IN THE COURT OF THE LD. DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT S I L I G U R I.

CONSUMER CASE NO. : 12/S/2014.                       DATED :30.03.2016.            

BEFORE  PRESIDENT              : SRI BISWANATH DE,

                                                              President, D.C.D.R.F., Siliguri.

                      MEMBERS              : SMT. PPRATITI BHATTACHARYYA &                     

                                                              SRI PABITRA MAJUMDAR.

COMPLAINANT                 : SRI PRAMOD AGARWAL,

  S/O Sri Srikishan Agarwal,

  R/O 28, K.C. Dey Road,

  P.O. & P.S.- Siliguri,

  Dist.- Darjeeling, (West Bengal).

O.P.                           : THE ORIENTAL INSURANCE COMPANY

                                      LIMITED,

  Malhotra Towers, P.O. – Pradhan Nagar, Siliguri,

  Dist.- Darjeeling.

FOR THE COMPLAINANT         : Sri S. K. Mitruka, Advocate.

J U D G E M E N T

Sri Biswanath De, Ld. President.

The complainant’s case in a nutshell is that complainant himself, his wife, daughter and son were insured by the Insurance Company under the Happy Family Floater Policy bearing No.313205/48/2013/1598 for a sum insured of Rs.3,00,000/- by paying the requisite premium and that the said policy was valid for the periods from 24.03.2013 to 23.03.2014.  It is stated that the complainant above named was having his health policy for last 15 years or so.  The complainant was admitted in hospital on 20.08.2013 and was discharged on 21.08.2013.  Thereafter, after coming from hospital, the complainant lodged his claim with relevant papers for reimbursement of said medical expenses, but the Insurance Company informed the complainant later on vide letter no.10.01.2014 by repudiating the claim under Section 4.11 of the terms and condition of Insurance Policy.  Such kind of refusal is unjustified as the family has been insured under Happy Family Floater Policy.  The claim in question had never arisen earlier and the said policy is continued for 12 years

past.  Accordingly, decisions of the Insurance Company are unjustified.

Contd........P/2

-:2:-

Accordingly, the case is filed for getting the sum paid in hospital amounting to Rs.41,000/- and cost of medicine and other reliefs as provided in the Consumer Protection Act.

The OP has contested the case by filing written version denying inter-alia all the material allegations as raised by the complainant.  The OP admits the complainant as policy holder.  The OP repudiated the claim of complainant on the ground “in absence of any complication does not justify hospitalization.  The said investigation can be done on OPD basis.  Hence, the claim is repudiated under Section 4.11.”  The OP further states that “expenses incurred at Hospital or Nursing Home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period or expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalization or primary reasons for admission, referral fee to family doctors, out station consultants/Surgeons fees, Doctor’s home visit charge/Attendant/Nursing Charges during pre and post hospitalization period etc.”  Accordingly, for the reasons as aforesaid, the claim has been repudiated.   

Point for decision

1.       Whether there is deficiency in service on the part of the OP ?

2.       Whether the complainant is entitled to get the relief as prayed for ?              

Complainant has filed the following documents :-

1.       Copy of the Insurance Policy.

2.       Copies of the documents pertaining to claim lodged by the complainant. 

3.       Copy of repudiation letter received from the OP insurance company. 

The complainant has filed affidavit-in-chief wherein he has stated how and when he was admitted in the Medanta Global Hospital for treatment for two days.  He has stated his fact at present.  This witness has been cross examined by the OP by putting different types of questions numbering 32.  The witness replied he was suffering from stomach pain and then heart.  He further stated Dr. Tendon and thereafter Doctors of Medanta Global Health referred him for treatment.  He went to Medanta Global Health for heart problem.  Firstly, he was treated as OPD patient and then doctor advised him to take admission in the hospital as indoor patient.

Contd........P/3

-:3:-

So, from the cross examination of this complainant by the OP, it transpires that complainant took admission in hospital for treatment mainly heart and stomach.

On the other hand OP has also filed evidence-in-chief as per their written averments. 

So, from the cross examination it appears, that the complainant admitted in the hospital due to suffering in pain and chest for treatment.  The complainant also submitted two papers discharge certificate issued by Medanta Global Health dated 21.08.2013 which is self explanatory.  These two discharge certificate and discharge summary with recommendations of medicines shows that he was treated there for different types of ailments as laid down in those two prescriptions and after that doctor has discharged his with some instructions. 

So, from these documents as well as answer in questionnaire positively show that he took admission due to pain in chest and stomach and other parts of the body.  These two certificates support his contentions that he has been suffering from different ailments.  Another Xerox copy dated 23.06.2013 filed by the complainant shows that he has been suffering from different types of problem.  So, the presence of these documents and answer in cross examination shows that he was admitted in the hospital for treatment with all his diseases and he has been discharged after determination of complication with advice of taking medicines. 

Accordingly, the OP’s defence as laid down hereinbefore that he is not entitled to get reimbursement of expenses incurred by the complainant during hospitalization and for his treatment afterwards as per Clause 4.11 of the policy does not tenable in law and facts of this case i.e., when the Insurance Company has made in contract by his product i.e., insurance and taking the premium regularly, so, Insurance Company is bound to give that money.  It is pertinent to note that such authority TPA works without application of mind.  They don’t consider the antecedent of the patient and consequences of the patient after hospitalization and condition of the patient in the hospital.  They act blindly without paying attention to the poor people’s need an ambit of the Insurance Act, 1939.  The TPA authority discharge their duty only by eyeing the paper and putting signature and they are much habituated an acquainted with the word repudiation which is devoid any sense and feelings towards the common man.

Contd........P/4

-:4:-

At the outset of discussion, we are saying that in every corner of the record, the positive case of complainant is moving whereas the negligence conduct of insurance company is dancing. 

After deep deliberation over the records within the purview of this case, this Forum is strong conviction that the complainant is entitled to get compensation expenditure and other costs.  Repudiation of the claim of the Insurance Company is highly condemned.  They are directed to be more vigilant towards the public interest. 

Accordingly, the case succeeds with cost. 

The complainant is entitled to get Rs.41,000/- towards the expenses for his medical treatment during the operation period of the policy.

The complainant is further entitled to get Rs.44,000/- towards compensation for negligence and deficiency in services of the OP and harassment and other loses. 

The complainant is further entitled to get Rs.10,000/- for cost of litigation. 

The complainant is further entitled to get 9 % interest on the awarded sum from the date of filing of this case till full payment. 

In the result, the case succeeds.

Hence, it is

                     O R D E R E D

that the Consumer Case No.12/S/2014 is allowed on contest against the OP. 

The complainant is entitled to get Rs.41,000/- towards the expenses for his medical treatment during the operation period of the policy.

The complainant is further entitled to get Rs.44,000/- towards compensation for negligence and deficiency in services of the OP and harassment and other loses.

The complainant is further entitled to get Rs.10,000/- towards litigation cost from the OP.

The complainant is further entitled to get 9 % interest on the sum of Rs.41,000/- from the OP from the date of filing of this case till full realization. 

The OP is directed to pay Rs.41,000/- towards the expenses for medical treatment of the complainant by issuing an account payee cheque in the name of the complainant within 45 days of this order.

Contd........P/5

-:5:-

 The OP is further directed to pay Rs.44,000/- towards compensation for negligence and deficiency in services of the OP and harassment and other loses by issuing an account payee cheque in the name of the complainant within 45 days of this order.

The OP is further directed to pay Rs.10,000/- by issuing an account payee cheque in the name of the complainant towards litigation cost within 45 days of this order.

The OP is further directed to pay 9 % interest on the sum of Rs.41,000/- to the complainant from the date of filing of this case till full payment. 

In case of default of payment, the complainant is further entitled to get interest @ 9% per annum on the awarded sum of Rs.85,000/- from the date of filing of this case till full realization. 

In case of default, the complainant is at liberty to execute this order through this Forum as per law. 

Copies of this judgment be supplied to the parties free of cost.

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