COMPLAINT CASE NO. – CC/381/2019

1. DR. KOYELA MONDAL

W/O MR. UTTAM KUMAR PAUL

UTTARAYAN, VILL. & P.O.- DEBANANDAPUR

DIST.-HOOGHLY, PIN-712123.

PRESENTLY RESIDING AT

C/3 NIMAK MAHAL ROAD, P.S.- WEST PORT

KOLKATA – 700 043.

                                                                                                    ………………….. COMPLAINANT

Vs.

1. THE ORIENTAL INSURANCE COMPANY LIMITED

REGISTERED & HEAD OFFICE AT A-25/27

ASAF ALI ROAD, NEW DELHI-110002.

REGIONAL OFFICE AT

1/4 LYONS RANGE, P.S.-HARE STREET

KOLKATA-700001.

2. MEDI ASSIST INSURANCE TPA PVT. LTD.

OFFICE AT THAPAR HOUSE (8^TH FLOOR)

25 BRABOURNE ROAD, P.S.-HARE STREET

KOLKATA – 700 001.

                                    ………..…….….. OPPOSITE  PARTIES

                         PRESENT — SRI  SWADES  RANJAN  RAY

                                                                               President

                                                MRS.  SAGARIKA  SARKAR

                                                                                Member

                                                SRI  SADANANDA  SARKAR

                                                                                 Member

                      ADVOCATE FOR THE COMPLAINANT – TARUN  JYOTI  BANERJEE

DATE OF FILING – 03.12.2019

JUDGEMENT

Date –  07.10.2021

SRI  SWADES  RANJAN  RAY

                                 President

Facts of this case in short is that, the Complainant is a Doctor, now posted at Medical Collage and Hospital, Kolkata.  Due to Gallbladder polyp and intramural fibroid, Complainant suffered acute abdominal pain with fever.  As a result, complainant got herself admitted in Srijoni Healing Home Private Ltd. under advice and care of Dr. R.N. Mukherjee, D.G.O. (Cal) M.D. (G&O) (Cal) on 10.06.2019.  After certain pathological test, operation of D/C and Laparoscopic Myomectomy was done on 10.06.2019 by Dr. R.N. Mukherjee under general anesthesia.

That on 13.06.2019 the Complainant was discharged from the nursing home with some advice and post operative treatment was done by Dr. R.N. Mukherjee and thereafter, on 17.06.2019, Dr. R.N. Mukherjee issued fit certificate in favour of Complainant.

During the period of treatment, Complainant had a valid Mediclaim Policy having Policy No. 311702/48/2020/61 and made a claim of ₹1,11,879/- and the insurer claim was registered as 311702/48/2020/000113.  That as per queries of O.P.s, Complainant supplied all the necessary papers and also gave proper reply of the queries of O.P.s. 

That on 30.08.2019, O.P. No.-2 sent a settlement letter to the Complainant regarding the claim amount of ₹38,000/- only instead of ₹1,11,879/-.  Subsequently, O.P. paid ₹38,000/- through online.  Complainant did not agree or accept or did not give the consent in respect of money transfer of ₹38,000/- and thereafter, Complainant made a claim for remaining amount i.e. ₹73,879/- and requested the O.P. to disburse the said amount.  But the O.P. remained silent without any step.  Thereafter, Complainant served legal notice through her Advocate, Mr. Tarun Jyoti Banerjee.  In spite of legal notice O.P. did not take any step.

Hence this case,

After receiving the notice, O.P. No.-2 remained absent without any step.  As a result, this complaint case proceeded ex parte against O.P. No.-2. 

O.P. No.-1 (Oriental Insurance Co. Ltd.) contested this case and filed Written Version (W/V) and thereafter filed questionnaire and accordingly, Complainant gave reply of the questionnaire.  Thereafter, O.P. No.-1 and O.P. No.-2 remained absent and this Commission considered the hardship and suffering of the Complainant and for the purpose of speedy disposal, liberty to file the reply of questionnaire by O.P. No.-1 has curtailed and the case was fixed for disposal on merit.

In the W/V, O.P. No.-1, denied all the statement made against O.P. No.-1 and it is the case of the O.P. No.-1 that Complainant is a policy holder under O.P. No.-1 and regularly pay the premium.

That the Complainant was well aware of the fact that Hospitals/Nursing Home in the Preferred Provider Network (P.P.N.) list have agreed the terms and condition of the insurance company regarding the P.P.N. enlisted nursing home and hospital.  Complainant choosed the nursing home i.e. Srijoni Healing Home Private Ltd. which is enlisted in the P.P.N. list.  As per P.P.N. list, maximum charge has been mentioned for surgery or treatment.  Accordingly, Complainant availing the hospital under P.P.N. list.  As per P.P.N. list charge for Myomectomy surgery is maximum of ₹38,000/-.  As the Complainant got herself admitted for surgery of Gallbladder stone which is a 2^nd surgery, as per P.P.N. list 2^nd surgery is 50% of the P.P.N. chart.  The 2^nd surgery as per P.P.N. chart is ₹13,000/-.  Accordingly, insurance company approved ₹6,500/- for the 2^nd surgery and informed the Complainant whether she is willing to take to amount or not.

There is no latches on the service of the O.P. and Complainant willingly admitted in the nursing home under the P.P.N. list and Complainant is bound by the terms and condition of the agreement as per P.P.N. list.  Complainant cannot claim the amount more than the price mentioned in the P.P.N. list.  Hence, Complainant has no cause of action to file this case and the case is liable to be dismissed.

Points for decision

1. Whether complainant has any cause of action to file this case or not?
2. Whether there is any deficiency of service on the part of  O.P.s or not?
3. Whether complainant is entitled to get any relief / reliefs as prayed for or not?

Decision with reason

All these points are taken together for sake of convenience and brevity.

I have carefully perused the complaint, Written Version, Questionnaire and the available documents of Complainant and the O.P.

It is the case of the Complainant that she has no knowledge that the Srijoni Healing Home Private Ltd. is enlisted under P.P.N. list.  Moreover, Complainant did not get cashless benefit as per terms of the P.P.N. list.  The only question before this Commission that whether the amount claimed by the Complainant though it is more than price list of P.P.N. list, will entitle or not?

Now the question before this Commission who will decide the Myomectomy surgery is a major surgery or not? And the 2^nd surgery is also fall under the major surgery or not?

O.P. No.-1 decided this point on the basis of the reports submitted by O.P. No.-2.  O.P. No.-2 did not disclose on what basis they came to this conclusion.  Moreover, O.P. No.-2 did not appear and contest this case.  On the other hand, Complainant clearly stated that both operations are major operation and these operations come under the general anesthesia.

Moreover, O.P. No.-1 stated that it is a option of the parties to chose whether he / she will chose the cashless benefit or not.  If the claimant chooses that he / she did not take the cashless benefit. Now who will be decided that the amount claimed by the Complainant is scientifically justified or not? The claim made by the Complainant should be verified by a competent person i.e. a person who is in medical practice. There is no evidence to this Commission that the O.P. No.-2 verified or examined the claim of the Complainant by the competent authority which includes a medical practitioner or medical expert. And he / she should be examined or verified what service and facilities are provided to the Complainant by the hospital authority during the operation.  There is no iota of evidence that O.P. No.-2 or O.P. No.-1 visited and examined the said nursing home (Srijoni Healing Home Private Ltd.) by their experts. O.P. No.-1 took the final decision on the basis of the report of O.P. No.-2, without any proper verification by the expert committee. So, in my view, O.P. No.-1 and O.P. No.-2 cannot deny the claim of the Complainant which she incurred at the time of operation.

Moreover, when a policy holder chooses that he/she will not get the cashless benefit from the P.P.N. enlisted Hospital / Nursing Home, these should be a clause that the expenses incurred by the policy holder should be examined and verified by Committee of medical expert and according to opinion of Committee of medical expert, policy holder should be entitled the entire claimed amount or certain percentage of claimed amount.  If there is no such clause in Policy agreement, there is a probability for taking whimsical bias and unjustified decision taken by claim sanctioning authority.

India is welfare country and object of mediclaim policy is to overcome the financial crisis during the treatment of the patient.

I do not find any clause in the document supply by the O.P. No.-1.

Hence, in my view, the claim of the Complainant is justified and according to law. By giving lesser amount is amount to a deficiency of service on the part of the O.P. No.-1 and O.P. No.-2.

Hence, Complainant has a cause of action to file this case.  As a result of which, Complainant will entitle relief accordingly.

All these point disposed of in favour of Complainant accordingly.

In the result, this complaint case succeeds.

Court fee paid correct.

Hence, it is

                                O R D E R E D

that the Complaint Case be and the same is allowed on contest against O.P. No.-1 and ex parte against the O.P. No.-2.

O.P. No.-1 and O.P. No.-2 are jointly and severally liable to pay 90% of the claim amount (i.e. 90% of ₹1,11,879/-) ₹1,00,691/- (Rupess One Lakh Six Hundred and Ninety One only) along with  interest @ 5% from the date of filing of this case i.e. 03.12.2019 till the date of realization of the entire decreetal amount, and also jointly and severally liable to pay compensation of ₹5,000/- (Rupees Five Thousand only) for mental pain and agony and also jointly and severally liable to pay litigation cost of ₹5,000/- (Rupees Five Thousand only).  The payment should be made within 3 months from the date of this order.

The amount already disbursed by O.P. No.-1 should be deducted from the total claim amount.

In default of payment of above mentioned amount within stipulated time, liberty given to the Complainant to file Execution Case for realization of the same.

Hence, this complaint case is disposed of accordingly.

Let a copy of this judgement be handed over to all the parties at free of cost.