This case has been filed U/s.12 of the Consumer Protection Act, 1986 filed by the complainant, Smt. Aroti Paul.
The case of the complainant’s in short is that complainant purchased one Mediclaim Policy from the opposite party No.1 on 18.3.2002 and subsequently it was renewed thereafter and lastly it was renewed on 22.3.2015 vide policy No.512501/34/14/2500001448 and the policy period was 22.3.2015 to midnight of 21.3.2016 and the sum insured amount was Rs.2,00,000/-. The payment of premium was Rs.14,607/- only.
During the continuation of policy the complainant felt a severe pain and weakness for five to seven days and accordingly she suffered from pain in whole of back and knee and when there was no sign of relief she consulted with her physician Dr. Sisir Kr. Mandal on 18.7.2015 for her treatment. As the complainant was suffering from acute pain the doctor advised her to get admission and accordingly the complainant got admission on 20.7.2015 at Belle Vue Clinic. As per advice of Dr. Mandal some diagnostic test was done for diagnosis and further treatment. The son of the complainant informed the matter about ailment of the complainant to the opposite party No.1 through e-mail. The complainant was discharged from said Belle Vue Clinic on 22.7.2015 and the doctor of the said clinic prescribed several medicines.
Thereafter the complainant lodged claim by filing up claim Form along with all relevant documents before the opposite party No.1 for an amount of Rs.36,345/-. The opposite party received the claim form from the complainant on 31.7.2015. The complainant also filed additional claim before the opposite party No.1 for an amount of Rs.5,523/- and the said claim was received by the opposite party on 18.8.2015.
The opposite party No.3 sent two letters to the complainant on 17.9.2015 and 10.10.2015 informing her that claim of the complainant was repudiated stating inter-alia that ‘During the course of hospitalization there was no active line treatment which can justify the hospitalization of the patient. On 23.5.2016 the complainant by sending letter requested opposite party No.1 to 3 to review the claim that repudiated earlier. But there was no fruitful result comes out. The complainant also averred that from the discharge certificate of Bell Vue Clinic it is clear that the complainant was under the treatment of Dr. Sisir Kr. Mondal and the said doctor prescribed some medicines to the complainant to therapeutic procedure during the hospitalization of the complainant but the opposite parties came to the erroneous conclusion and /or findings regarding absence of the therauptic procedure during the hospitalization of the complainant and misutilizing the inappropriate clause of the policy condition intentionally and motivatedly frustrated the legitimate claim of the complainant. For the unauthorized act and willful inaction and omission on the part of the opposite parties the complainant has been suffering gross mental agony, anxiety and harassment along with huge monetary loss due to not receiving his rightful and just claim till now.
Finding no other alternative the complainant filed this case before this Forum for relief with prayer to direct the opposite parties to make payment of Rs.41,868/- (Rs.36,345/-+ Rs.5,523/-) along with interest @ 18% from 18.8.2015, to pay a sum of Rs.1,00,000/- towards compensation for mental pain and harassment, to pay Rs.15,000/- towards litigation cost to the complainant.
The opposite party, New India Assurance Co. Ltd. contested this case by filing written version denying inter-alia all the material allegations as leveled against it. This opposite party submits that after receiving the claim from the complainant, the said branch office of the company sent the aforesaid claim file with documents to TPA, the claim adjudicating authority as per terms and conditions of the said policy and the said TPA on receipt of the said claim file started to proceed with the settlement of the said claim and observed from the submitted documents that the patient/complainant was admitted for investigation only and also found that the expenses incurred/claim for was/were mere investigation only following inpatient hospitalization and the same are not covered under the scope of the said policy and as such the said claim was not payable. The TPA also found that the said patient/complainant admitted and diagnosed as a case of Osteoarthritis along with Respiratory Tract Infection and during the said course of hospitalization there was no active line of treatment and the said hospitalization and expenses incurred was solely for investigation purpose which was thus out of the scope of the policy. Hence, the said TPA rightly repudiated the claim following the exclusive clause 4.4.11 of the said policy condition. As the said claim was for expenses of investigation only, are not payable under the said policy. As such the New India Assurance Co. Ltd. has/ had no deficiency of service in the instant case on the ground as stated above and as such the claim of the complainant should be dismissed with cost.
The opposite party, TPA also contested this case by filing written version denying all the allegations as leveled against it. This opposite party submits that from the submitted documents it is evident that the patient was admitted for investigation only. As expenses incurred for mere investigation following inpatient hospitalization are not covered under the scope of the policy, hence the claim is not payable. Internal remarks-case history- patient admitted and diagnosed as case of Osteoarthritis along with respiratory tract infection. During the course of hospitalization there was no active line of treatment which can justify the hospitalization of the patient. Only medicine of Rs.295/- administered whereas the total incurred hospital bill is Rs.36,345/-. Hence, it is very much obvious that hospitalization regarding this patient is solely for investigation purpose which is thus out of the scope of the policy and hence stands repudiated vide exclusion clause 4.4.11 of NIA 2012 policy condition. This opposite party communicated the aforesaid decision of repudiation of the claim vide letters dated 17.8.2015 and 17.9.2015 to the complainant and also to the opposite party No.1 & 2. The opposite party No.2 by its letter dated 24.9.2015 has confirmed the recommendation of the opposite party No.3 and as per instruction of the opposite party No.2, the opposite party No.3 has issued the letter of repudiation of the claim. Hence the case.
ISSUES/POINTS FOR CONSIDERATION
1). Whether the Complainant Smt. Aroti Paul is a ‘Consumer’ of the opposite party?
2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?
3).Whether the O.Ps carried on unfair trade practice/rendered any deficiency in service towards the Complainant?
4).Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to her?
DECISION WITH REASONS
In the light of discussions here in above we find that the issues/points should be decided based on the above perspectives.
(1).Whether the Complainant Smt. Aroti Paul is a ‘Consumer’ of the opposite party?
From the materials on record it is transparent that the Complainant is “Consumer” as provided by the spirit of section 2(1)(d)(ii) of the Consumer Protection Act,1986.The complainant herein being the customer of the OP insurance company i.e. OP No.1&2 and opposite party no.3 is the TPA of insurance company entrusted to investigate the claim of policy holder, so being consumer she is entitled to get service from the opposite Company.
- Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?
Both the complainant and opposite parties are residents/carrying on business within the district of Hooghly. The complainant prayed for a direction upon the opposite parties to pay thebalance of mediclaim of Rs.41,868/- to the complainant, compensation against the opposite party of Rs.100,000/- for mental agony and harassment and litigation cost amounting to Rs.15,000/- ad valorem which is within Rs.20,00,000/- limit of this Forum. So, this Forum has territorial/pecuniary jurisdiction to entertain and try the case.
- Whether the opposite party carried on Unfair Trade Practice/rendered any deficiency in service towards the Complainant?
The opposite party being the largest Insurance Company associated with the insurance of a lot of people of throughout the whole nation since a long back with self generated assets i.e. goodwill of the business. So, the credibility of the opposite party Insurance Company is unquestionable and that is why the complainant insured her life before the said company without any doubt.It is well settled proposition of law that a contract of insurance is based on the principles of utmost good faith-uberrimae fidei applicable to both the parties. The rule of nondisclosure of material facts vitiating a policy still holds the field. The bargaining position of the parties in a contract of insurance is unequal. The insured knows all the facts, the insurer is unaware of anything which may be material to the risk. Very often, it is the insured who is the sole person who has this knowledge. The insurer may not even have the means to find out facts which would materially affect the risk. The law, therefore, enjoins on the insured an absolute duty to disclose correctly all material facts which is within his/her personal knowledge or which he ought to have known had he made reasonable inquiries. A contract of insurance, therefore, can be repudiated for non disclosure of material facts.
The case of the complainant is that she purchased one mediclaim policy from the opposite party No.1 on 18.3.2002 and subsequently it was renewed thereafter and lastly it is renewed on 22.3.2015.The policy No.512509/34/14/2500001448 valid from 22.3.2015 to 21.3.2016 and the sum assured is Rs.2,00,000/- and the premium fixed Rs.14,607/-. During the period of continuance of said policy she suffered severe pain and weakness and consulted with her physician Dr. Sisir Kumar Mondal on 18.7.2015 for her treatment and as per his advice she took admission on 20.7.2015 at Belle Vue Clinic, where a few diagnostic test was done for diagnosis and further treatment and also given some medicines.She discharged from the said clinic on 22.7.2015 and thereafter informed the opposite party regarding her treatment through email. During the period of staying at hospital a sum of Rs.41,868/- expensed for her treatment. Then she filed claim form before opposite party No.1 along with relevant documents and papers. After a few days she received letter from opposite party No.3 in respect of repudiation of her claim. From the letter she came to know that during the course of hospitalization there was no active line treatment which can justify the hospitalization of the patient. Thereafter, she wrote letters to opposite party No.1, 2 & 3 requesting to review her claim.But opposite parties failed to consider her claim as a result she preferred the recourse of this Forum praying directions upon the opposite parties as envisaged in the prayer portion of the complaint petition.
Opposite party No.1, 2 & 3 filed written version followed by evidence on affidavit and written argument in which they assailed that after getting the claim file from the complainant the opposite party insurance company sent the claim file to TPA.After investigation TPA found that the said patient/complainant admitted and diagnosed as a case of Osteoarthritis along with Respiratory Tract infection and during the course of hospitalization there was no active line of treatment and the said hospitalization and expenses incurred was solely for investigation purpose which was out of the scope of the said policy. According to opposite party insurance company said TPA rightly repudiated the said claim following the exclusion clause 4.4.11 of the said policy condition.As the claim was for expenses of investigation only so it is not payable under the said policy.As such the opposite party insurance company is not deficient in providing service to its consumer by repudiating the claim of the complainant.
After perusing the complaint petition, written version, evidence on affidavit and documents in the case record and hearing the arguments advanced by the Ld. Advocates of both sides, it appears that there is no dispute regarding the admission of the complainant in the Belle Vue Clinic as per advice of treating doctor.Dispute cropped up in between the complainant and the opposite party insurance when the claim of the complainant turned down with a remark that “patient admitted and diagnosed as case of osteoarthritis along with respiratory tract infection during the course of hospitalization there was no active line of treatment which can justify the hospitalization of the patient. Only medicine of Rs.295/-administered on the complainant.Whereas the total hospital bill is Rs.41868/-. Hence, it is very much obvious that hospitalization regarding this patient is solely for investigation purpose which is thus out of the scope of the policy and hence stands repudiated vide exclusion clause 4.4.11 of Mediclaim 2012 Policy Condition” vide letter dated 10.10.2015.It appears from the Mediclaim 2012 Policy Document Sec.4.4.11 that ‘Charges Incurred at Hospital primarily for diagnosis, X-ray or Laboratory Examination or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any illness or injury for which confinement is required at a hospital.” The complainant referred the case decision, Mohan Sethia Vs. Branch Manager United India Insurance Company Ltd., SCDRC, Raipur, Chattisgarh being appeal No.FA/12/09. In which Hon’ble State Commission directed the Insurance Company to pay hospitalization and medicine bill to the complainant.
The opposite party No.1 & 2 in their written version, evidence on affidavit and argument assailed that as theopposite party No.3 i.e. TPA being the investigating authority in respect of settlement of claim repudiated the claim of the complainant vide letter dated 10.10.2015 so they are on the same opinion to repudiate the claim of the complainant.As the treatment of the complainant need not admission in the hospital, so the hospitalization of the complainant is not essential. The opposite party No.1 & 2 put their leg in the exclusion clause 4.4.11 of policy condition which runs ‘Charges Incurred at Hospital primarily for diagnosis, X-ray or Laboratory examination or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any illness or injury for which confinement is required at a hospital’.From the document in case record andfrom the admission of the opposite party on record it appears that complainant was admitted in the hospital/nursing home under the doctor to remove her suffering and was in the hospital for the period mentioned herein before.It is not expected from the opposite party No.3 to put any question regarding the line of treatment of a doctor while settling the claim of the complainant.So, the reason shown by the opposite party No.3 is not acceptable and devoid of merit. The complainant obviously entitled to get cost of expenditure of any treatment whatsoever in the hospital or nursing home. The repudiation is not justified and utter negligence to the spirit of the law of the country.Thus the opposite party No.1 & 2 is under liability to pay the amount expensed during the period of hospitalization including treatment and investigation to this complainant. The complainant prayed that a sum of Rs.41,868/- expensed for her treatment and the document of expenditure produced before the opposite party No.3 for settling her claim is deserved to be allowed.This Forum is in the opinion to allow the claim of the complainant amounting to Rs.41,868/- including interest @8% p.a. since the date of repudiation till realization and others as this Forum deems fit and proper.
4). Whether the complainant proved her case against the opposite party, as alleged and whether the opposite party is liable for compensation to her?
The discussion made herein before, we have no hesitation to come in a conclusion that the Complainant has abled to prove her case and the Opposite Party No.1&2 are liable to pay compensation for mental pain and agony of the complainant. As the interest is allowed for compensation so there is no question to allow compensation separately.
ORDER
Hence, it is ordered that the complaint case being No.170 of 2016 be and the same is allowed on contest against the opposite party with a litigation cost of Rs.8,000/-.
The Opposite Party is directed to pay a sum of Rs.41,868/- with interest @8% p.a. from the date of repudiation of claim on 10.10.2015 till the realization, to this complainant.
All the payments are to be made within 45 days from the date of this order.
At the event of failure to comply with the order the Opposite Party shall pay cost @ Rs.100/- for each day’s delay, if caused, on expiry of the aforesaid 45 days by depositing the accrued amount, if any, in the Consumer Legal Aid Account.
Let a plain copy of this Order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/ sent by ordinary Post for information & necessary action.
