JUDGEMENT

          Complainantby filing this complaint has submitted thathe is the holder of a Mediclaim Policy under the Oriental Insurance Co. Ltd. being Policy No.311200/48/2011/5585 and the said policy is being continued by paying the premium for the said policy since 2007 in regular manner and till now and without any single default.  That on 09.06.2011complainant was admitted in Kothari Medical Centre, Kolkata on emergency basis for her immediate medical treatment under Dr. Anil Malhorta and she was discharged on 13.06.2011 after being treated.

          But after physical examination of the complainant in emergency department of Kothari Medical Centre, the concerned doctor advised the complainant to admit in hospital immediately and accordingly the complainant for such treatment from 09.06.2011 to 13.06.2011 spent a sum of Rs.59,932/- only towards medical expenses for her treatment in Kothari Medical Centre.  Being discharged complainant applied on 01.07.2011 for re-imbursement of her aforesaid medical expenses as a legitimate claim after complying of all formalities for the same and in accordance with the mediclaim policy through TPA “M/s India Healthcare Services Pvt. Ltd.” having its registered office at 169, Sarat Bose Road, Kolkata – 700026.

          After a few months suddenly complainant received a letter on 11.11.2011 from the Divisional Manager, The Oriental Insurance Co. Ltd. Division-II, and came to know that her aforesaid claim is not a payable one and it will be treated as NO CLAIM.

On 15.03.2012 complainant sent letters by speed post to the ops through her husband, who is an advocate for settlement of her aforesaid claim, but against that no fruitful result was achieved and ultimately on 17.04.2012 complainant sent reminders by hand to the op through her husband for the settlement of complainant’s claim, but till date op has not disposed of the matter for which the complainant has been suffering mental and physically and also suffered financial loss for the laches on the part of the op and in the above circumstances, complainant has prayed for re-imbursement of the medical treatment cost of Rs.59,932/- including interest and compensation etc.

On the other hand op no.1 by filing written statement has submitted that no doubt complainant was admitted to Kothari Medical Centre on emergency basis for her treatment under covering the treatment in mediclaim.  But no document is being filed to show for admission on emergency basis and the entire medical reports shows that the admission in hospital was made for diagnosis purposes and was being referred to Gynecologist, which is not covered by Mediclaim Insurance Policy.

Further it is submitted that hospitalisation was not followed by policy in line of treatment and as per term of the policy, claim of complainant is not covered by the said policy.  It is further alleged that no doubt its policy sum assured was Rs.50,000/- only for covering treatment as stated in the Mediclaim Insurance Policy for individual which will not cover the chronic symptoms as it appears from the medical record.  Lastly it is alleged that entire claim is baseless and without any foundation and allegations are false and claim is not covered under the mediclaim policy under Clause 4.9, 4.10 & 4.23 and also other provisions as reflected in Mediclaim Insurance Policy for individual.

In the circumstances, op has prayed for dismissal of this complaint.

                                       Decision with reasons

In fact in this case everything is admitted by the op in respect of admission of the complainant at Kothari Medical Centre on 09.06.2011 wherefrom complainant was discharged on 13.06.2011.  Fact remains that she was admitted under Dr. Anil Malhotra in the Kothari Medical Centre and at hospital on admission it was detected low back pain raidiating to left lower limb for one year, vertigo weakness for 3 months and pain both knees and swelling joint of hands and on examination it was found that she was suffering from Anaemia(+)/Cycnosis/Jaundice/Odema/Clubbing etc. and after final diagnosis the doctor came to a conclusion that she was suffering from iron deficiency Anemia, Menorrhagia under evaluation and Hypo Vitaminosis D and during that period injection, tablet and other doses were given and thereafter she was found stable, she was released and fact remains prior to admission she was examined and in this case the chance of taking previous opinion or consultation of doctor was not there because she lost her physical stability and she was suffering from severe pain and other feelings for which promptly she was admitted.  So, question of previous opinion of the doctor for admission at the Kothari Medical Centre does not arise and practically in the present case when the complainant felt severe pain feelings in such a situation invariably as a patient her husband to save her life admitted her at Kothari Medical Centre and no doubt the doctors before giving any proper treatment made all such clinical examinations i.e. blood test, x-ray, CT Scan etc. which is evident from the medical report of the Kothari Medical Centre and after thorough check up and investigation doctor found that she was suffering from iron deficiency Anemia, Menorrhagia under evaluation and Hypo Vitaminosis D and against that medicines were given for her recovery from severe illness and for her recovery doctor examined and held all positive tests and also gave medicines during that period and thereafter complainant became stable and she was discharged with a direction to meet with Dr. Anil Malhotra the treating doctor after 2 weeks from the date of discharge and also to consult Gynecologist.

So, considering the entire medical report, it is clear that treatment was done by the doctor which is evident from the fact that doctor during the said period of stay of the complainant in the Kothari Medical Centre and treatment period gave several types of medicines for improving her anemia and other matter.  So, under any circumstances it cannot be said that no treatment was done during the said period as alleged by the complainant.  Now the question is whether complainant is entitled to get hospitalization benefit as per policy terms or not and in this regard we have gone through the policy wherefrom it is found that in clause 2.2, it is specifically stated that in respect of expenses on hospitalization are domiciliary and after studying that clause it is found that there is one clause i.e. XXVI in which it is noted “or any such disease/procedure care by TPA/company before treatment”.

Further there is another clause 2.3 wherefrom it is found that domiciliary hospitalization benefit means treatment for a period exceeding 3 days for such illness/disease or injury which is in the claim occurs to the required care and treatment at a hospital and nursing home as in patient.  But actually taken whilst confined that home in India under any of the following circumstances namely the condition of the patient is such that he/she cannot be removed from the hospital or nursing home or for lack of accommodation in hospital in the city, town or in the village.  For both the clauses are con-jointly taken into consideration and it can safely be said that expenses or hospitalization charge are domiciliary for any type of disease for which any person may be admitted who has his mediclaim policy.

But considering clause 4.3 it is found that the complainant was not admitted for the disease as noted in clause 4.3.  So, clause 4.3 is not applicable in the present case in respect of the present complaint.  Fact remains that there is one clause 4.22 in the Mediclaim Policy which speaks that any stay in the hospital for any domestic reason or where no active treatment is given by the specialist such an insured is entitled to get such benefit if the policy is found continuous in nature for more than 4 years.  No doubt in this case after considering the entire policy the document, it is found that the present policy of the complainant is continuous in nature since 2007 and in the meantime complainant paid regular premium and renewed the same from its inception which is evident from the policy document.  So, it is clear that complainant as insured is a policy holder under the op for more than 4 years continuously and for which as per provision of clause 4.22, complainant is entitled to get such benefit for her hospitalization for any disease and in this case under any circumstances it can be said that there was no necessity of consultant physician on the part of the complainant before admission because emergency admission is made when the condition of any patient is found beyond control.

In the present case invariably complainant’s condition was beyond control for which her husband considering such situation admitted her to Kothari Medical Centre and no doubt the position of the complainant was not fair for which she was admitted Kothari Medical Centre on 09.06.2011 and the doctor gave treatment i.e. medication and held different type of tests, CT Scan etc. and thereafter medication she recovered when she was discharged on 13.06.2011 she was found stable.  Then it is clear that treatment was given, may be such a treatment can be done in her house but doctor did not release her for which under any circumstances complainant was not at fault.

Another factor is that clause 4.22 is applicable in the present case when complainant is a continuous policy holder for more than 4 years preceding to present policy and it is continuous in nature.  But anyhow the op or their agent TPA did not consider that fact.  But their only defence is that there was no treatment only testing was done but we find from the document that treatment was done, medicines were given, tests after tests were made and ultimately it was detected that she was suffering from anemia iron deficiency i.e. Anemia, Menorrhagia under evaluation and Hypo Vitaminosis D.  If we rely upon that report of the Kothari Medical Centre, it is found that without testing and check-up it was not possible to determine the nature of illness and always any testing cannot be done by placing her in the house when the condition of the patient at the relevant point was found un-stable.

Practically in the present case physical condition of the complainant was un-stable and serious for which she was admitted and doctors also failed to diagnose the cause of her illness and un-stableness for which after thorough tests and check-up they found that it is a case of iron deficiency and other deficiency.  So, during that period from 09.06.2011 to 13.06.2011 complainant was given medicines and other injections etc.  Thereafter she recovered from herAnemia, Menorrhagia under evaluation and Hypo Vitaminosis D.  So, on release doctor advised to continue certain injections and medicines, but we have failed to understand why the op or TPA rejected the entire bill when so many tests were done for determination of her actual disease.  Renowned doctor also failed to determine the un-stableness and feeling pain of the complainant etc. and Dr. Anil Malhotra well known doctor of Kothari Medical Centre of Kolkata ultimately diagnosed the total cause of her un-stable condition of her health and sometimes such a situation is arisen in respect of particular type of female patient and in the present case complainant is female and no doubt her husband rightly admitted her forthwith because for lackness, callousness of her husband sometimes wife may die.  But in the present case husband of the complainant took right decision to admit her and fact remains the condition of the complainant was beyond control which is evident from the nature of treatment and testing made by the Dr. Anil Malhotra.

So, we are convinced that the present hospitalization of the complainant for the period from 09.06.2011 to 13.06.2011 was not a fanciful hospitalisation as claimed by the op and we have gathered from the entire medical documents that there was justified ground for admission of the complainant and there was justified reasons for such treatment made by Dr. Anil Malhotra.  But TPA did not consider it morally, did not consider the condition of the patient at the relevant time and the subsequent factor during the period of testing and treatment made by Dr. Anil Malhotra and ultimately TPA refused the entire claim of the complainant.  But the reasons for rejection is completely baseless and without any foundation.  But we have gathered from the Insurance Policy that sum assured is Rs.50,000/-.  So, under any circumstances the claim of the complainant cannot go beyond of Rs.50,000/-.  But anyhow the complainant claimed a sum of Rs.59,932/- but that excess amount ought not to have been considered by the op.  But the reasonable amount may be treated what the complainant is entitled to as per provision of clause 4.22 as a continuous policy holder for more than 4 years preceding to present policy and to release certain amount after considering the bills etc. but that have not been done.  So, minutely we have consulted the documents, particularly the bills and other reports and also the total amount of sum assured of Rs.50,000/- and considering that fact we are sure that bed head charge shall be Rs.500/- per day and fact remains that she was in the hospital for 5 days i.e. from 09.06.2011 to 13.06.2011,so she is entitled to Rs.2,500/-.  But complainant stayed in bed whose charge was of Rs.13,000/- but complainant is not entitled to get Rs.13,000/- .  So we shall have to adjust the entire bills as per terms and conditions of the policy and accordingly complainant is entitled to Rs.2,500/- for bed charge and for test she is entitled to Rs.15,000/- and for other CT Scan etc. she is entitled to another Rs.10,000/- and for medicines and doctors’ fees she is entitled to get Rs. 5,000/-, so in total complainant is entitled to Rs.32,500/-.

So, after proper assessment and evaluation of the entire fact and circumstances and materials and also the policy condition including the complaint we are confirmed that complainant is entitled to Rs.32,500/- as mediclaim against her entire claim of Rs.59,932/- from the op and op is bound to pay the same in view of the fact that complainant did not commit any breach condition of the policy.  But op ought ot have released the same after considering the medical reports, bills etc. but that was not properly considered by the TPA.  But TPA completely brushed aside the truth of the entire incident but only they applied their legal terms only not factual aspect along with that for which the TPA was in error in refusing the entire claim as no claim.

Fact remains that complainant submitted everything with all materials but anyhow the Board of Doctor of TPA did not scan the matter properly and for which complainant reasonable claim was also not properly entertained and for which we are convinced that the complainant is entitled to Rs.32,500/- out of the entire claim in view of the present position of the treatment and other matter as done by Kothari Medical Centre during the stay of the complainant for her treatment by Dr. Anil Malhotra.  In this regard we shall have to mention one thing that in the Kothari Medical Centre discharge summary column the treatment is not noted.  But what they have done i.e. noted after final diagnosis probably that was overlooked by the ops.  So, we are confirmed that different hospitals are preparing different type of summary of discharge for which some complications are created by TPA and TPA shall be moral in future at the time of settling any claim of any insured so that one after another litigation must not be started in between the insured and the complainant and in fact for some abnormal attitude of TPA Insurance Co is paying unreasonable fund for litigations as filed before Forum and Civil Court and for which insurance company is losing public money more and more by giving compensation etc. as additional relief even after payment of actual amount which an insured is entitled to. 

We are sure that in future the present insurance company and other insurance company shall be more moral in handling the claim case otherwise the situation of the insurance company shall be very precarious in respect of maintaining their capital and running their business.

Whatever it may be in the present case, complainant has been able to prove her claim but after proper evaluation of assessment we find that she is entitled to Rs.32,500/- as mediclaim against the present claim of Rs.59,932/- from the ops and op insurance company is liable to pay the same along with litigation cost and to some extent compensation also.

Thus, the complaint succeeds.

Hence, it is

                                                 ORDERED

That the complaint be and the same is allowed on contest against the ops with cost of Rs.5,000/- against op no.1 Oriental Insurance Co. Pvt. Ltd.and op no.1 is liable to pay the entire cost to the complainant.

Op Oriental Insurance Company Pvt. Ltd. is hereby directed to pay Rs.32,500/- as final settlement of mediclaim amount to the complainant and also a sum of Rs.5,000/- as compensation for causing mental pain and agony to the complainant and also for not properly considering her claim in time.

Thus op Oriental Insurance Company Pvt. Ltd. is hereby directed to pay Rs.32,500/- (final settled mediclaim of the complainant) + Rs.5,000/- compensation + Rs.5,000/- for litigation cost i.e. total Rs.42,500/- within 15 days from the date of this order to the complainant positively.  If op no.1 fails to comply the order of Forum within the stipulated period in that case for each day’s delay and till full satisfaction of the decretal amount he or they (op) shall have to pay penal damages @ Rs.200/- per day and if it is collected, same shall be deposited to the head of President, District Consumer Disputes Redressal Forum, Kolkata Unit –II.

Op Oriental Insurance Company Pvt. Ltd. is hereby directed to implement the order within the stipulated period in delay penal action shall be started against them for which they shall have to pay Rs.10,000/- for which op shall be responsible.