DATE OF FILING : 18/12/2015.
DATE OF S/R : 05/02/2016
DATE OF FINAL ORDER : 28/12/2016
Sri Sishir Kumar Ghosh,
son of late Sushil Kumar Ghosh,
residing at 7, New Park, Kayasthapara,
P.O. Haltu, P.S. Kasba,
Kolkata 700 028………………………………………………….. COMPLAINANT.
1. The Senior Divisional Manager,
Oriental Insurance Company Ltd.,
P 4, Dobson Lane, 4th floor,
Howrah 711 101.
2. The Medi Assist,
India TPA Pvt. Ltd.,
53A, Rafi Ahamed Kidwai Road,
Kolakta 700 016.
3. Dr. Tapan Kumar Patra,
Repose Clinic & Research Centre Pvt. Ltd.,
20C, Broad Street ( Ballygunge ), P.S. Ballygunge,
Kolkata 700 019.
4. Dr. Mauli Madhab Ghatak,
T.R.A. General Hospital,
7, Dr. Biresh Guha Street,
Kolkata 700 017.
5. T.R.A. General Hospital,
7, Dr. Biresh Guha Street,
Kolkata 700 017. ...……………………………………OPPOSITE PARTIES.
P R E S E N T
Hon’ble President : Shri B. D. Nanda, M.A. ( double ), L.L.M., WBHJS.
Hon’ble Member : Smt. Jhumki Saha.
Hon’ble Member : Shri A.K. Pathak.
F I N A L O R D E R
1. This is an application U/S 12 of the Consumer Protection Act, 1986 filed by the petitioner, Sri Sishir Kumar Ghosh, praying for a direction against the O.Ps. Oriental Insurance Company Ltd. and four others, to pay claim amount of Rs. 1,10,353/- against policy No. 311700/48/2014/5198 and Rs. 1,75,000/- as compensation for mental agony, anxiety, pain and unnecessary harassment and Rs. 30,000/- as litigation costs.
2. Brief fact of the case is that the complainant purchased medi claim policy from the o.p. no. 1, vide policy no. 311700/48/2014/5198 and made regular payment to the o.p. no. 1 and the o.p. no. 1 insurance company issued medi claim card being no. MAID 5008450651 with Medi Assist India TPA Pvt. Ltd., o.p. no. 2 in this case. Suddenly in April, 2014 complainant faced serious accident due to falling from chair and his spinal cord was damaged for which he was admitted in hospital and there various medical tests were done. Due to that accident complainant faced nerve disorder problem and he was admitted in Qadra Medical Services ( Pvt. ) Ltd.,and after check up he was referred to Dr. Deep Das, neurologist. After proper diagnosis by the concerned doctor, one medical board was formed and MRI Scan was done and going through all reports they opined that critical medical surgery of spinal cord including placement of upper and lower lumber is necessary and accordingly Dr. T. K. Patra operated him and discharged the petitioner on 27.05.2014. All costs and expenses were borne by the family members of the petitioner and the reimbursement claim form wassubmitted before the o.p. no. 1 on 31.5.2014 and finally on 10.09.2014 the o.p. no. 2, Medi Assist, India TPA Pvt. Ltd., issued a letter to the petitioner requesting him to submit documents for finalization of claim. Thereafter the petitioner contacted Dr. T. K. Patra, who advised him physiotherapy and referred him to Dr. M.M. Ghatak, o.p. no. 4, by a letter dated 16.06.2014.Subsequently the condition of the petitioner was deteriorated and he contacted Dr. M.M. Ghatak. After seeing the deteriorated condition of the patient, he advised the petitioner for immediate admissionin Medical Rehabilitation Centre of TRA General Hospital and on 23.6.2014 the petitioner was admitted. He was discharged from the TRA General Hospital on 09.08.2014. Though all bills were paid by him yet the prayer of the complainant was not considered. After lapse of much time complainant sent advocate’s letter dated 31.03.2015 through speed post to the o.p. no. 1 demanding reimbursement of claim but that attempt was not fulfilled. Being frustrated and finding no other alternative, complainant filed this instant complaint with the aforesaid prayers before this Forum.
3. The o.p., Oriental Insurance Company Ltd., contested the case by filing a written version denying the allegations made against them and submitted that the case is barred by limitation as the cause of action in the instant case arose in the month of April, 2014 and the case has been filed by the petitioner on 18.12.2015. They further submitted that the o.p. no. 2, M/s. Media Assist India Pvt. Ltd., is an authorized TPA of the Oriental Insurance Company Ltd. was to deal with the claims under medi claim policy regarding reimbursement and cashless claims and the o.p. no. 2 had obtained licence from IRDA to practise as a 3rd party administer ( TPA ) on behalf of the o.p. insurance company.
4. The o.p. no. 1 admitted that the petitioner took medi claim policy for his family from the o.p. PNB Oriental RoyalMediclaim Insurance Policy which is restricted to PNB account holders and employees only bearing policy no. 311700/48/2014/5198-2 valid from 10.12.2013 to 09.l12.2014 and this o.p. received premium for a sum of Rs. 5,700/- covering a sum assured amount ofRs. 4 lakhs as mentioned in the policy. The o.p. further submitted that the present petitioner was duly covered under the medi claim policy for the year 2012 – 13 and for the year 2013 – 2014 and the sum assured was 4 lakhs.They further submitted that in support of statement made by the petitioner they are unable to admit the claim as per Clause 4.1 of the terms and conditions of the policy document and also they repudiated the claim as their panel doctor Vineet Mittal stated that the insured underwent surgery under Dr. T.K. Patra who simply advised medicines later on but not advised hospitalization but the patient was later hospitalized as per advice of Dr. Ghatak who was not the operating doctor.
5. Upon pleadings of parties the following points arose for determination :
- Is the case maintainable in its present form ?
- Whether the petitioner has any cause of action to file the case ?
- Whether there is any deficiency in service on the part of the O.P. ?
- Whether the complainant is entitled to get any relief as prayed for ?
6. DECISION WITH REASONS :
This Forum heard the ld. counsels for both the parties as well as scrutinized the copies of written notes on argument and finds from the submission of the counsel as well as from the repudiation letter dated 12.2.2015 written to the petitioner by the Senior Divisional Manager, Oriental Insurance Company Ltd. P-4, Dobson Lane, Howrah, that they repudiatedthe claim as per the advice of their panel doctor Dr. Vineet Mittal who stated that the insured underwent surgery underDr. T.K. Patra for cervical cord compression in month of May, 2014 and was doing fine for a month and on 16.6.2014 he consulted Dr. Tapan Kumar Patra who in his prescription dated 16.6.2014 did not mention any clinical findings that the patient is need of hospitalization and the doctor simply advised the medicines to continue. Thus the said doctor Patra clearly stated that there was no need of hospitalization otherwise he would have advised the same being the attending operating doctor of the patient. Ld. counsel for the insurance company further submitted that Dr. Ghatak who is a doctor of medicine advised hospitalization for rehabilitation and considering the fact that the operating doctor who examined the patient seven days prior to the advice of Dr. Ghatak never felt the need of hospitalization and the fact that Dr. Ghatak only advised hospitalization for rehabilitation, the claimnot filed within the purview of policy terms and conditions and hence not tenable and thus they repudiated the claim.
7. It is unfortunate to mention here that the said panel doctor,Dr. Vineet Kr. Mittal failed to notice when he scrutinized the prescription of Dr. Tapan Kumar Patra dated 16.6.2014 wherein Dr. Patra referred to M.R.C., Dir, Dr. M.M. Ghatak, who advised hospitalization for rehabilitation. Thus even if the operating doctor T.K. Patra did not feel the need of hospitalization as opined by the panel doctor, Dr. Vineet Mittal he also failed to see the advice of Dr. Patra referring the patient to Dr. Ghatak. If this Forum finds that the operating Dr. T.K. Patra thought it wise to refer him to Dr. M.M. Ghatak and his observation with note when the patient reaches Dr. Ghatakand said Dr. Ghatak advised hospitalization for rehabilitation and thus the claim falls well within the purview of the terms and conditions and is well tenable because there is a clear nexus or rather a clear relation between the prescription of Dr. T.K. Pathak dated 16.6.2014 and Dr. M.M. Ghatak dated 23.6.2014 wherein Dr. Ghatak advised the patient for hospital for rehabilitation and thus theo.p. has wrongly repudiated the claim on the basis of wrong report of their panel doctor, Dr. Vineet Mittal who overlooked that the patient was referred to Dr. M.M. Ghatak by Dr. T.K. Patra and said doctor Ghatak advised hospitalization and such advice of Dr. Ghatak on the reference ofDr. Patra was reasonable and availed one. This is fit case for the petitioner to get the claim as advice of both Dr. Patra and Dr. Ghatak to be taken together and the case be considered then for the claim.
In view of above discussion and findings thisForum finds that the o.p. insurance company on the wrong findings of panel Dr. Vineet Mittal wrongly repudiated the claim of the petitioner who is entitled to get the reliefs as prayed for.
In the result, the complaint case succeeds.
Court fee paid is correct.
Hence,
O R D E R E D
That the C. C. Case No. 444 of 2015 ( HDF 444 of 2015 ) be and the same is allowed on contest with costs against the O.P. nos. 1 & 2 and dismissed without cost against the rest o.ps.
That the petitioner is entitled to the relief as prayed for. The O.P. no. 1 is directed to pay the claim amount of Rs. 1,10,353/- to the petitioner and to pay Rs. 20,000/- as compensation for mental agony and unnecessary harassment and to pay Rs. 30,000/- out of which Rs. 5,000/- would go in favour of the petitioner as litigation costs and the rest Rs. 25,000/- would be deposited in the Consumer Legal Aid A/c of this Forum.
The above order must be complied within 30 days from the date of this order failing the petitioner would be at liberty to put the order in execution and also the whole amount would carry interest @ 9% p.a. from this date till realization and the petitioner would be at liberty to put the final order in execution.
Supply the copies of the order to the parties, free of costs.
DICTATED & CORRECTED
BY ME.
( B.D. Nanda )
President, C.D.R.F., Howrah.
