- Dr. Dhruba Mitra,
701, Auroville,
10, Mdevilla Gardens, Kolkata-19. _________ Complainant
____Versus____
- The United India Insurance Co. Ltd.
Through its Chairman,
‘Himalaya House’, 2nd Floor, 38B, Jawaharlal
Nehru Road, Kolkata-71, P.S. Park Street.
- The Divisional Manager,
The United India Insurance Co. Ltd.
‘Himalaya House’, 2nd Floor, 38B, Jawaharlal
Nehru Road, Kolkata-71, P.S. Park Street. _________Opposite Parties
Present : Sri Sankar Nath Das, Hon’ble President
Dr. Subir Kumar Chaudhuri, Member.
Smt. Samiksha Bhattacharya, Member
Order No. Dated
The case of the complainant in short is that complainant has an insurance policy with o.p. being Mediclaim Policy no.030200/48/10/0002715. Complainant stated that on 9.10.10 a disease was detected viz. Macular Degeneration for the first time by Dr. Vivek Dutta, an Opthalmologist and an Opthalmic Surgeon too. Complainant stated that on 25.10.10 he was admitted in Probal Eye Institute, Kolkata for his treatment. He was injected drugs like Lucentis, Macugel, etc. and after completion of the treatment there he was discharged from the said institute on 26.10.10. Thereafter, complainant lodged a claim to o.p. on 12.11.10 for reimbursement of the medical expenses incurred by him for the said treatment. But after lodging such claim he did not receive any response from o.p. company. A copy of the said claim has been annexed by complainant with the petition of complaint.
Being aggrieved complainant made representation to the Divisional Manager of the said company on 8.11.11 and submitted a claim a sum of Rs.66,612.60 in Oct. 2010, Rs.47,530.60 in Nov. 2010, Rs.38,310/- in Dec.2010 in total it comes Rs.1,52,453.20. A copy of the said letter has been annexed as annex-B by complainant with the petition of complaint. Complainant further stated that on 18.11.11 o.p. stated that the claim is not payable in terms of the letter dt.3.2.11 and the reasons of which is specified there. Copy of the said letter dt.3.2.11 has been annexed as annex-C with the petition of complaint.
Complainant further stated that a circular being Ref. No.HIM/Circular/2010-2011/003 and CMD/Sectt. Master Circular No.026/2010-2011 has been issued to the complainant by o.p. company in respect of the disease known as Macular Degeneration and the injection administered to complainant. Complainant further stated that upon careful consideration of the said circular, complainant stated that the said circular of o.p. company is arbitrary and malafide and has got no relation with the treatment of complainant and the administration of injection to him in respect of the disease as stated above. Copy of the said circular has been annexed by complainant and marked with the letter D with the petition of complaint. Thereafter complainant made several correspondences to o.p. in respect of reimbursement of the medical expenses under Hospitalization and Domiciliary Hospitalization Benefit Policy issued by o.p. but all in vain. Under such condition complainant found no other alternative but to file this instant case before this Forum with the prayer as contained in the prayer portion of the petition of complaint.
O.ps. had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case. During the submissions o.ps. submitted that it appears from the claim form that complainant has not claimed any amount of money which has been annexed by complainant himself in the petition of complaint. O.ps. further stated that complainant has submitted a bill for Dr. Dhruba Mitra and break up details of package charges amounting to Rs.10,600/- only and which has been annexed by complainant at page no.25 of the petition of complaint.
Moreover, o.ps. further stated that the treatment was done in OPD and he was not admitted in the hospital for at least 24 hours and such provision is not there in the policy towards reimbursement of any treatment which has been done in OPD without admission in the hospital. Besides, o.ps. further stated that there is no prescription of any doctor wherefrom it reveals that complainant has been advised by any doctor for hospitalization and such provision is not there in the policy that reimbursement might be awarded even if there is no advice of doctor for hospitalization to complainant.
Decision with reasons:
Upon considering the facts and circumstances and submissions of the parties and on careful scrutiny of the entire materials on record, we are of the view that complainant has admitted in hospital on 28.12.10 and discharged on 29.12.10. So it is clearly evident that complainant has admitted in the hospital for a day. Though it is true that complainant has not made any amount in the claim form for reimbursement of his treatment, but it appears from letter dt.8.11.11 that complainant made a communication to o.ps. for reimbursement of Rs.1,52,453.20 total expenditure incurred by him towards his treatment as stated above.
So it appears that complainant has admitted in the hospital for one day. So the ground for repudiation of o.ps. vide their letter dt.18.11.11 as stated above that there is no claim for reimbursement is not possible by them for OPD treatment is not tenable since complainant has admitted for a single day for his treatment in the hospital.
After considering the record we are of the view that complainant has not filed the bills or any document or whatsoever wherefrom it reveals that he has incurred Rs.1,52,453.20 towards his treatment. Moreover, he has not claimed any amount in the claim form. Under such circumstances, this Forum is not in a position to allow the case but to reject the instant case due to lack of the documents in details in respect of the expenditure incurred by him for the treatment as stated above.
Hence, ordered,
That the case is dismissed on contest without cost against the o.ps.
Supply certified copy of this order to the parties free of cost.
