Order No. 12 dt. 06/02/2017
The case of the complainant in brief is that the complainant was insured with o.p. by paying a premium of Rs.7475/-. The complainant is a housewife and sum insured was Rs.2,25,000/-. The complainant underwent laparoscopic Ovarian Cystectomy surgery by renowned Dr. Pranab Dasgupta at Bhagirathi Neotia Mother & Child Hospital. Being insured under the said health insurance policy Gold brought by o.p. the complainant through her husband claimed an amount of Rs.1,67,274/- for the aforesaid surgery. The o.p. through its TPA agreed to pay an amount of Rs.32,728/- after deduction of Rs.1,34,546/- on the ground that the document from the hospital was not submitted. The claim of doctor’s fees of Rs.1 lakh was not payable as per clause 1.2 C. DVD charge of Rs.450/-, attendant charges of Rs.3300/- and other amount was deducted from the claim of the complainant. In order to prove the fact that the complainant paid the doctor’s fee of Rs.1 lakh the document was submitted by the complainant but the same was not accepted by o.p. In view of the said fact the complainant has prayed for the amount of Rs.1 lakh plus the amount o.p. agreed to pay to the complainant along with other reliefs.
The o.p. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that since the documents were filed by the complainant towards the medical expenses incurred by her therefore the said amount was not paid. As per the terms and conditions of the policy the claim of the complainant was denied. In view of the said fact o.p. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy at the relevant point of time.
- Whether she had undergone treatment in the said hospital.
- Whether the complainant paid an amount of Rs.1 lakh to Dr. Pranab Dasgupta for operating the said patient.
- Whether there was any deficiency in service on the part of o.p.
- Whether the complainant will be entitled to get the relief as prayed for.
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant had the valid policy at the relevant point of time and she had the problem for which she was admitted to Bhagirathi Neotia Mother & Child Hospital and she underwent laparoscopic Ovarian Cystectomy surgery by renowned Dr. Pranab Dasgupta. From the documents filed by the complainant it can be found that the complainant produced all the documents including doctor’s fee, since the said amount was not mentioned in the hospital bil, o.p. refused to allow the said bill. The complainant after coming to know of the said fact contacted the said doctor who operated upon the complainant and he wrote to the insurance company regarding his receiving the amount of Rs.1 lakh from the said patient / complainant. The complainant also submitted the documents to show that the said operation was done upon the complainant in the said hospital. Simply because the hospital did not include the amount paid to the said doctor on that score only the claim of the complainant cannot be denied.
Ld. lawyer for o.p. argued that since the amount was not mentioned in the hospital bill therefore the said amount was not allowed. If this Forum finds that the payment was made by the complainant to the doctor for the said operation and the operation was held in the said hospital after considering all those documents necessary order may be passed.
Considering the submissions of the respective parties it appears that the complainant had the valid policy at the relevant point of time. It is also an admitted fact that the complainant was admitted to the Bhagirathi Neotia Mother & Child Hospital for undergoing operation. The documents filed by the complainant including letter sent by the doctor regarding his receiving of the amount from the complainant towards his fees was mentioned in the hospital documents which has been annexed by the complainant it appears that the complainant was operated by Dr. Pranab Dasgupta which goes to show that the complainant paid an amount to the doctor in respect of the operation done by him. Therefore it cannot be said that the complainant did not pay the doctor’s fees and since the said fact was not mentioned in the hospital bill, but considering the entire documents filed by the complainant it can be found and it is also well established that the amount of Rs.1 lakh was paid to the doctor by the complainant for undergoing the said operation. Considering all these aspects we hold that the complainant will be entitled to get the reimbursement of the medical expenses incurred by her for her treatment at Bhagirathi Neotia Mother & Child Hospital with regard to the amount already the o.p. agreed to pay the sum of Rs.32,728/- plus Rs.1 lakh towards the doctor’s fees. Since the complainant had already received an amount of Rs.32,728/-, therefore the o.p. is directed to pay an amount of Rs.1 lakh. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.629/2014 is allowed on contest with cost against the o.p. The o.p. is directed to pay the complainant a sum of Rs.1,00,000/- (Rupees one lakh) only along with compensation of Rs.10,000/- (Rupees ten thousand) only for harassment and mental agony and litigation cost of Rs.2000/- (Rupees two thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
