Date of filing : 14.07.2017

Judgment : Dt.13.12.2018

Mrs. Sashi Kala Basu, Hon’ble President

         This consumer complaint was originally filed by Narayan Chandra Chattopadhyay (Who died during pendency of the case and the present Complainant namely (1) Lily Chattopadhyay, (2) Kamalika Mukherjee and (3) Tulip Chatterjee being his legal heirs substituted in his place) against opposite parties namely (1) The National Insurance, Kolkata Division, (2) The Heritage Health TPA Pvt. Ltd., and (3) Sagar Bhattacharya, alleging deficiency in rendering services on their part.

            Brief facts of the Complainant’s case is that Narayan Chandra Chattopadhyay (since deceased) was holder of mediclaim policy being No.100600501610003203  and total insured sum was Rs.4,40,000/-. The policy was valid for the period from 08.10.2016 to 07.10.2017. He being patient of C.K.D. was admitted in Medica Super Specialty Hospital on 13.10.2016 due to anemia, raised TLC, raised CRP, raised urea creative level and was discharged on 03.11.2016. Said Narayan Chandra Chattopadhyay claimed medical expenses borne by him through the agent of OP No.1 namely Sagar Bhattacharya (OP No.3) to whom original documents were also handed over on his assurance to proceed with the claim benefit. But, all went in vain as the OP No.3 thereafter was not available. An amount of Rs.7,19,745/- was paid towards medical treatment by the Complainants. Opposite party had made query vide its letter dt.20.12.2016 and 09.01.2017 but, all the documents were already handed over to the OP No.3, the agent of OP No.1. As the OP No.1 did not pay the insured sum, a legal notice dt.21.4.2017 was sent to the opposite parties requesting to settle the claim but OP No.2 replied stating due to non-compliance of query, claim was closed and the file sent to U/W office dt.20.02.2017. So, being compelled, this complaint is filed praying for directing the opposite party to pay the insured sum of Rs.4,40,000/-, to pay compensation of Rs.4,00,000/- and litigation cost of Rs.50,000/-.

            OP No.1 contested the case by filing written version denying the material allegations made in the complaint contending inter-alia that this case is not maintainable as this Forum lacks the territorial jurisdiction. Complainant did not reply to the query by OP No.2 vide their letter dt.20.12.2016 and 09.01.2016 which is a violation of insurance contract. Actual eligibility of the sum insured of Rs.4,40,000/- would be subject to maximum, limit provided under the terms of the Policy. Thus, the OP No.1 has prayed for dismissal of the complaint petition.

            OP No.2 and 3 did not take any step in spite of serving notice and thus the case proceeded ex-parte against them.

            Complainant annexed with the complaint petition, copy of insurance, a certificate by the Doctor Medica Hospital, copy of letter dt.09.01.2017 and 20.12.2016 sent by OP No.2, medical document advising urgent admission, medical bills, medical Lab. Examination reports and discharge summery.

            In course of evidence, Complainant and OP No.1 adduced their respective evidence by filing affidavit-in-chief followed by filing questionnaire and reply thereto.

            Argument was advanced by both the parties and they also filed written notes of arguments.

            Following points thus require determination:-

            (1) Is this complaint maintainable in its present form?

(2) Whether there has been any deficiency in providing service by the opposite parties?

(3) Whether the Complainant is entitled to the relief as prayed for?

                                    Decision with reasons

            Point No.1

            It is contended by the opposite party No.1 that this Forum does not have territorial jurisdiction to try this case. According to OP No.1, cause title in the complain petition reveal that neither OP No.1 nor OP No.2 falls within the territorial jurisdiction of this Forum. It is urged that OP No.3 has been added as a party in this case only to bring the case within the territorial jurisdiction of this Forum. OP No.3 is neither a necessary party nor a proper party as he is only an agent who acts only on the principle and guidance of the principal the OP No.1. He cannot be involved in any way in a claim proceeding.

            On perusal of the complain petition it is evident that OP No.3 is an agent of OP insurer Company and Complainant Narayan Chandra Chattopadhyay (since deceased) had taken the National Mediclaim Policy on being approached by the opposite party No.3. According to Complainant OP No.3 had approached him to insure himself for medical benefit and he (OP No.3) had received the entire original documents relating to his treatment assuring him to settle the claim benefit and for the said reason, he could not submit the history sheet from hospital and past medical illness to the OP No.1 when asked. So, in the given facts and circumstances in this case, dispute does involve OP No.3 and as such, he being a resident within the territorial jurisdiction of this Forum, complaint is maintainable in its present form.

            Point No.1 is thus answered accordingly.

Point No.2 & 3

Both these points are taken up together for discussions for the sake of convenience and in order to avoid repetition.

Admittedly Complainant Narayan Chandra Chattopadhyay (since deceased and his heirs being substituted) was the holder of the policy for himself vide Policy No.10060050161003203 with sum insured amounting to Rs.4,00,000/- and calculative bonus of Rs.40,000/- valid from 08.10.2016 to 7.10.2017. There is also no dispute that the said Complainant was admitted in Medica Super specialty Hospital on 13.10.2016 and was discharged on 03.11.2016. It is evident from the discharge summary filed by the Complainant.

The fact that the Complainant had taken the mediclaim policy through OP No.3 an agent of OP No.1 is also not in dispute.

The dispute which has been raised by the OP No.1 is that two letters dt.20.12.2016 and 09.01.2017 were sent to the Complainant seeking additional documents i.e. (1) Zerox of history sheet from hospital, (2) History of Past medical illness with duration from the treating doctor but the same were not submitted, so they were not able to process the claim and thus ultimately same was closed.

Ld. Advocate for opposite party No.1 by drawing the attention of this Forum to the condition as stated in 5.5.3 & 5.5.4 of the Policy has argued that supply of medical history of the patient was to be filed with the claim within the prescribed limit and the T.P.A.  also could require any other document.

As already highlighted above that the Complainant had obtained the Policy through OP No.3 is not in dispute. So, it is but natural that he trusted him and handed over the document relating to his treatment which might also include the medical history in order to settle his claim. Since OP No.3 was admittedly an agent of OP No.1, there was no reason for the Complainant not to trust the OP No.3 and for that  reason Complainant did not ask for any acknowledgement regarding handing over of those documents to the OP No.3. There cannot be denial that OP No.1 being the Principal will be responsible for the act of his agent.

It may be pertinent to point out that Discharge Summary filed by the Complainant and which was also submitted before the OP No.1 is very categorical that the Complainant had undergone treatment from 13.10.2016 to 03.11.2016. Course of event in the hospital reads a follows – “This 67 years old known case of type 2 diabetes mellitus, hypertension, chronic kidney disease, BPH and IHD presented with shortness of breath, fever and accelerated hypertension. On admission his BP was 220/110 mmHg. Investigations revealed anemia, raised TLC(22620) raised CRP(317), raised urea (207), cr (6.33) level. Raiseds Trop 1 and NT pro BNP level. HRCT chest revealed bilateral air space consolidation & infiltrates distributed near diffusely in bilateral lungs leading to loss of architecture & septal thickening in keeping with pneumatisation, bilateral mild effusion with basal atelectasis. MRI brain showed no acute focal abnormality, age related diffuse cerebral atrophy with small vessel ischemic changes.

MRI cervical spine showed spondylotic changes, posterior protrusion at C4-C5 & C5-C6 levels. The disc osteophyte complex are causing thecala compression, impingement of bilateral traversing respective nerve roots, subtle bulge at C6-C7 level is causing thecal compression, no nerve root compression. He was on Bipap support. Echocardiography showed LVEF 44%. Cardiologist and Pulmonologist opinion was taken. HD was initiated through Rt IJV catheter on 16.10.2016. 2 units of PRBC transfusion done on 19.10.2016 and 1 units PRBC transfusion done on 21.10.2016. Treated with IV antibiotics. He had pain while defecation – coloscopy showed small haemorrhoids. Last HD was done on 29.10.2016. Now his urine output improved and no need of HD at present. Patient being discharged in hemodynamically stable condition.”

Final diagnosis was – “Type 2 diabetes mellitus, Hypertension, Ischemic heart disease. Benign prostatic hyperplasia, Atrial fibrillation, Lower respiratory tract infection, Anemia, Chronic kidney disease, Haemorrhoids”.

By reading the course of events and final diagnosis referred to above makes it clear regarding the ailment and the treatment of the Complainant. So, there remains no doubt that the Complainant did undergo the treatment and he had no justifiable reason not to submit the medical history and thus it leads to inference that the same was handed over to the agent OP No.3.

It may also be mentioned here that Complainants have also filed a certificate dt.19.01.2017 issued by Dr. Dilip Kumar Pahari, Vice-Chairman of Medica Institute of Kidney Diseases, wherein it has been stated that Narayan Chandra Chattopadhyay was a patient of CKD (Stage 5). So, the said certificate by the doctor reveals the history that Narayan Chandra Chattopadhyay was a known patient of CKD (Stage 5) i.e. chronic kidney disease.

Medical history and other related documents are required in order to know whether the claim falls within the exclusion clauses of the policy. A careful scrutiny of the policy, it appears that none of the ailment finally diagnosed by the hospital fell within the exclusion clauses. If that be so than not settling the claim and closure of the same is unjust and unreasonable. Thus for these reasons, there has been deficiency in services on the part of the opposite party.

Coming to sum claimed Complainants have filed the medical bill from which it appears that a sum of Rs.7,19,745/- was paid by the Complainant. Admittedly, insured sum was Rs.4,40,000/-. Ld. Advocate for the OP has argued that as per terms and conditions of the Policy, Complainant would be entitled to admissible cost of Rs.3,88,000/- as per maximum limit. On perusal of the condition regarding the coverage as provided in 2.1 (room charges), 2.2(medical practitioner’s fees) and 2.3 (other charges) there is maximum limit. Medical final bill filed by the Complainant reveals the charges paid towards the above mentioned categories. If it is calculated with the maximum limit provided under the policy than the argument of Ld. Advocate for the OP that an amount of Rs.3,88,000/- is admissible, cannot be discarded. However, Complainants are also entitled to compensation for the harassment and mental agony suffered by them together with the litigation cost. An amount of Rs.50,000/- towards compensation and litigation cost of Rs.10,000/- will be justified.

These points are thus answered accordingly.

Hence

                                        Ordered

CC/392/2017 is allowed on contest against OP No.1 and ex-parte against OP No.2 & 3.

OP No.1 is directed to pay Rs.3,88,000/- towards insured amount for providing medical health services within two months from the date of this order. OP No.1 is further directed to pay compensation of Rs.50,000/- and Rs.10,000/- towards litigation cost within the aforesaid period of two months in default the entire sum shall carry interest @ 8% p.a. till realization.