technology and which is undertaken in a Hospital/Day Care Center on the recommendation of a Medical Practitioner. Any OPD Treatment undertaken in a Hospital/Day Care Center will not be covered. Pre and Post Hospitalisation Medical Expenses are not payable under this benefit.”
In support of her claim, Complainant has filed two prescriptions dated 16/10/2018 and 24/10/2018 wherein concerned doctors namely Dr. Joydeep and Ayan Mukhopadhyay have specifically mentioned “advice admission at Day Care”. So the said advice of the Doctors of the Kothari Medical Center is very categorical that the Complainant was adviced admission at Day Care. However, there is also mentioned in the prescription dated 24/10/2018 that care taken by Dr. Joydeep Porel at OPD. So in one of the prescription there is mentioned about the OPD. However, in both the prescriptions it is specifically mentioned that she has been advised admission even though at “Day Care”.
It may be pertinent to point out that the insurance is a contract and conditions contained in the policy is binding both on the insurer and insured and that no deviation can be done by either side after the operation of the policy. Insurance Company would be under the liability in the event clause in the policy have been violated. Mere mention of OPD in one of the prescription as highlighted above especially when the Doctors have mentioned “advice admission at Day Care” same cannot be considered as OPD Treatment. However even accepting the contention of the Opposite Parties than where there is possibilities of two interpretations than one in favour of policy holder has to be accepted. This came into consideration before the Hon’ble Apex Court in case of Sashi Gupta Vs Life Insurance Corporation of India wherein Hon’ble Apex Court held that it is trite law that in dispute relating to insurance policies, if there is possibility of two interpretations, then one which favours the policy holder is to be accepted by the Courts. So keeping in view the legal proposition in the above mentioned case law there remains no doubt that Complainant is entitled to the sum paid by her towards the treatment as Day Care of Rs.3,946/- and as due to non-payment by the Opposite Party of the said sum inspite of the repeated letters and emails sent, she is also entitled to the compensation for harassment and mental agony. So an amount of Rs.8,000/- as compensation and litigation cost of Rs.6,000/- will be justified.
Hence,
ORDERED
CC/70/2019 is allowed on contest against Opposite Party No.1 & 3 and ex-parte against Opposite Party No.2.
Opposite Parties are directed to pay Rs.3,946/- to the Complainant within two months from this date. They are further directed to pay compensation of Rs.8,000/- and litigation cost of Rs.6,000/- within the aforesaid period of 2(Two) months in default the entire sum shall carry interest @ 9% p.a. till realisation.
