DATE OF FILING : 14-02-2011.
DATE OF FINAL ORDER : 09-12-2011.
Susanta Kr. Datta,
son of Late Keshab Lal Dutta,
Uttar Buxarah, Santragachi, P.S. Jagacha,
District –Howrah--------------------------------------------------------------- COMPLAINANT.
- Versus -
1. United India Insurance Co. Ltd.
having its regional office at
Himalaya House, 38-B, Jawarlal Nehru Road,
Kolkata – 700001.
2. Heritage Health Services ( P ) Ltd.,
having its office at NICCO House, 5 th floor,
2, Hare Street, Kolkata – 700001, and also
at 60, Lenin Sarani, Dharmatala,
Kolkata – 16.
3. West Bank Hospital,
Andul Road, P.S. Sankrail,
District – Howrah.-------------------------------------------------OPPOSITE PARTIES..
P R E S E N T
1. Hon’ble President : Shri T.K. Bhattacharya.
2. Hon’ble Member : Smt. Samiksha Bhattacharya.
C O U N S E L
Representative for the complainant : Shri Ramen Sadhukhan,
Ld. Advocate.
Representatives for the opposite party no. 1 : Shri Soumendra Nath Ganguly,
Shri Sukhendra Nath Mallick,
Ld. Advocates.
Representative for the opposite party no. 2 :
Representative for the opposite party no. 3 : Smt. Peu Das,
Ld. Advocate.
F I N A L O R D E R
1. The complainant, joint policy holder with his wife under Gold Policy Condition covering the amount of Rs. 2,50,000/- each from 08-04-2009 to 07-04-2010 under the o.p. no. 1, admitting himself in West Bank Hospital ( o.p. no. 3 ) on 7th January, 2010 for Subdural Haematoma discharged on 13-01-2010 on risk bond due to financial stringency and again getting himself admitted to S.S.K.M. Hospital on 15-01-2010 for further follow up treatment, could not receive the claim amount of Rs. 54,270/-. A cheque amounting to Rs. 5,337/- towards the medical reimbursement in the S.S.K. M. Hospital was only received by the complainant after much ordeal for the deliberate typographical mistake in writing ‘Dutta’ in place of ‘Datta’. He has prayed for Rs. 2,00,000/- as compensation along with further prayer for the claim amount of Rs. 54,270/- + cost of the proceeding for deficiency in service.
2. O.P. no. 3 in his separate written version admitted the case of the complainant and stated that he received Rs. 48,200/- as the bill of the treatment rendered by the West Bank Hospital and no amount is outstanding.
3. The o.p. no. 1 in his written version contended interalia that both the admissions to the two different hospitals in one identical illness ( Haematoma ) shall be considered as a single claim as per the scope of Clause 3.0 of the policy ; that the complainant turned a deaf ear to the repeated queries of the o.p. no. 2 for stating the reasons of DORB resulting the non settlement of the actual claim amount requiring the interference of the Arbitrator as per Clause 5.10 of the policy and thus prayed for dismissal of the petition.
4. Two points arise for determination upon pleadings of the parties namely -
(a) whether there is deficiency in service by o.p. no. 1 in withholding the main claim amount amounting to Rs. 54,270/- and ( b ) whether the complainant is entitled to the relief as prayed for ?
DECISION WITH REASONS :
5. Both the points are taken up together for consideration. On scrutiny of the record it is palpable that the complainant was first admitted at West Bank Hospital ( o.p. no. 3 ) on 07-01-2010 with clinical finding of gradual progressive disorientation with vomiting and was medically managed with Burrholes of left chronic Subdural Haematoma and was discharged on risk bond on 13-01-2010. Thereafter on 15-01-2010 within a gap of 30 to 40 hours the complainant was further admitted to SSKM Hospital with same clinical disorder and discharged on 19-01-2010.
6. Now let us examine what factors prompted the complainant to seek discharge from the West Bank Hospital ( O.p. no. 3 ) on 13-01-2010 after signing risk bond and again to take admission at the SSKM on 15-01-2010. The claimant stated by swearing affidavit that owing to financial stringency and for dilly - dallying on part of the o.p. no. 1, he at the behest of his family members took release from the same hospital after signing the risk bond clearing the bill amount of Rs. 48,200/-. Ld. Lawyer for the o.p. no. 1 categorically argued that the complainant never allowed sufficient time for settlement of the dues as he showed unnecessary haste. He further argued that settlement of the dues requires considerable time for scrutinization as per the rules and regulations of the I.R.D.A. together with the clause of the policy itself. He further argued that the o.p. no. 2 receiving the information of hospitalization on 07-01-2010 asked the o.p. no. 3 hospital to send preauthorization form which was received by the o.p. no. 2 on 09-01-2010 through FAX stating therein that the patient required to be treated for 8 to 10 days and approximately a sum of Rs. 61,000/- might be incurred. This claim by the ld. Lawyer for the o.p. is validated by Annexures C & D. On receipt of reply from the hospital on 11-01-2010 cashless approval for Rs. 40,000/- was sent to the West Bank Hospital ( Annexure E ).
7. We appreciate the problem of the o.p. no. 1 that no bill was received by the o.p. no. 2 against cashless authorization on the contrary the claim form on 10-03-2010 was submitted seeking for reimbursement of Rs. 54,270/-. We come across in the Annexure ‘G’ that the o.p.no. 2 requested the complainant vide letter dated 04-04-2010 to appraise them about the reason of DORB done in aberration and such letter remained unanswered by the complainant. Even the second reminder sent on 14-05-2010 ( Annexures H & I ) remained unattended. In the mean time the claim for medical treatment for the identical illness in the SSKM Hospital was submitted and the same was issued through A/C payee cheque in the name of the complainant. But the complainant disputed the surname ‘Dutta’ instead of ‘Datta’. For this alleged lapse the o.ps. no. 1 & 2 are not to blame because the policy ( Annexure ‘D’ ) carries his surname as ‘Dutta’.
8. The conduct of the complainant from 07-01-2010 to 13-01-2010 and thereafter 15-01-2010 till 19-01-2010 appears mysterious. Before the West Bank Hospital he took early discharge on risk bond within the lapse of six days and thereafter from SSKM Hospital within four days. Annexure ‘B” the discharge certificate of the SSKM Hospital in the case summary column states that the patient took an early discharge from the hospital and joined office. In both the cases he underwent operation once by the West Bank Hospital and thereafter by the SSKM Hospital for identical ailment. We fail to understand why he was in such haste for taking release from both the hospitals. This pertinent question remains unanswered.
9. Be that as it may, we are not unmindful of the actual cost incurred by the claimant and since his policy was still in force, he is entitled to the claim amount and we think the o.p. no. 1 is not unwilling to disburse the amount i.e., Rs. 54,270/-. The other bill for Rs. 5,337/- has already been cleared by the o.p. no. 1. It is our common experience that in case of emergency when a patient is admitted in hospital, his relative always remains worried with respect to the cost of operation and other expenditures. In the instant case the complainant was under medical treatment and he had no choice if his relatives sought for his release furnishing risk bond. In such perplexed state of mind the relatives of the patient some times think of better treatment to any other hospitals or medical institutions. The same phenomenon might have crept in the mind of the relatives of the complainant. Similar factor might have played a role for his early release from the SSKM Hospital. Whatever be the reasons, the complainant though admitted twice in two different hospitals for identical ailment he cannot be blamed in a pointless manner. One psychological factor in case of the complainant cannot be overlooked. His further stay in the West Bank Hospital might incur huge cost. When the operation was done, he took early discharge and thereafter admitted in the SSKM Hospital, a renowned one for follow up treatment. So the claim of the o.p. no. 1 that two bills cannot be entertained for identical treatment shall not have any basis at all. Complainant is entitled to the claim amount. But with respect to the compensation of Rs. 2,00,000/- for deficiency in service we are unable to accept his prayer in toto.
In the result the case succeeds.
Hence,
O R D E R E D
That the HDF Case No. 12 of 2011 filed U/S 12 of the C.P. Act, 1986 as amended till date be allowed on contest with costs against the o.p. nos. 1 & 2 and dismissed against the o.p. no. 3.
The o.p. nos. 1 & 2 be directed to pay Rs. 54,270/- the claim amount to the complainant within one month from the date of this order.
The complainant is allowed litigation cost of Rs. 2,000/- from the o.p. nos. 1 & 2 within one month from the date of this order.
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The complainant do get an award of Rs. 20,000/- towards compensation from the o.p. nos 1 & 2 for mental agony and harassment within 30 days from the date of this order.
The o.p. nos. 1 & 2 shall pay total amount of Rs. 76,270/- ( Rs. 54,270 + Rs. 20,000 + Rs. 2,000/- ) to the complainant in total within one month failing the amount shall carry interest @ 9% per annum within 30 days from the date of this order.
Supply the copies of the order to the parties, free of costs, as per rule.
