Tripura

StateCommission

A/11/2024

SMT. SUBIDITA DAS - Complainant(s)

Versus

THE SENIOR DIVISIONAL MANAGER, NEW INDIA ASSURANCE CO. LTD. - Opp.Party(s)

ANJAN KANTI PAL

15 Jul 2024

ORDER

Tripura State Consumer Disputes Redressal Commission

Agartala: West Tripura

Case No. A. 11 of 2024

 

 

1. Smt. Subidita Das,

W/o Sri Sadhan Chandra Das,

14 Krishnanagar, Colonel Chowmuhani,

P.O. Agartala, P.S. West Agartala,

District - West Tripura.

.… … … … Appellant/Complainant

 

Vs

 

1. The Senior Divisional Manager,

New India Assurance Company Ltd.,

87 Mahatma Gandhi Road, Mumbai - 400001.

 

2. The Senior Divisional Manager,

New India Assurance Company Ltd.,

A Government of India undertaking 

Divisional Office: 2^nd Floor, Mount Casa Blanca Building,

No.260, Anna Salai, Chennai - 600006, Tamil Nadu.

 

3. The Managing Director,

Indian Health Care Private Service Ltd.,

Guna Complex, New Door No.443 & 445,

Old Door No. 304 & 305, Anna Salai Teynampet, Chennai - 600018.

 

4. The Divisional Manager,

New India Assurance Company Ltd.,

4^th Mantribari Road, Agartala,

P.S. West Agartala, District - West Tripura.

 

5. CITI Bank, 2nd Floor,

Mount Casa Blanca Building,

No.260, Anna Salai, Chennai - 600006, Tamil Nadu.

                                                            … … … … Respondents/Opposite Parties

 

 

 

 

Before

Hon’ble Mr. Justice Arindam Lodh

President, State Commission

 

Smt. Daliya Saha

Member, State Commission

 

Shri Jhantu Debnath

Member, State Commission

 

 

 

 

Present:

For the Appellant:                                                      Mr. Anjan Kanti Pal, Adv.

For the Respondent Nos.1, 2 & 4:                             Mr. Gitangshu Sekhar Das, Adv.

For the Respondent Nos.3 & 5:                                 Absent

Date of Hearing & Delivery of Judgment:                 15.07.2024.

 

 

J U D G M E N T [ORAL]

Heard Mr. Anjan Kanti Pal, learned counsel appearing for the appellant-complainant. Also heard Mr. Gitangshu Sekhar Das, learned counsel appearing on behalf of the respondents-Insurance Company. None appears for the respondent nos.3 and 5. Record of the Registry reveals that the notices sent to them were returned un-served.

2. This is an appeal against the final order dated 29.02.2024 passed by the learned District Consumer Disputes Redressal Commission, West Tripura, Agartala in connection with Case No.C.C.55 of 2023.
3. The appellant, Smt. Subidita Das had lodged a complaint before the learned District Commission stating, inter alia that she went to a hospital, namely, Dr. Mohan’s Diabetic Specialities Centre at Chennai for treatment. With the advice of doctors, she got admitted and the hospital authority conducted some medical tests upon her. Altogether she spent Rs.51,780/-. Thereafter, on return to her house, she raised her claim and prayed for reimbursement of the amount she spent for her treatment, but the Insurance Company, the respondent herein, repudiated the claim of the appellant-complainant.
4. Mr. Pal, learned counsel appearing for the appellant submits that during the course of recording evidence, certain documents were filed before the learned District Commission wherefrom it is revealed that she spent Rs.96,985/- and it is wrongly stated in the plaint that she spent Rs.51,780/- as stated above.
5. Defending the action of the respondent-Insurance Company, Mr. Das, learned counsel appearing for the respondent submits that entire claim of the appellant-complainant is baseless. Clause 4.4 and Clause 4.4.1 of the insurance policy deal ‘exclusion’ and ‘investigation & evaluation(Code-Excl04) ‘ which are reproduced here-under:-

“4.4 EXCLUSIONS

The Company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of:

4.4.1 INVESTIGATION & EVALUATION (Code-Excl04)

a. Expenses related to any admission primarily for diagnostics and evaluation purposes.

b. Any diagnostic expenses which are not related or not incidental to the Current diagnosis and treatment.

However, Treatment for any symptoms, illness, complications arising due to physiological conditions for which aetiology is unknown is not excluded. It is covered with a Sub-Limit of upto 10% of Sum Insured per policy period.”

 

6. Mr. Das, learned counsel has further submitted that no discharge summery is found in the record. However, on perusal of the records, we find that there is discharge summery which was filed on 20.02.2024 by way of Firisti.
7. According to us, a patient is unknown to the methodology of the treatment to be undertaken by the doctors of a hospital. When a patient attends a hospital, then the patient is guided by the advice of the doctors. The Insurance Company has not adduced any evidence to justify their plea that the appellant-complainant was not admitted in the hospital at the advice of the doctors. We find no substance in the submission advanced on behalf of the respondent-Insurance Company that the appellant-complainant was not advised by the doctors to get admission and conduct tests to detect her disease.
8. Many a times, it also happens that after conduct of tests, the doctors may opine that for that relevant point of time no medication is necessary. In this circumstance, it would be wrong to say, rather it would be unjustified to suggest that the patient get admission to the hospital at their whims. The same thing has occurred in the instant case. As we said earlier, the appellant-complainant before going to the hospital, had no knowledge from which disease she was suffered. She was advised to get admission in the hospital and doctor conducted some tests. So, in our opinion, the stipulations made in Clauses 4.4 and Clause 4.4.1 are not applicable to the instant case. According to us, the admission as well as the tests conducted upon the appellant-complainant since was done by the advice of the doctors it comes within the purview of the language used in the said clauses that it is related or incidental to the diagnosis and treatment.
9. The learned District Commission has not noticed the stipulations that, “However, Treatment for any symptoms, illness, complications arising due to physiological conditions for which aetiology is unknown is not excluded”.
10. Without entering into the interpretation of the above stipulation, we have already expressed that the expenses which the appellant-complainant incurred were related and incidental to diagnose her complications.
11. Accordingly, we find error in the final order dated 29.02.2024 passed by the learned District Commission, West Tripura, and accordingly, the same stands set aside and quashed. As a sequel, the respondent-Insurance Company is directed to reimburse an amount of Rs.51,780/- to the appellant-complainant within a period of one month from today. It is also found that the respondent-Insurance was negligent in settling the claim of the appellant-complainant and the claim had repudiated arbitrarily without proper application of law. As such, the respondent-Insurance Company is found to be deficient in rendering service to the appellant-complainant for which the respondent-Insurance Company is liable to pay a compensation of Rs.25,000/- to the appellant-complainant. The appellant-complainant is also entitled to a litigation cost of Rs.5,000/- within a period of one month.

Having observed thus, the instant appeal stands allowed in the above terms.