Judgment : Dt.19.12.2017
Shri S. K. Verma, President
This is a complaint made by one Rathijit Bhattacharjee, son of Ramendra Mohan Bhattercharjee, residing at 19T, Naktala Road, Tanisha Apartment, 2nd floor, Kolkata-700 047 against The Manager, Claim Star Health and Allied Insurance Company Limited, OP No.1 and Star Health and Allied Insurance Company Limited, having their respective registered Corp Claim Offices situated at KRM Centre, VI floor, No.2, Harrington Road, Cheypet, Chennai-600 031 and having their Branch Office at Behala 2nd floor, 738/2, Diamond Harbour Road, Kolkata-700 008,OP No.2 praying for a direction upon the O.P. to disburse the claim amount raised by the Complainant and a direction to give litigation cost of Rs.50,000/- and also compensation to the tune of Rs.2,00,000/-.
Facts in brief are that Complainant is a policy holder of the OP No.2 company under Health Optima Policy No.P/191117/01/2016/006539 for the period from 3.12.2015 to midnight of 2.12.2016 which covered the Medical Treatment of Complainant upto Rs.3,00,000/-. Complainant started suffering from low back pain radiating to left lower limb with numbness and so he consulted with Dr. Amlan Mondal on 20.5.2016 where he was advised to take some medicines but he did not get any relief. Soon after Complainant consulted with another Doctor namely Dr. Rajiv Chatterjee an orthopaedics at Columbia Asia Hospital Salt Lake on 22.5.2016. From the diagnosis of both the Doctors, it became clear that Complainant suffered from immense low back and left leg pain which cannot be cured by medications. Copy of prescriptions are Annexure B. After that Complainant underwent MRI of L.S.SPINE on 14.7.2016 at Appollo Gleangles Heart Centre at Gariahat and the report revealed that Complainant was suffering from Lumber spondylosis with degenerative disc diseases. Thereafter, situation worsen and Complainant was operated at Fortis Hospital at Bangalore under Dr,. Dibanath Chakraborty on 18.7.2017. Complainant remained admitted at Fortis Health Management from 18.7.2016 to 24.7.2016. On 18.7.2016 Complainant’s wife Shreya Mukherjee Bhattacharjee filled up the form of OP No.2 for cashless hospitalisaion for medical insurance policy. On 23.7.206 OP No.2 sent a query letter and thereafter, another letter denying cashless treatment at the hospital. There it was stated that OP No.2 cannot disburse the amount of Rs.2,21,502/- on the ground that patient was suffering from Gilbert’s Syndrome from the age of 16/17. On 23.7.2016 Complainant wrote a letter to OP No.2 stating that he never suffered or was diagnosed with Gilbert’s syndrome. On 23.7.2016 Dr. Dibanath Chakraborty also wrote a certificate that Complainant neither suffered from Gilbert Syndrome nor he had any symptoms of that. Complainant submitted his claim to OP No2 with all the treatment papers and documents issued by the Fortis. In spite of receiving all papers, OPNo.2 issued letters dt.5.10.2016 and 21.10.2016 asking about treatment record of Gilbert syndrome. OP No.2 also demanded copy of complete set of Indoor Case paper which were not available to the Complainant in any manner, but, OP No.2 was in a position to collect from the hospital. Complainant never had Gilbert Syndrome. Complainant made several pursuation for reimbursement of his claim but OPs did not oblige. So, Complainant filed this case.
OPs filed written version and denied the allegations of the complaint. They have further stated that Complainant suppressed the facts and he had a pre-existing disease of Gilbert Syndrome. The Insurance policy purchased by the Complainant as per condition No.4 all original bills are to be returned by the OPs. Further, OPs have submitted that Complainant is not entitled to any compensation.
Decision with reasons
Complainant filed affidavit-in-chief wherein he has reiterated the facts mentioned in the complaint petition to which OPs have filed questionnaire to which Complainant filed affidavit-in-reply. OPs filed affidavit-in-chief wherein they have reiterated the fact mentioned in written version to which Complainant filed questionnaire to which OPs filed affidavit-in-reply.
Main point for determination is whether Complainant is entitled to the reliefs as prayed for.
On perusal of the prayer portion of complaint petition, it appears that the Complainant has prayed for disbursement of claim amount. This claim amount as per paragraph 15 of the complaint petition is Rs.2,21,502/-. A copy of Insurance Policy is filed as Annexure ‘A’ which reveals that the period of Insurance was from 3.12.2015 to 02.12.2016. Complainant was hospitalized for the period from 18.7.2016 to 24.7.2016. This makes it clear, Complainant remained hospitalized during the subsistence of the policy.
Further, Complainant has filed Xerox copy of the bills issued by Fortis Hospital and also other documents from where it is clear that Complainant underwent hospitalization and he was denied the expenses made therein.
It is settled position that Insurance Company charges excess premium for providing cashless treatment and for the cashless treatment the Insurance Co. allures the innocent persons and they deny to provide cashless facility which is fatal to a person. It is because a policy holder remains confident that in case of emergency hospitalisation he will be looked after through his policy but the OP boldly abandons patient and leave them on the mercy of the God to die in the nursing home or hospital where they remain admitted. This conduct clearly reveals that OP issues Mediclaim Policy for earning profit and not providing succor to the ailing patient. This is a clear instance of unfair trade practice by the OP. OP has taken a plea for denying the claim that Complainant was suffering from Gilbert’s Syndrome. On perusal of the report of the Doctor who operated it is clear that patient did dnot have a preexisting disease as alleged by OP and this is just an excuse to deprive the patient of his genuine claim.
It appears from the copy of the policy document that first policy was purchased on 3.12.2012 and as such the OP cannot take a plea that Complainant was suffering from Gilbert’s Syndrome from the age of 16.
So, we are of the view that OP is liable for the claim made by the Complainant as well as for the compensation and the litigation cost for the reason that OP deprived the Complainant of cashless treatment and indulged in unfair trade practice.
Hence,
ordered
CC/117/2017 and the same is allowed on contest. OPs are directed to pay to the Complainant Rs.2,21,502/- within two months of this order, provided Complainant files original receipts showing that his documents, receipts and prescriptions issued by Fortis Hospital are lying with the OPs. In addition, OPs are directed to pay compensation of Rs.1,00,000/- and litigation cost of Rs.25,000/- to the Complainant within the above mentioned period, in default total amount Rs.3,46,502/- shall carry interest @ 10% p.a. from the date of this order till realization.
