Case No. CC/ 08/2020
FINAL ORDER/JUDGMENT
Sudeb Mitra, President:-
The epitome of the complaint case is that the complainant had obtained a mediclaim policy initiated from 23.09.2016 from the O.P. no 1 and the complt. was the insured person of that policy besides his wife Sobita Roy and son Rohan Roy and it was renewed vide policy no 311901/48/2018/1698, covering a period from 23.09.2017 to 22.09.2018 with the sum assured for Rs- five lakhs against premium of Rs- 7,173/- in total with the said mediclaim insurance policy, being initiated on 23.09.2016 continued from 23.09.2018 to 22.09.2019 uninterruptedly.
The complt’s case in short is that in the evening of 8th Aug 2018 he had abdominal pain and he was medically treated by Dr. Asit Basak, had undergone U.S.G. as per the concerned doctor’s medical advice on 11.08.2018 and it was detected that the complt. had developed acute Appendicitis with Appendicle Mass and Calculus Cholecystitis, the complt. consulted with surgeon Dr. D. Maity on 13.08.2018 and finally taking his medical treatment up to 24.08.2018, the complt. contacted Dr. A. Basak and as per his advice, the complt. attended Apollo Hospital, Chennai, and got himself admitted there on 29.08.2018, the and had undergone surgical interference and underwent Laparoscopic Cholceystectomy and Appendicectomy in the surgical Gastroenterology Deptt. of Apollo Hospital and the complt. had to pay Rs- 2,06,388/- as the total cost of his medical treatment in the said hospital where he was admitted from 29.08.2018 till his discharge there from on 02.09.2018, following his undergoing surgery on 31.08.2018, at that hospital.
It is the specific case of the complt. that on 13.09.2018 by furnishing all the relevant documents of his medical treatment by speed post, the complt. had submitted his medical claim with his insurer that is the O.P. no 1 vide reference no 17866392 and 311901/48/2019/000083 and in response to his such claim, the O.P. no 1 asked the complt. to submit the ‘exact duration of Cholecystitis with Appendicitis’, certified by his treating doctor and also directed the complt. to submit the first consultation note with advice for admission.
The complt. contends by filing the complaint of this case that he had sent the relevant papers to the O.P. no 1 as sought from him besides the first prescription of consultation with Dr. A. Basak, by sending letters dtd. 27.11.2018, 06.12.2018, 11.12.2018 but inspite of his such sending of the documents to the O.P. no 1, the O.P. no 2 sent letters dtd. 02.11.2018, 13.11.2018, 27.11.2018, 06.12.2018 and 11.12.2018, asking for the said
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particulars, as referred above from the complt. and inspite of personal appearance of the complt. before the O.P. no 1 & 2 there remained lack of progress for realisation of the complt’s mediclaim amount of Rs- 2,06,388/-
The complt., in the case, specifically contends that his mediclaim of Rs- 2,06,388/- was partially entertained by the O.P. side since the O.Ps have provided him in his bank A/C Rs- 87,000/- on 23.01.2019, without any justification for making the deduction of Rs- 1,19,388/- from the amount of total mediclaim and on being asked repeatedly by the complt., the O.Ps hadn’t assigned any reason to justify that deduction amount from the complt’s total claim on medical insurance and in the absence of reflection of detailed of assessment made in respect of the complt’s claim, the O.Ps had arbitrarily and illegally made curtailment of the complt’s genuine claim and inflicted deficiency in service towards the complt. So, the complt. has filed this complaint and prays for reliefs as stated in the prayer portion of the complaint.
The case record reveals that the O.P. no 2 of this complaint was duly summoned and was given scope to appear and contest in this complaint but as the O.P. no 2 hadn’t turned up to contest in this complaint case, so this Commission/Forum vide order no 03 dtd. 26.02.2020 determined that the complaint case should be heard exparte against the O.P. no 2 of this complaint.
The O.P. no1 filed W.V. in this complaint, denied all the material allegations as averred in the complaint and contended, inter alia, that this complaint case is not maintainable in it’s present form and this complaint lacks existence of cause of action.
The gist of contentions of the contesting O.P. no1 of this complaint case, as found from it’s filed W.V., the O.P. no 1 shows that the complt. had failed to produce the first consultation note with advice for admission, to the O.P. no 2. It is also contended by the O.P. no 1 that the complt. hadn’t produced pertinent medical prescription of Dr. A. Basak, Dr. D. Maity and the complt. also hadn’t produced specific information as to the exact duration of Cholecystitis with Appendicitis certified by the complt’s treating doctor and as the complt. failed to produce first consultation note with advice for admission and the information of the exact duration of the physical difficulties faced by him, inspite of receiving repeated letters from the O.P. side, so the O.P. no 2 processed and settled the claim of the complt. to the extent of Rs- 87,000/-
The O.P. no 1, contesting by filing W.V. also agitated that as per scopes of clause 4.1 and 4.2 of the insurance policy taken by the complt., since the surgery of Gall Bladder and
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calculus disease has a waiting period of 02 years and as in the instant case such operation was undergone by the complt. within 02 years of the waiting period from the policy inception, in favour of the complt., the complt, cannot claim the reliefs as sought for in the form of reimbursement of his medical expenses of undergoing Calculus Cholecystitis.
By filing the W.V. the O.P. no 1 also asserted that it has to abide by the T.P.A’s findings over settlement of claims and agitating that in this case by filing W.V., the O.P. no 1 has claimed to have not committed any deficiency in service towards the complt. and claimed for the dismissal of this complaint.
In the light of the contentions of the contesting parties, their respective stand points against each other in this complaint the following issues are framed for determination to reach the decisive conclusion over the matters in issue of this complaint.
ISSUES / POINTS FOR DETERMINATION
- Is the complainant a consumer as per Sec 2 (i) (d) ii of the C.P. Act of 1986?
- Has this Commission/Forum jurisdiction to entertain the instant complaint, as per C.P. Act of 1986?
- Have the O.P’s any deficiency in service caused from their end towards the complt., as alleged and are they liable in any way towards the complainant?
- Whether the complainant is entitled to get the relief(s) as prayed for?
DECISION WITH REASONS
Issues No. 1 & 2:-
At first we take up both these two issues for discussion since on the basis of the decisions of these two issues in this complaint case the justification to take up the remaining two issues for discussion can only be ascertained and appreciated.
Having regard to the nature of relationships subsisting in between the contesting parties of this complaint case their respective standpoints existing against each other here, it is well established that as per scopes of clause ii of Sec 2(i)d of the C.P. Act of 1986, the complt. of this case was the consumer being the beneficiary of the service intended to be rendered and rendered by the O.Ps who were the medical insurance service providers towards the complt. and assessors of the pecuniary value of such service provided to the
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beneficiary/complainant of this complaint respectively. Accordingly, the complt. being the beneficiary of the service of providing medical insurance coverage given to him and his family from the O.P. side obviously is the consumer in this case and on the basis of this finding, this issue is decided in the affirmative in favour of the complt. As the case record reveals, the addresses of the O.P. no 1 as well as the complt. reflecting that the complt. and the O.P. no 1 have their respective residences as well as place of work within the territorial jurisdiction of this Commission/Forum , so in consonance with the scopes of the Sec 11 of the C.P. Act of 1986, this Commission(previously Forum) has also the territorial jurisdiction to deal with this complaint case.
The available materials on record, prayer for reliefs sought in this case by the complt. from the O.P. also lends sufficient ground to hold that this Commission/Forum has the pecuniary jurisdiction too to deal with this complaint.
This further transpires from the available materials on record that the cause of action of this complaint arise on 28.03.2019 and since this complaint was filed on 06.12.2020 by the complainant, so in consonance with the scopes of sec 24A of the C.P. Act of 1986, this complaint is found not barred by limitation.
In this premises, we find that this issue is also decided in favour of the complainant.
Accordingly, both these issues are decided and disposed of in favour of the complainant.
Issues No. 3 & 4:-
For the sake of convenience and brevity both these two issues are taken up for discussion and for avoiding prolixity and repetitions the same is found appropriate.
It is forthcoming from the available materials on record that it is admitted from the end of the O.P. side that the complt. had been under the medical insurance coverage of the O.P. no 1 of this complaint from 23.09.2016 to 22.09.2017 and thereafter from 23.09.2017 to 22.09.2018 and thereafter from 23.09.2018 to 22.09.2019 uninterruptedly against his paying premium for remaining under such medical insurance coverage under the O.P. no 1 of this complaint case, for sum insured of Rs-five lakhs.
This is the complt’s specific case is that he was affected with abdominal pain on 08.08.2018 and following his failure to get reliefs, from the medical treatments, provided to
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him his attending physician and surgeon respectively, the complt. had, as per medical advice, attended Apollo Hospital, Chennai on 29.08.2018, undergone Laparoscopic Cholecystectomy and Appendicectomy on 31.08.2018 since he was diagnosed to have been suffering from ACUTE APPENDICITIS WITH APPENDICIAL MASS CALCULOUS CHOLECYSTITIS and was discharged from there on 02.09.2018. it is further contended by the complainant that his filed prayers to the O.P. for providing him the mediclaim insurance coverage facility as per norms of that policy were repeatedly turned down by the O.P., on various pretexts, and thereafter only Rs- 87,000/- was paid by the O.P. no 1 in the complt’s bank A/C though his total claim was Rs- 2,06,388/- which was charged by the concerned Apollo Hospital as the medical expenses for his treatment over there. It is the complt’s specific contention that the expenses incurred by him for his medical treatment were not fictitious or baseless and the same were meticulous and on that point the O.P. side hasn’t raised any question and he had furnished all the available documents/medical papers to the O.P. no 1 as wanted by the O.P. side, to substantiate his claim yet the O.P. side has provided him the medical insurance coverage to meager extent and avoided to pay up, without just cause, the actual medical expenses made by him genuinely for his medical attention. So he has filed this complaint.
On the other hand the O.P. side contended that the complt. couldn’t furnished information regarding his first consultation note with advise for admission and information as to exact duration of Cholecystitis with Appendicitis, certified by the treating doctor and it is also pressed by the O.P. no 1 that surgery of Gall Bladder and calculus diseases has a waiting period of two (02) years but in the instant case of the complainant, his such operation had taken place under two years of waiting period from the point of time of policy inception and for that reason cost of the Laparoscopic Choleystictomy was not payable as per policy terms and condition.
It is forthcoming from the submissions of the O.P side that the O.P. relied on the point no 4.1 and 4.2 of the exclusion clause of the medical insurance policy taken by the complt. from the O.P. no 1. I have given through attention of those clauses. The point No.4.1 of exclusion clause referred that this exclusion point in particulars reflects exclusion of pre-existing disease/ailments/injuries up to 03 years of the policy being in force continuously. However, the nature of disease suffered from by the complt. can’t categories it medically as pre-existing disease. So this exclusion clause does not affect the complainant and arguments on this point remained meritless since not supported by medical science.
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However, the exclusion clause no 4.2 of the instant Medical Insurance policy entered into by the complt with the O.P. no1 of this case has a potential impact to affect the realization of complt’s mediclaim benefits sought for by the complt from the O.P. no1 since it is scheduled in the said exclusion clause 4.2 of the Medical Insurance policy that the expenses of the treatment of surgery of Gall Bladder , as admittedly undergone by the complt. of this complainant case, are not payable for a specified period of 2 years from the inception of that Mediclaim Policy.
Here in this case it is forthcoming that complaint had mediclaim policy of the sum assured to the tune of Rs- five lakhs from 23.09.2016 to 22.09.2017 and from 23.09.2017 to 22.09.2018 and from 23.09.2018 to 22.09.2019 uninterruptedly but unfortunately in the absence of exhibition of the existence of any medical insurance coverage in favour of this complainant prior to September 2016 and in the presence of the fact that for that particular Calculus Cholecystitis he (complt.) had to get admission at Apollo Hospital on 29.08.2018 and on 31.08.2018 he had to undergo Laparoscopic Cholecystectomy besides Appendectomy which was also then causing him acute sufferings, complt. couldn’t complete the specific waiting period of 02(two) years from the point of time of policy inception i.e. from September 2016 and as the disease in particular i.e. Calculus Cholecystitis was inflicting manifestations to the complt. in the first part of August 2018 and culminated in the surgical interference, for removing the physical difficulties, arising out of that particular disease of Calculus Cholecystitis, on 31.08.2018, so as the complt. couldn’t wait or cross the waiting period of two years from September 2016 to avoid the said exclusion period of two years from September 2016, as a result the complt. couldn’t be found eligible to get his mediclaim prayer entertainable as per exclusion clause 4.2, during the currency of two years of his remaining in insurance coverage of the O.P. no 1.
It is pertinent to reflect that since the Appendectectomy doesn’t come for any waiting period as exclusion clause 4.2 reveals, so the complt. could get partially benefitted, as can be legitimately inferred from the available materials on record.
Accordingly, there remains no positive basis in this case to hold that there was causation of deficiency in service by the O.P. side against the complainant, for the reasons as discussed above and consequently the complt. can’t appear to get the reliefs as prayed for in this complaint.
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In the premises both these issues no 3 and 4 are decided against the complainant and are thus disposed of.
Hence it is…
ORDERED
That the instant complaint case be and the same is dismissed on contest against the O.P. no 1 and dismissed exparte against the O.P. no 2, but without cost.
Let a plain copy of this order be supplied to the contesting parties of this complaint case, by hand/ by Regd. Post with A/D forthwith, free of cost, for information and necessary action, as per law & relevant rules.
