This case has been arising out of the complaint filed by the complainant against the O.Ps named above u/s. 12 of the Consumer Protection Act, 1986.
The case of the complainant is that the complainant is a businessman deals with medicine under the name and style Bhagawati Medicals. The complainant has purchased Health Insurance Family Policy being No. 51230034182800000012 from the O.P No. 1 on 22/04/2003 through its agent O.P No. 3. On 22/04/2010 the complainant renewed his Health Insurance Family Policy from the O.P No. 1 and added his minor son Gavreet Agarwal which is still continuing. The complainant is regularly paying the premium since its inception. On 18/04/2018 the son of the complainant became ill and he was treated at Alipurduar by one child specialist Dr. Arundhati Sanyal and his child was also treated by Dr. Jaydeb Ghosh on 08/12/2018. The son of the complainant was not cured at Alipurduar and the complainant was advised by the said doctor to shift for better treatment and being advised by the doctor of Alipurduar the complainant took his minor son at the Super Specialty Hospital “Medanta-The Medicity” situated at Sector-38, Gurgaon(Haryana) on 14/01/2019 where his son was admitted under Dr. Nilam Mohan and Team for treatment. He was discharged on 17/01/2019. The entire hospital bill was paid by the complainant himself. Thereafter, the complainant has submitted his health insurance claim before the O.P No. 1 with relevant papers and documents. O P. No. 1 acknowledges the claim which was registered Vide claim No. 97636664. The complainant was contacted with the O.P Nos. 1 and 2 in several times but the O.P No. 1 repudiated the claim of the complainant on 01/08/2019 by serving a letter. Thereafter, the complainant applied before the Ombudsman on 04/01/2020 but no fruitful result came out. After receiving the repudiation letter complainant was shocked because he was deprived his genuine claim from the O.Ps. The complainant has prayed for direct the O.P No. 1 to pay the claim amount of Rs. 87,653/- and also pay compensation of Rs. 1,00,000/- for his harassment and mental agony and also to pay Rs. 30,000/- for visiting the office of the O.Ps on several times and also to pay Rs. 30,000/- as litigation costs.
The O.P No. 1 has contested the case by filing written version, evidence-in-chief and written argument. In his written version the O.P No. 1 as admitted that the complainant is the policy holder of Health Insurance Policy under then and it was since 2003 and he is paying the premium every year since then and the said insurance covered the complainant himself, his wife and his minor son. Regarding the claim of the complainant they stated that the child was admitted at the hospital “Medanta-The Medicity” only for investigation and evaluation purpose. The claim merits of repudiation as per clause 4.4.11 of the policy of the complainant as he is not entitled. He has denied all the allegations made by the complainant. He has prayed for dismissal of the case.
The complainant has filed evidence-in-affidavit and also filed written argument and documents.
We have perused the materials on record meticulously. Considering the above pleadings the following issues are necessarily come out to consideration to reach just decision of the case.
POINTS FOR CONSIDERATION
- Is the complainant a consumer u/s. 2(7)(ii) of Consumer Protection Act, 2019?
- Has this Commission jurisdiction to entertain the instant case?
- Have the O.Ps any deficiency in service as alleged by the complainant?
- Is the complainant entitled to get any relief/reliefs as he prayed for?
DECISION WITH REASON
Considering the nature and character of the case all the points are taken up together for consideration for the sake of brevity and convenience.
Point Nos. 1 and 2:- This two points for taken up together. The O.P No. 1 did not raise any objection regarding the status of the complainant as a consumer and also jurisdiction of this commission. After careful scrutiny of the case record we find that as per provision of Consumer Protection Act the complainant is a consumer as he has purchased the Health insurance by making payment of premium and this Commission has the jurisdiction to try this case.
Point Nos. 3 and 4:- In this case it is not disputed that the complainant is the valid policy holder of health insurance policy under O.P No. 1 and he is making payment regularly since 2003 and this policy have covered complainant himself, his wife and minor child. It is also not disputed that since 2003 no claim has been initiated prior to the present claim by the complainant. From the case record of evidence as well as the annexure we find that the minor child of the complainant became ill and he was treated by the local doctor on 18/04/20218 Annexure - 5 is the document to prove the same. Annexure - 6 also proved that on 08/12/2018 the minor child of the complainant was treated by another Dr. Jaydeb Ghosh of this locality. But the child was not cured as treated by the local doctors then the complainant took his child to Gurgaon(Haryana) at “Medanta-The Medicity” hospital for treatment. The child was admitted on 14/01/2019 for medical treatment under the Dr. Nilam Mohan and the child was admitted with a pain of abdomen for last two years and other ailments. At hospital several investigations were done by the doctors in course of the treatment of the child thereafter, the child of the complainant was discharged on 17/01/2019 after treatment by the doctors and Annexure – 7 (collectively) is the documents which proved the treatment of the child at “Medanta-The Medicity”. Thereafter, the hospital placed the bill of Rs. 82,002.86 /- including the critical care charges, Radiologist charges and Room charges etc. The complainant has paid the said amount from his own credit card. Thereafter, the complainant filed his claim petition before the O.P No. 1 along with other medical documents but the O.P No. 1 ultimately, repudiated the claim of the complainant only on the ground that the admission of the patient was for investigation and evaluation purpose.
Ld. Advocate for the O.P No. 1 refer the guidelines of Medi-claim of rule 4.4.11 that the complainant is not entitled to get his claim as because at hospital several investigations were done only like blood test etc. We find from the documents as well as the evidence that the child was suffering from abdominal pain since last two years and he was treated as local doctors but not cured and ultimately, he went to Gurgaon(Hariyana) “Medanta-The Medicity” hospital with his child where the doctor took admission of the child on 14/01/2019. Treatment was started there and several investigations were done and we find that this investigations and evaluation were done in course of treatment. He was admitted in critical care unit and after completion of the treatment the child was discharged on 17/01/2019. From the hospital the discharge summary is proved the same that he was treated under pediatric gastro team Headed by Dr. Nilam Mohan. From these documents we find that the child was admitted for his treatment as he was suffering from abdominal pain for last two years several investigations were done in course of the said treatment. So, it is not for investigation or evaluation only it is for the treatment of the child as he was suffering from ailments including the abdominal pain for last two years. The investigation which was done at the hospital at “Medanta-The Medicity” was the part of the treatment. The O.P No. 1 can not refuse the claim only because the investigation was done at the hospital. The O.P did not consider the treatment advance by the doctor at the hospital to the child and the investigations were done in course of that treatment. The O.P No. 1 has repudiated the claim of the complainant only on flimsy ground. The repudiation of the claim by the O.P No. 1 is nothing but in deficiency in service as defined in Consumer Protection Act. The O.P No. 1 has taken the premium since 2003 from the complainant but when the claim has come to O.P No. 1 he flatly repudiated taking the plea that the hospitalization was done for the investigation purpose which was not correct. If the O.P No. 1 is refused to pay the claim amount in a flimsy ground then in future no person will be interested to purchase the health insurance.
After careful scrutiny of the entire evidence on record we find that the child of the complainant was admitted at “Medanta-The Medicity” hospital for his treatment as he was suffering from abdominal pain and other ailments for last two years. At first he was treated as local doctors thereafter he went to “Medanta-The Medicity” hospital. Where in the child was admitted in a critical care unit treatment was started several investigation was done in course of that treatment and ultimately, he was discharged. The complainant has filed the claim petition along with all medical papers but the O.P No. 1 after a long period repudiated the claim of the complainant on the ground of the admission of the patient was only for investigation and evaluation purpose which is not correct. The complainant paid the all hospital bills and he has submitted the claim in respect of the said hospital bills but the O.P No. 1 has refused the said claim. It is a clear case of deficiency of service from the side of the O.P No. 1 and we find that the complainant is entitled to get the claim amount. There is laches from the part of the O.P No. 1 and the complainant was harassed and he was suffering from mental agony and he also entitled to get compensation of Rs. 50,000/- for that and he also entitled to get Rs. 20,000/- as litigation costs. The complainant is also entitled to get interest @ 6% Per annum on the claim amount from the date of claim till the realization of the amount. The above two points are hereby discussed and disposed of in favour of the complainant.
O.P No. 3 did not contest the case after receiving the notice. No notice was served upon O.P No. 2.
Thus all the points are disposed of accordingly.
Hence, for ends of justice; it is;-
ORDERED
that the instant case be and same is allowed on contest against the O.P No. 1 and ex-parte against O.P No. 3. The case is dismissed against O.P No. 2 as there is no claim or allegation against him. The complainant do get the award amounting to Rs. 87,635/- (Eighty Seven Thousands Six Hundred Thirty Five) for his claim of hospital cost along with interest of 6% Per annum from the date of claim to till the realization of the amount. The complainant is also do get an award amounting to Rs. 50,000/- (Fifty Thousands) as compensation for his harassment, mental agony and sufferings and also Rs. 20,000/- (Twenty Thousands) as his litigation costs; total decreetal amount of Rs. 1,57,635/- (One Lakh Fifty Seven Thousands Six Hundred Thirty Five) excluding interest. The O.P No. 1 is hereby directed to comply this order within 30 days from this day, failing which legal action will be taken against him. There is no direction upon the O.P No. 3 as he acted as a Agent of O.P No. 1 and did not receive any amount from the complainant personally.
Let a copy of this final order be sent to the concerned parties through registered post with A/D or by hand forthwith for information and necessary action.
Dictated & Corrected by me
