JUDGEMENT

          Complainant by filing this complaint has alleged that he has taken the Health Insurance Policy for himself and his wife in the year 1999 for a covered insured sum of Rs.1 lac each from the op and said Health Insurance Policy was renewed year to year by paying the renewal premium, last of such Mediclaim Policy was renewed for the period 2011 to 2012 as the terms, conditions and clauses attached to the declaration dated 14.12.2001 and the said insurance coverage was increased up to Rs.1,25,000/- each by adding bonus on the basis sum assured of Rs.1 lac.

          During continuation of the said Insurance Policy, complainant was advised by doctor for operation of prostrate and operation was done on 20.06.2012 by renowned surgeon Dr. Dilip Karmakar (Urologist) at Kalidas Mullick Sebayatan at 47, Ganesh Chandra Avenue, Kolkata – 13 and due intimation for the same was submitted to the op and thereafter complainant was discharged from the said Nursing Home on 24.06.2012 and after that complainant submitted claim against the Health insurance policy bearing No.030800/48/11/97/00006177 for the total amount of Rs.36,814/- along with the original documents and papers and at the time of submission of such claim papers, documents were fully scrutinized by the TPA authority and accepted the same without raising any objection thereto.  But subsequently, TPA sent a cheque of Rs.10,504/- against full and final settlement of the complainant and it appears from the said report that TPA has deducted some amount of Rs.26,310/- which was indicated details in the said letter of the TPA dated 03.09.2010 and after receipt of the same complainant was perplexed because the TPA deducted Rs.20,000/- and Rs. 5,000/- the operation charge of Dr. Dilip Karmakar and Anesthesist’s charge of Dr. Sourendra Nath Konar.  But practically they issued receipts which were submitted and in their recipts it is specifically mentioned that they operated in the Kalidas Mullick Sebayatan at 47, Ganesh Chandra Avenue, Kolkata- 13 and so such sort of deduction is arbitrary, uncalled for and complainant did not submit any false bill as a honest practitioner of the Hon’ble High Court.  But the bill was wrongly rejected by the TPA and insurance company also did not consider the same on the ground that they relied upon TPA’s final bill.  In the circumstances, complainant has prayed for payment of balance of Rs.26,310/- including compensation.

          On the other hand, the insurance company by filing written statement submitted that insurer is liable to pay hospitalization bill only which does not include consultant charges and in regard to private expenses like bill of Dr. Dilip Karmakar and bill of Anesthetist Dr. S.N. Konar since it is not included in the hospitalization bill and no blood report is annexed so bill was Rs. 800/- was also deducted and further op submitted that practically everything was decided by the TPA as per terms and conditions of the policy.  So, present case is not tenable.

                                             Decision with reasons

          In the present claim case complainant has no doubt stated vividly the cause for filing the complaint and undisputed fact is that his prostate was operated by Dr. Dilip Karmakar under the control of Anesthesist  Dr. Sourendra Nath Konar at Kalidas Mullick Sebayatan at 47, Ganesh Chandra Avenue, Kolkata- 13 on 20.06.2012 and he was no doubt discharged on 24.06.2012 and admitted fact is that complainant submitted all papers and claimed Rs.36,814/- and out of that op deducted vital portion i.e. operation charge of Rs.20,000/- as it was received by Dr. D. Karmakar Urologist and Rs.5,000/- received by Anesthetic Dr. Sourendra Nath Konar.

          Anyhow in the receipt it is noted that surgery was done on 20.06.2012 at Kalidas Mullick Sebayatan at 47, Ganesh Chandra Avenue, Kolkata- 13, for which an amount Rs. 20,000/- by Professor Dilip Karmakar and Rs.5,000/- by Dr. S. Konar were received Probably TPA did not consider those two receipts drawing it as private consultant report and it was private expenses but fact remains that the said two doctors received the said amount as their operation charge or anesthesit charge and to that effect that receipt was granted and it was not private expenses and now a days in many nursing home or private hospital, the operation and anesthesia charge are being paid by the party separately because of certain complication arising in the hospital, nursing home and doctors engaged for operation and anesthesit work and in this case same incident happened.  So, we find that both doctors Dr. D. Karmakar, and S. Konar did not take the said fees as private expenses but after operation they took it and granted receipt and invariably it was paid by the party to the Kalidas Mullick Sebayatan at 47, Ganesh Chandra Avenue, Kolkata- 13 and granted receipt by the respective doctors because they are not their permanent doctors but they are hired doctors.  That matter was probably not considered by the TPA for some unknown reason and truth is that the said private nursing home Kalidas Mullick Sebayatan at 47, Ganesh Chandra Avenue, Kolkata- 13 ought to have endorsed by paying such amount but that was not done and that is fault for which the TPA refused to grant the said final amount.  Can a prudent man believe that prostate gland was operated but there is no bill for doctor fees or anesthesit fees.

          No doubt it was a fault on the part of the TPA.  TPA should amend it henceforth about assessment of claim of any patient.  Even if any bill is granted by the doctors after operation separately at the same time the insured shall have to produce those bills with seal and signatures of nursing home where he was operated and practically for some technical cause this vital matter was rejected by the TPA that was not at all legal, in view of the fact that it was not private expenses.  But it is part of entire operation.  Anyhow insurance company did not try to show for what reason vital operation charge and anesthesit charge were rejected.  But only it was their plea that as because it was consultant fees so it was rejected but the body of the receipts simply prove that it was charged by the surgeon and anesthesist for their operation work done on the present complainant in the said Kalidas Mullick Sebayatan at 47, Ganesh Chandra Avenue, Kolkata- 13.

          In view of the above findings, we are convinced to hold that no doubt the complainant is entitled to further Rs.25,000/- from the op as operation charge not operation related charge but claim related to operation has been paid to the extent of Rs.10,504/-.  But operation charge and anesthesist charge were rejected that was not justified.  In the light of the above we are convinced to hold that op is liable to pay further Rs.25,000/- out of the balance claim of Rs.26,310/-.  Complainant is entitled to get Rs.25,000/- (for operation charge and anesthesia charge) and op is legally bound to pay the same for final settlement of the entire claim of Rs.36,814/-  because for other charges a sum of Rs.10,504/- had already been paid.

          In the result complaint succeeds.

          Hence, it is

                                                      ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs.5,000/- against the op no.1 and same is dismissed against op no.2 without any cost.

          Op no.1 is directed to pay a sum of Rs.25,000/- as balance claim amount in respect of the claim made by the complainant along with a compensation of Rs.5,000/- so total sum of Rs.30,000/- shall be paid to the complainant by the op within 15 days from the date of this order failing which for each day’s delay op shall have to pay penal damages @ Rs.300/- per day till full satisfaction of the decree.