In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No. 394 / 2010.
1) Sri Sanjib Kumar Bera, Chartered Engineer,
EX-187, Salt Lake City, Sector-I, Kolkata-700064. .---------- Complainant
---Versus---
1) TPA Family Health Plan Ltd.,
16/2, Lake View Road, 1st Floor, Kolkata-700029.
2) National Insurance Co. Ltd.,
J.L. Nehru Branch, 8, India Exchange Place, Kolkata-700001.
Presently shifted to
Salt Lake Branch, Gr. Floor, 31, GN Block, WBFCL Building,
Sector-V, Salt Lake, Kolkata-700091. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Smt. Jhumki Saha, Member.
Dr. A. B. Chakraborty, Member
Order No. 15 Dated 22/03/2012.
It is the specific case of the complainant, Shri Sanjib Kr. Bera that in spite of availing himself of a valid mediclaim policy for Rs.75,000/- duly issued by o.p. no.2 vide annex-A, o.p. no.2 repudiated the claim of the complainant for Rs.34,952/- which arose in the month of Feb, 2007. Complainant took the said policy being no.100302/48/05/8500004002 through o.p. no.1, third party administrator of o.p. no.2, that is only responsible for processing and facilitating the entire process in the event of any claim arises.
On advice of the house physician of the complainant as he felt chest pain and had profuse sweating on 27.2.07 complainant was taken to hospital vide annex-A1. And the team of doctors of the said hospital examined and advised immediate hospitalization vide annex-B. But when it was informed to o.p. no.1, TPA, cashless service was denial vide annex-C, stating th4e ground. Even hospital authority tried to contest the view of TPA stating that it was a case of hospitalization, vide annex-D. But TPA o.p. no.1 remained silent. After being discharged by the hospital complainant submitted his claim for Rs.34,952/- along with supporting documents as per o.p. no.1’s direction on 21.3.07. But o.p. no.1 repudiated his claim after waiting or seven months vide letter dt.6.10.07, annex-E stating therein that his hospitalization was only for investigation and evaluation of the ailment which could have been done in out patient centre and there was no necessity of admission for the same. As the complainant was not satisfied with the ground of repudiation, he wrote to some high officials of o.p. no.2 vide annex-G. But on constant follow up with o.p. no.2 by complainant, o.p. no.2sent another letter on 23.3.10 stating therein the reasons including a clause of pre-existing one for non-payment of h e claim of the complainant. He also received some other letters from other officials of o.p. no.2 repudiating his legitimate claim. Complainant also stated that he was not hospitalized on his own. Firstly his house physician and secondly a panel of doctors of the hospital advised for his hospitalization which is also a pre-condition of his mediclaim policy incorporated as item no.1 which states that if any insured person upon the advice of a duly qualified physician / medical specialist / medical practitioner or of a duly qualified surgeon incurs any hospitalization expenses, it would be reimbursed. Accordingly, the ground taken by o.p. no.1 has got no meaning. At the same time the policy was first taken on 29.3.01 and the claim arose in 2007. So, the ground of pre-existing disease is also not tenable equally. Being frustrated, complainant filed this complaint praying for a direction to be given upon the o.ps. to reimbursement the claim Rs.34,952/- along with 12% interest, to pay Rs.15,000/- as compensation and Rs.5000/- towards cost along with other order or orders as the Forum may deem fit and proper. Notices were served upon o.ps. O.p. no.(ii) appeared and filed w/v but o.p. no.(i) never appeared and filed w/v. Accordingly, case was heard ex parte against o.p. no.(i).
Decision with reasons:
We have gone through the w/v of o.p. no.(ii), National Insurance particularly para no.7 where o.p. no.(ii) repeatedly said that that complainant got hospitalized on his and if it was on advice of doctor/doctors, it should have been proved by adducing evidence. But here we fail to accept this plea of o.p. no.(ii) as we have perused prescription dt.27.2.07, annex-A1, where it is clearly written ‘hospitalization against Advice column which also corroborates the prescription of the hospital dt.27.2.07. Complainant was admitted on 27.2.07 and discharged on 2.3.07. It was not the luxury of the complainant to get admitted to a hospital. And without investigation doctors cannot come to a conclusion. Investigation is a part and parcel of a proper treatment. At the time of discharge, complainant was advised to take several medicines with a direction to check up. After taking premium from the complainant regularly o.p. no.(ii) should not be allowed to evade their responsibility. As human being, we are carrying various diseases which is not within out knowledge. When we came across problems after proper investigation actual disease is detected. The taking of a plea like ‘pre-existing’ is nothing but an arbitrary action and unfair trade practice of o.p. no.(ii) which is not at all acceptable in the eye of law. Principle of natural justice also demands that when o.p. nos.(ii) took premium from complainant, it is their binding duty to pay the legitimate claim of he complainant. By not doing so, o.p. no.(ii) is found to be deficient in service by way of their sheer negligence towards the complaian nt. Accordingly case succeeds on merit against o.p. no.(i) and (ii) with cost.
Hence, ordered,
That o.ps. are jointly and severally directed to pay Rs.34,952/- (Rupees thirty four thousand nine hundred fifty two) only to complainant within 45 days from the date of communication. The o.ps. are further directed to pay Rs.10,000/- (Rupees ten thousand) only as compensation and Rs.2000/- (Rupees two thousand) only as litigation cost. The o.ps. are directed to comply with the order within 45 days from the date of communication of this order, i.d. it will carry an interest @ 10% p.a. till full realization.
Supply certified copy of this order to the parties.
_____Sd-_____ _______Sd-______ _______Sd-_______
MEMBER MEMBER PRESIDENT
