Complainant by filing this complaint has submitted that since 1998 she has been holding a Mediclaim Policy under the op and same is being renewed year to year and lastly it was renewed on 13.10.2013 for the period from 13.10.2013 to 12.10.2014 having Policy No. 030300/48/11/97/00004780.  During subsistence of the validity of the said Mediclaim Policy, complainant became seriously ill at about 3:00 P.M. on 17.06.2012 and that was due to tooth extraction two days back and at the time of feeling unwell of some portion of the anesthetic compound swallowed which was the cause as stated during admission and subsequently complainant came to know that swallowing of anesthetic agent cannot be the cause of any infection as per dentist.

          So, complainant took admission at Calcutta Medical Research Institute (CMRI) and during treatment the doctor of the said hospital detected that no infection at tooth extraction site and Dr. S.S. Nandi, M.D. the eminent doctor of that institute confirmed that patient was admitted with Urinary Tract Infection and the tooth extraction had no problem.  Thereafter complainant was treated for Urinary Tract Infection at CMRI and for treatment paid the entire bill of her.  Thereafter complainant submitted her claim being Claim No. 030300/48/12/97/90000 percent percent4 and on receipt of the claim application, same was repudiated as no claim vide their letter dated 28.09.2013 on the ground -any kind of tooth extraction is not payable under Clause No. 4.8 under the terms and conditions of the policy- and for refusal of the claim by the op is nothing but arbitrary decision having no basis and the repudiation of the claim is without considering the papers and documents properly and for which for deficiency of service, complainant has filed this complaint praying for allowing the claim and to direct the op to pay the same along with compensation, interest etc.

          On the other hand op by filing written statement submitted that no doubt complainant is holding the said policy having its validity period from 13.10.2013 to 12.10.2014 and it was individual mediclaim policy.  Fact remains complainant on 16.06.2012 underwent tooth extraction and during such process she swallowed anesthetic agent which was used during the extraction and following such she started feeling uneasiness like headache, rise in temperature, palpitation, vomiting, pain in abdomen, etc. and with the trail of such symptoms on the next following dated i.e. 17.06.2012, she was admitted at the CMRI and thereafter was discharged on request on 27.06.2012 and during hospitalization of the complainant, pre-authorisation request form for cashless authorization was filled up by the treating doctors of the CMRI in which the diagnosis was for ‘infected tooth’ for which conservative medical treatment was administered with application of antibiotics.

          It is specifically mentioned that it is apparent from the content of the said pre-authorisation request from for cashless benefit, filled up by the treating doctors of CMRI that the complainant was treated for infected tooth and not for other disease.  It is further mentioned that no expert opinion of any dental surgeon is credence with the complaint so as to rebut such medical proposition.  More so significantly no bio-chemistry and/or pathological report of urine of the complainant has been filed with the complaint to show the alleged infection of RTI.  However subsequent to discharge on request from CMRI, complainant submitted claim form for reimbursement of hospitalization expenses on 06.07.2012.

          It is further submitted that TPA being the authority sought for necessary doctor’s advice for hospitalization of the complainant, all relevant bio-chemistry, pathological report, treatment sheet, first prescription and f\confirmation of diagnosis by the treating doctor from the CMRI by their letter dated 19.06.2012 addressed to CMRI and it appeared to the paneled doctor of the relevant TPA that conservative treatment to the complainant was made following infected tooth and that no urine report and chest x-ray report are credence from which at least the medical proposition of alleged infection of urinary track and lower respiratory tract infection can be deduced.

          After scanning the medical treatment sheet, available bio-chemical reports, it was concluded by the doctors of the TPA that in fact a preservative treatment was given to the complainant following infected tooth and nothing more and since any expenses incurred on tooth extraction and/or dental treatment or surgery of any kind, is not payable within the purview of exclusion clause of the pertinent policy.  So, the claim was repudiated as no claim and in turn as per necessity this op by their letter dated 28.09.2013 addressed to complainant repudiated the claim on the ground stated earlier as stated therein.

It is further submitted that subsequent certificate of Dr. S.S. Nandi of CMRI dated 13.10.2012 stating that complainant was treated for acute U.T.I. and treatment had no relation to tooth extraction is nothing but perfunctory and collusive for that said medical certificate did not explain firstly as to why such certificate was issued, secondly there was no medical explanation as to what prompted that doctor to issue such certificate without furnishing and/or referring urine report and chest x-ray report of the complainant which in fact go to reflect that complainant was infected with UTI and lower respiratory tract infection and as such no credence can be attached to such certificate and in the above circumstances there was no ground for allowing such claim when the expenses incurred on treatment of post tooth extraction infection, the said expenses is not covered by the exclusion clause of the relevant policy and as such the claim was repudiated as no claim.  So there was no negligent and arbitrary act on the part of the op is proved and for which this complaint should be dismissed.

Decision with reasons

On proper study of the complaint including the written version and also considering the discharge summary issued by CMRI, it is clear that she was hospitalized at the said institute on 17.06.2012 and was discharged on 27.06.2012 with a history of uneasiness, dizziness, dysuria along with mild shortness of breath having her past history of tooth extraction one day back that means it is a fact that her tooth was extracted on 16.06,2012 but she has not claimed any amount in respect of tooth extraction.  But on proper consideration of the entire discharge summary issued by the CMRI, it is found that after clinical test and investigation, it is found that it was diagnosed as acute Urinary Tract Infection, Lower Tract Respiratory Infection, Altered Hepatic function with dilated CBD, Hypothyroid, Hypertension, Ischemic Heart Disease etc. and treatment was given thereafter she somehow recovered and was released on 27.06.2012 and from the bed head ticket, it is found that it is the cause of acute lower tract respiratory infection, altered hepatic function having dilated CBD, hypothyroid, hypertension and ischemic heart disease etc. and after treatment she gradually recovered and discharged from CMRI on 27.06.2012.

Fact remains that complainant was admitted with history of acute urinary tract infection and lower urinary tract infection and she prayed for release of total amount of Rs.1,44,6 percent1/- that means complainant has prayed for release of the said amount as against her mediclaim.  But after hearing the Ld. Lawyers of both the parties and also considering the policy document, it is found that policy covers an insured amount of Rs. 1 lac.  But complainant has claimed Rs. 1,44,6 percent1/-.  So, in any circumstances, complainant is not entitled to claim more than Rs. 1 lac. 

Considering the entire fact and circumstances and materials, we find that complainant was in the said hospital from 17.06.2012 to 27.06.2012 and claim was rejected on 22.06.2012 and finally claim was repudiated on 28.09.2012 and present complaint was filed on 17.04.2014.  No doubt it is within time but fact remains from the repudiation of claim by the op, it is clear that complainant inspite of reminders did not file certain documents.  Whatever it may be, it is fact that there was no direct or indirect effect of tooth extraction for the subsequent treatment for UTI and other treatment for the period from 17.06.2012 to 27.06.2012.

No doubt complainant is not entitled to get Rs. 1,44,6 percent1/- as treatment cost.  But her claim shall be consideredsame within the insured amount of Rs. 1 lac.  But as because it was the claim of the complainant, we find that it is impossible for the Forum to assess the actual responsibility of the op to pay.  So, considering that fact, we are passing such necessary order by directing the ops to take such necessary step and to dispose of the claim application which has been repudiated no doubt without any medical foundation in respect of the treatment of the lady/complainant for the period from 17.06.2013 to 27.06.2013 and ops shall have to consider her claim without considering the present treatment and cost for such ailment with tooth extraction and op shall not have to consider the tooth extraction at all but only to consider the treatment documents for the period from 17.06.2013 to 27.06.2013 and to assess the claim of the complainant and the complainant is entitled to such amount as per terms and conditions of the policy.  As we have gathered that complainant as per policy condition is not also entitled to Rs. 1 lac also because certain items in respect of which complainant is not entitled to get such claim.

Hence, it is

ORDERED

So, we are directing the op to restore the said claim application and only to consider what the complainant is entitled to in respect of her prayer out of the insured amount of Rs. 1 lac as per terms and conditions of the policy and in this regard complainant shall have to submit the detail bill for her treatment in the said hospital and in this regard ops may check- up the detail bill etc. from hospital authority and as per terms and clause of the contract shall dispose of the claim application of the complainant and do the needful within 4 percent days from the date of this order and without asking the complainant to file further document.  If bill and other documents are required, op shall have to go to CMRI to check up and collect required documents and dispose of the matter and settle the claim finally and to collect her bank account number and settle the amount within 4 percent days from the date of this order and if op fails to comply that order within the 4 percent days of this order in that case op shall have to release the final amount of Rs.  percent0,000/- to the complainant and if the order is not complied with by the ops in that case ops shall have to pay penal damages  at the rate Rs. 200/- per day which shall be paid to this Forum till full satisfaction of the decree and even penal action shall be started against them for implementation of this order for which they shall be further prosecuted and further penalty and fine may be imposed.

Accordingly the complaint is allowed in part but without any cost against the ops.

Ops shall have to comply the order as already mentioned in the body of the judgement and that portion of the order shall be the part of this order and op shall have to strictly comply this order otherwise the necessary penal action shall be started against them.