BEFORE THE DISTRICT CONSUMER REDRESSAL COMMISSION

UNOKUTI DISTRICT : KAILASHAHAR

 

                                    C A S E   NO. C. C. 05/2019

 

SHRI SAJAL KANTI DEB,

S/o- Lt. Krishna Sundar Deb

Of -Fatikroy,

PO -Fatikroy, 

PS and Sub-Div:- Kumarghat 

Unakoti District

                                                                                      …......COMPLAINANT.            

           V E R S U S

 

UNITED INDIA INSURANCE COMPANY LTD,

PO & PS:- Kailashahar,

Sub-Div:- Kumarghat

Unakoti District

Represented by the Branch Manager

                                     

….....OPPOSITE PARTY.

                                                     

               P R E S E N T

 

                                       SHRI J. M. MURASING

                                               PRESIDENT

                   DISTRICT CONSUMER REDRESSAL COMMISSION

                                 UNAKOTI DISTRICT::KAILASHAHAR

          A N D

                                     SHRI P. SINHA, MEMBER

       SMT. M. DATTA, MEMBER

 

                         C O U N S E L

 

                      For the Complainant :- Mr. C. Bhattacharjee , Advocate

         & Mr. Prantosh Das, Advocate                      

      For the OP                :- Mr. G. De, Advocate

                                     

                    ORIGINAL DATE OF INSTITUTION :12-03-2019

 

JUDGMENT DELIVERED ON :22-03-2020

 

                        J U D G M E N T

 

This is a complaint preferred by the complainant Sri Sajal Kanti Deb U/s 12 of the C.P. Act, 1986 against the opposite party praying for passing necessary order directing the opposite party to make payment of Rs. 48,000/-(Rupees forty eight thousand) and also to pay compensation for rendering pain and sufferings to the complainant by its deficient service.

2. The facts leading to the filing of the instant complaint petition are that the complainant took an individual health policy under the opposite party vide No. 1309812815P114509198 and the policy was in respect of 3(three) persons viz. Sajal Kanti Deb, the complainant, Smt. Manisha Deb, wife of the complainant and Sri Subhamit Deb, son of the complainant and the insured amount against each insured was              Rs. 2,50,000/- and the policy was valid from 26.02.2016 to 25.02.2017. It is stated in the complaint petition that on 09.01.2016 the wife of the complainant, Smt. Manisha Deb, got admitted at ILS hospitals, Agartala with ailments of “Urticarial Vascularise-Hypothyroidism” and she was treated in the ILS hospitals upto 13.01.2017. After admission of his wife at ILS hospitals the complainant informed the registered TPA of the opposite party, namely, “Heritage Health TPA Private Ltd”  for cashless facilities and submitted all the investigation report. On 11.01.2017 Heritage Health TPA Private Ltd informed the ILS hospitals to the effect that the patient (Smt. Manisha Deb) is not entitled to get authorization for cashless hospitalization. On 12.01.2017 the Medical Superintendent of ILS hospital informed the Heritage Health TPA Private Ltd that the patient is not suffering related to her Hypothyroid status and as such, she is entitled to get cashless treatment. In the complaint petition the complainant stated that at the time of discharge of his wife from the ILS hospital he paid Rs. 48,000/-(Rupees forty eight thousand)  as total payment of hospital charge. On 30.07.2017 the complainant made a prayer before the Divisional Manager of the OP and also wrote letter on 26.02.2018.  On 16.03.2018 the complainant received a letter from the OP whereby the OP requested the complainant to send the original documents for settlements of his claim and as the complainant had already sent the copy of documents to the OP on 30.07.2017, the complainant informed the same to the OP on 30.04.2018 by a letter.

 

3. It is further contended in the complaint petition that he inquired about his claim with the OP several times, but no positive reply was given from the part of the OP. as per terms and conditions of the Insurance Policy the complainant is entitled to get cashless treatment for the insured person and as such, he is entitled to get hospital cost of Rs. 48,000/- (Rupees forty eight thousand). As the OP did not pay the amount to the complainant in spite of his repeated correspondences, he suffered a lot and as such, he also prayed for proper compensation and interest besides the treatment cost of Rs. 48,000/- (Rupees forty eight thousand). 

 

4. On receipt of the notice OP appeared and contested the case by filing written statement stating, inter alia, that the instant claim petition is not maintainable in its present form and nature, there is no cause of action against the answering OP, that the claim petition is baseless and the complainant is not entitled to get any compensation, that the claim petition is barred for non-joinder of necessary parties. It is further stated by the OP in the written statement that it is totally false that on 09.01.2016 the wife of the complainant was admitted at ILS hospitals, Agartala and she was treated there up to 13.01.2017. The OP denied that the complainant informed the registered TPA of the OP, namely, Heritage Health TPA Private Ltd. for cashless treatment and the OP also denied that the complainant paid hospital charge of Rs. 48,000/- and the cash memos submitted before the forum are not correct.  As per OP, the real fact is that the complainant for taking illegal gain filed this claim petition as the treatment taken by the complainant does not fall under the policy and the disease mentioned is also not covered under the terms and conditions of the policy and as such, the OP is not bound to pay any compensation to the complainant. The OP prayed for dismissal of the claim petition preferred by the complainant.  

 

5. Complainant has adduced evidence by way of examination-in-chief on affidavit as PW-01 in the same line as stated in his complaint petition and as such, for the sake of brevity his evidence is not repeated. However, during re-examination, complainant has exhibited the following documents: -

 

(i) Original insurance policy issued by the OP in the name of the complainant: - Exbt.1.

(ii) Original health card issued by the Heritage Health TPA Pvt. Ltd. in the name of the complainant, his wife Smt. Manisha Deb and his son Subhamit Deb: - Exbt.2,

(iii) Original guide book of the Heritage Health TPA Pvt. Ltd.: - Exbt. 3.

(iv) Letter of information addressed to the Officer In-Charge, United India Insurance Co. Ltd., Kailashahar, Unakoti District submitted by the complainant: - Exbt. 4.

(v) Information issued by the Heritage Health TPA Pvt. Ltd. regarding denial of the claim of the complainant addressed to the ILS hospital, Agartala, Tripura: - Exbt. 5.

(vi)  Letter issued by the Medical Superintendent, ILS hospital, Agartala addressed to the Heritage Health TPA Pvt. Ltd. regarding denial of cashless hospitalization of Smt. Manisha Deb: - Exbt. 6.

(vii)Certificate issued by the Medical Superintendent, ILS hospital, Agartala in favour of the wife of the complainant: - Exbt. 7.

(viii) Letter issued by the complainant addressed to the Divisional Manager of the OP: - Exbt. 8.

(ix) Letter dated 26.02.2018 issued by the complainant addressed to the Divisional Manager of the OP: - Exbt. 9. 

(x) Letter dated 16.03.2018 issued by the OP addressed to the complainant: - Exbt. 10.

(xi) Letter dated 25.04.2018 issued by the complainant addressed to the In-charge, Kailashahar, Micro Office of the OP: - Exbt. 11.

(xii) Discharge summary issued by the ILS hospital, Agartala in favour of Smt. Manisha Deb, the wife of the complainant: - Exbt. 12.

(xiii) Bills/vouchers issued by ILS hospital, Agartala in respect of the treatment of Smt. Manisha Deb, the wife of the complainant      (7 sheets):- Exbt. 13/1 to 13/7.

(xiv) Original prescriptions in respect of the complainant: - Exbt. 14.

(xv) Document hand over receipt in respect of the treatment of Mrs. Manisha Deb, the wife of the complainant and copy of forwarding of the treatment related documents of Smt. Manisha Deb, the wife of the complainant by the OP to its Divisional Office : - Exbt. 15/1 & 15/2. 

 

 

In cross, to the question put by the OP counsel complainant denied that after sending the letter to the Insurance Company regarding claim of his Mediclaim, he did not make any correspondence with the Insurance Company and further denied that there is no date on which he corresponded with the OP insurance company and that the documents submitted by the complainant to the Heritage Health TPA Pvt. Ltd. are not genuine.

 

6. Heard argument of both sides.

In course of argument Learned counsel of complainant submitted that as per terms and conditions of the Health care Insurance Policy the wife the complainant is entitled to cashless treatment facility being insured and the policy was insured by the OP and during the period of treatment the policy was valid. The OP willfully denied the claim of the complainant and deceived him and complainant had to make several correspondences with the OP for getting the cost of the treatment, but no payment was made by the OP and his case being legitimate one the complainant apart from the cost of the treatment is also entitled to compensation and interest. 

 

In the argument Learned counsel of the OP only reiterated that the complainant failed to produce the authentic documents to the OP regarding the treatment of his wife and as such, the OP denied to pay the claimed amount to the complainant. This apart, no other point was raised by the Learned counsel of the OP.

 

7. The only point required to be adjudicated in this case is whether the complainant is entitled to treatment cost of Rs. 48,000/- which has been incurred towards treatment of his wife at ILS hospitals, Agartala along with compensation and interest?

 

DECISION AND REASONS FOR DECISION

 

8. From Exbt.1, Family Medicare Policy, which includes the complainant, his wife Smt. Manisha Deb and his son Shri Subhamit Deb, it is found that complainant took policy No. 1309812815P114509198 from the United India Insurance Co. Ltd. and the policy had its coverage from 26.02.2016 to the midnight of 25.02.2017. The policy was Family Medicare Policy and the sum insured was Rs. 2,50,000/- and under that policy insured were Sri Sajal Kanti Deb, the complainant, his wife Smt. Manisha Deb and his son Shri Subhamit Deb. 

 

  It is stated in the policy as follows: -

“This policy witnesses that subject to the terms, conditions, exclusions and definition contained hear in or endorsed, or otherwise expressed hereon the company undertakes that if during the period stated in the schedule or during the continuance of this policy by renewal any insurer persons shall contract any diseases or suffer from any illness or sustained any bodily injury through accident and if such diseases or injury shall require any such insurer person upon the advice of the duly qualified physician/medical specialist/medical practitioner or of a duly qualified surgeon to incurred hospitalization expenses for medical/surgical treatment at any Nursing Home/Hospital/Day care Center in India as herein defined as an inpatient, the company will pay through third part administrator(in short TPA, to the Hospital/Nursing Home or the insure person the amount of such expenses incurred as are medically necessary and reasonable and customary in respect thereof by or on  behalf of  such insured person but not exceeding the sum insured in aggregate in any period of any insurance.” 

 

From Exbt.12, discharge summary, issued by ILS hospitals, Agartala in favour of Mrs. Manisha Deb, wife of Sajal Kanti Deb, it appears that Smt. Manisha Deb was admitted to ILS hospitals on 09.01.2017 with complaint of Rosular rash over both thigh back and abdomen and itching having past medical history of Hypothyroidism. After all relevant investigation patient was kept for observation and conservative management was given. She was discharged on 13.01.2017 with the advice for taking medicines prescribed the doctors. From Exbt. 13/1 to 13/7, the bills/vouchers, issued by the ILS hospitals, Agartala in favour of the patient Smt. Manisha Deb, it is found that for the purpose of the treatment wife of the complainant, the complainant incurred an expenditure of Rs. 48,000/-. From Exbt. 4, it is found that the complainant informed the officer In-charge of the United India Insurance Co. Ltd., Kailashahar, Unakoti District, the OP, that his wife Smt. Manisha Deb was admitted to ILS hospitals on 09-01-2017 and requested to have cashless treatment facility. Exbt. 2 is the Health Card issued by the TPA, Heritage Health Pvt. Ltd. From the said document(Health Card) it is found that the wife of the complainant being an insured person is entitled to have cashless treatment facility.  From the guide book issued by Heritage Health TPA Pvt. Ltd. Exbt. 3 it is found that ILS hospitals, Agartala is the registered Hospital/Nursing Home in Tripura for the purpose of having cashless treatment facility. As it was within the knowledge of the complainant that ILS hospitasl, Agartala is the Centre in Tripura for getting cashless treatment facility for any insured covered under the policy of Family Medicare, issued by the opposite party having in collaboration with the Heritage Health Pvt. Ltd., the TPA, considering  the urgency of the treatment the complainant took his wife straightway to the ILS hospital, Agartala, but it is quite astonishing that Heritage Health TPA Pvt. Ltd. issued a letter dated 11.01.2017 to the ILS hospitals, Agartala in response to the request of the ILS hospital for authorization of cashless service to be rendered to the wife of the complainant, an insured under the policy, informing that they are unable to issue the authorization letter for the following reasons:-

 

CASHLESS DENAIL AS PER POLICY TERMS & CONDITION

LOOKING AT THE RECENT POLICY(26.02.2016) AND PRE-EXISTING NATURE OF THE DISEASE(HYPER SENSATIVITY REACTION, ROSEOLA RASHES, PATCHES OVER BODY DUE TO LONG TERM MEDICATIONS FOR HYPERTHROIDISM SINCE 5 YRS) WE REGRET OUR INABLITY TO SANCTION CASHLESS AUTHORIZATION(CL. NO. 4.1 FAMILY MEDICARE POLICY/UII).

 

Exbt. 6 is a very important letter dated 12.01.2017 addressed to the authorized signatory to the Heritage Health TPA Pvt. Ltd. issued by the Medical Superintendent, ILS Hospitals, Agartala wherein it is found that information has been given to the Heritage Health TPA Pvt. Ltd. to the effect that Mrs. Manish Deb(CCN No. : HH461700531) was admitted with a severe form of Articarial Vasculitis and it was not related to her Hypothyroid status or tis treatment and it is also specifically stated in the said letter dated 12.01.2017 that the patient (Mrs. Manisha Deb) is not suffering from Hyperthyroidism as mentioned  in the denial letter. In the State of Tripura ILS hospital is a referral hospital and patients are treated there by the expertise doctors and so opinion of the ILS hospitals can be considered as the final opinion. The OP just mechanically denied the claim of the complainant on the basis of the clause No. 4.1 of the insurance policy, they did not make any inquiry as to the correctness of the opinion of the ILS team of doctors and as such, there is no scope on the part of the Heritage Health TPA Pvt. Ltd. to detract from the opinion of the doctors of ILS hospitals. As the ILS hospitals, Agartala is the registered Hospital/Nursing Home in the state of Tripura for getting cashless facility of treatment, the OP has most illegally denied the claim of the complainant. The policy of the insurance was valid during the period of treatment and for the purpose of getting cashless treatment, the wife of the complainant was also having health card issued by the Heritage Health TPA Pvt. Ltd.. As it was the liability of the insurer, the OP in the instant case to pay the amount to the complainant, the said OP did not pay the cost of the treatment, rather the complainant had to undergo much pain and suffering for correspondence with the OP to get his claim settled.  From the Exbt. 15/1 & 15/2, it is found that all the treatment related documents were submitted by the OP to the Heritage Health TPA Pvt. Ltd. through its Divisional Office, but ultimately no payment was made by the OP, though it was the obligatory duty of the OP to arrange cashless payment of the treatment cost to the wife of the complainant. 

 

All these discussions only go to say that the OP was not at all dutiful in disbursement of amount to the complainant, rather the OP is found to be very much deficient in rendering service to the complainant. 

 

9. Having considered all the documents and aspects, we order that the complainant is entitled to the treatment cost of his wife amounting of Rs. 48,000/-. We further order that as the complainant had to suffer much pain and suffering, OP is to pay a compensation of Rs. 5000/- to the complainant. The complainant is also entitled to get interest @ of 7% per annum on payable amount of Rs. 53,000/-.

 

10. The point is decided accordingly in favour of the complainant.

 

ORDER

                         

11. In the result, it is ordered that the complainant is entitled to the amount of Rs. 53,000/- (Rupees fifty three thousand) from the OP-insurance company with 7% interest per annum from the date of filing of this claim petition on and from 12.03.2019. The OP has to pay the amount with interest to the complainant within a period of 2 months, falling which the OP has to pay penal interest @ 9 % p.a till the date of actual payment. 

 

12. With this observation, the complaint filed by the complainant stands disposed of on contest.

 

 13. Furnish copy of this judgment to the complainant and O.P free of cost through their respective learned counsels.

 

                          ANNOUNCED

                                                                          (J.M. Murasing)

                                                                             PRESIDENT

         (P. SINHA)            (M. DATTA) 

         MEMBER               MEMBER