JUDGEMENT

          Complainant by filing this complaint has submitted that complainant is a senior citizen and complainant and his wife are covered by Individual Health Insurance Policy under the company United Insurance Co. Pvt. Ltd. and they are paying annual premium @ Rs.7,196/- and took benefit under Individual Health Insurance Policy and said policy number is 030600/48/11/97/00006010 for the period from 02.02.2012 to 01.02.2013.

          It is further submitted that Smt Sikha Ash was admitted in the nursing home namely Alpha Family Health Mall a unit of Alpha Medical Services Pvt. Ltd. for Anal fissure and piles surgery under the supervision of Dr. D.K. Sarkar who is attached with the said nursing home and complainant specifically stated that from the very beginning Smt Sikha Ash consulted with the said doctor at his chamber in the Alpha Medical Services Pvt. Ltd and during that period of admission the complainant no.2 informed to the said insurance company regarding the admission on 07.08.2012 of his wife for her surgery and also about successful surgery under supervision of the said doctor as suggested at nursing home namely Alpha Medical Services Pvt. Ltd. and finally complainant no.1 Smt Sikha Ash was discharged on 12.08.2012 and discharge certificate was issued by the said nursing home with consent of the said doctor.

          Complainant submits that after receipt of all bills related to the said surgery and treatment at the said nursing home by the said doctor, he submitted claim for reimbursement to the United India Insurance Co. Pvt. Ltd.  on 10.09.2012 with all bills and the other documents of the said surgery and discharge certificate etc. for settlement of the claim for a sum of Rs.19,065/- and against that insurance company informed to the complainant that complainant is entitled to Rs.6,157/- as settled amount out of Rs.19,065/- for which the claim was made by the complainant.

          On receipt of the settled voucher issued by the United India Insurance Co. Pvt. Ltd. complainant no.2 wrote a letter on 20.02.2013 to the Division Manager of United India Insurance Co. Pvt. Ltd. at his Kolkata regional office and the head office in Chennai for considering his claim amount and one complaint was lodged by the complainant to the head office of the op Insurance company being registration No.DG0010642012 but complainants’ grievances had been lodged against the insurance company and their higher authority.  But ultimately on 27.02.2013 op insurance company informed the complainant no.2 through a letter under reply of the letter dated 20.02.2013 of the complainants that the said insurance authority clarified the reason that the hospital authority issued some defective bills in regards so the complainant no.1 cannot get the full amount, on the contrary complainant has further submitted that there is no negligent on the part of the complainant.  But it is completely a deficiency in service on the part of the ops for not supplying the proper bills etc by the nursing home authority. 

          Thereafter complainant sent demand notice for claiming the medical expenses amount of Rs.19,065/- address to the Deputy Manager of United India Insurance with a copy to Alpha Medical Services Pvt. Ltd. and Dr. D. K. Sarkar and same were duly received by the said authorities.  But the Advocate Dr. D.K. Sarkar sent on behalf of complainant the demand notice of the complainants and it is admitted by the said doctor that he issued valid receipts for his professional fees and other ancillaries fees for the said operation as the receipt of Rs.9,000/- and that receipt is completely a valid document and are eligible for claim before the Insurance Company.  But insurance company did not make any reply.

          For negligent and deficient manner of service of the Insurance company and also of the nursing home the present case is filed praying for release of medical expenses of Rs.19,065/- and other compensation.

          On the contrary the Insurance Company by filing written statement submitted that insurer has no scope to consider the complainants’ claim going beyond the ambit of the policy and insurer vide their letter dated 27.02.2013 gave reply to the complainant’s letter dated 20.02.2013 and in the said reply the insurer categorically stated the basis of computation of claim and the reasons for not considering some bills by the insurer and the TPA.  Further it is submitted that bills of Rs.9,000/- as issued by Dr. D.K. Sarkar was not final because as per policy condition No. 1.2 (C) Note 2, Dr. Sarkar’s bills was not part of the Hospitalisation bill and Dr. Sarkar’s fee for Rs.400/- dated 12.04.2012 is also not payable because pre-hospitalisation expenses is for the period up to 30 days prior to hospitalization.  Therefore the bill dated 20.04.2012 is prior to 30 days of hospitalization and hence not payable and further it is submitted that even if the Dr. D.K. Sarkar received such amount for consultation but due to non-hospitalisation of the same, bill could not be prepared and in respect of medical charts there is no breakage and hence it was not paid and if complainant can file break up charts of medical bills, the same may be considered which was informed, moreover Glucometer and Oxymeter test fees are not payable as per policy exclusion clause 4.1.

          It is further submitted that Diagnostic Test Rs.300/- could not be considered due to non-availability of the money receipt and service charges for Rs.800/- is not payable as per policy exclusion clause 4.21.  So, the complainant practically did not satisfy the condition of the policy and also the bills were not properly submitted for which it was not considered as submitted.  Practically the claim was settled but complainant did not receive the said settled amount out of the claimed amount of Rs.19.065/- and practically settled amount is Rs.6,157/- what the complainant is entitled to and in the above circumstances the present complaint should be dismissed and complainant may receive the final settled amount of Rs.6,157/-.

          Whereas Dr. D.K. Sarkar submitted that on 12.04.2012 complainant along with his wife visited his chamber for investigation purpose and also for treatment of her (Complainant no.2) disease and on through investigation, it was detected that Sikha Ash was a patient of Anal Fissure Senlinel Piles and as such the said Sikha Ash was advised for an operation on 12.08.2012 to be performed by this doctor and practically said Sikha Ash was admitted in the op no.2 nursing home on 10.08.2012 and Sikha Ash was gone for the said operation of Anal Fissure Senlinel Piles on 10.08.2012 in the said nursing home the op no.2 under op no.3, the doctor and the said operation was successful and after successful operation she was discharged from the said nursing home on 12.08.2012 and for the said operation the said doctor received Rs.9,000/- as his operation charge and other ancillaries fees and as per professional fees and that lady was discharged after her recovery from the said ailment after operation.  Doctor is not associated with United India Insurance Co. and at the same time there is no connection in between the complainant and the doctor in this regard and doctor is falsely implicated in this case, so the case must be dismissed against that doctor.

                                                      Decision with reasons

          Fact remains that after considering the entire materials on record and also hearing the Ld. Lawyers of both the parties, it is found that regarding holding of the policy under the op Insurance Company by the complainant is a fact and there was valid period of the said insurance policy from 02.02.2012 to 01.02.2013.  Fact remains Sikha Ash complainant no.1 was admitted for operation under Dr. D.K. Sarkar and no doubt Dr. Sarkar performed surgery of the complainant in the Nursing Home Alfa Medical Services Pvt. Ltd. with whom Dr. Sarkar is attached with.  Sikha Ash was admitted on 10.09.2012 and discharged on 12.08.2012 and a Anal Fissure Senlinel Piles was operated by the doctor and discharge certificate was issued by the doctor of the Alfa Medical Services Pvt. Ltd. and the bill was also supplied by the said Alfa Nursing Home, complainant submitted the bill for Rs.19,065.35/- wherefrom it is found that surgeon doctor received Rs.9,000/-, Nursing Home Bill was Rs.6,198/-, Diagnostic test bill was Rs.1,323/- and Rs.300/-, Chemist fee was Rs.99/- and Rs.440.90/- and consultancy charges bill of Rs.1,600/- and by that way complainant claimed Rs.19,065/- and all the bills are found dated 09.08.2012 to 13.08.2012.  Another bill of doctor consultation fees of Rs.1,600/- was of dated 07.09.2012.  But fact remains total bill vouchers were submitted by the complainant in details subsequently which was issued by the Alfa Nursing Home.  But op did not consider all those documents in view of the fact that it was not issued by the Alfa Nursing Home at the time of filing the claim by the complainant.  But anyhow we have gathered that detail bills were subsequently submitted by the Alfa Medical Services and Dr. D.K. Sarkar also issued receipts and truth is that Dr. Sarkar examined her prior to admission and operation was done by her and that lady recovered from such ailment after operation and it is also a fact that it was a serious operation and no doubt that operation is covered by the present policy being No.030600148/11/97/00006010 and as per policy term, the sum insured is Rs.1.5 lakh for Gora Chand Ash and Sikha Ash separately and policy was valid.  But after considering the entire materials it is found that insurance company adopted very technical approach at the time of deciding the claim and no doubt the claim amount was very small Rs.19,000/- and odd.  But out of that op only released a sum of Rs.6,157/- as hospitalization charges only but operation charges and other charges were not granted by the op insurance company and for which the complainant appeared before this Forum for redressal.

But at the time of hearing the argument of op Insurance Company Ld. Lawyer submitted practically all problems were created only for the fault of the complainant for not submitting the detail bills of the nursing home.  But truth is that subsequently nursing home authority supplied all those bills which were submitted by the complainant but that was not considered.  No doubt out of the total bill of Rs.19,065/- we have gathered that complainant is not entitled to service charges for Rs.800/-, Glucometer and Oxymeter charges for Rs.420/- as per condition of the policy.  But other charges for which the bill has been submitted by the surgeon and the nursing home is found quite correct.

          Fact remains that it was spent so we find that though there was some fault on the part of the nursing home authority for which the said claim could not be properly settled by the op.  But anyhow we have gathered that matter is clear and truth is that prior to hospitalization and after hospitalization and pre-hospitalisation, the said amount was spent by the complainant and it was actually paid to the doctor for testing and for hospitalization.

          So, after deducting that Rs.1,220/- what the complainant is not entitled as per terms and conditions of the policy, the complainant is actually entitled to Rs.17,845/- from the op as final settlement of the said claim and op is bound to pay that other litigation cost in view of the fact the moral approach was not shown at the time of deciding of such matter knowing fully well that operation was done by Dr. D.K. Sarkar who already issued bill etc. but that was not entertained.

          It is no doubt unfortunate for which the complainant is also entitled to litigation cost because complainant is sent to the Forum for lack of moral attitude of the op Insurance Company.

          Accordingly the complaint succeeds.

Hence, it is

                                                ORDERED

That the complaint be and the same is allowed on contest with cost of Rs.5,000/- against op no.1, the Insurance Company when same is dismissed against op Nos. 2 & 3 but without any cost.

Op no.1 is hereby directed to pay a sum of Rs.17,845/- and also interest of Rs.3,000/- as compensation and further the cost as awarded of Rs.5,000/- i.e. total Rs.25,845/- to the complainant within one month from the date of this order and without any fault, failing which for disobeyance of the Forum’s order and for non-compliance of the Forum’s order within stipulated period, for each day’s delay op no.1 shall have to pay penal interest @ Rs.200/- per day till full satisfaction of the decree and if it is collected same shall be deposited to this Forum.  But even if it is found that op no.1 is reluctant to comply the order, in that case, the penal proceeding u/s 27 of C.P. Act 1986 may be imposed for which op no.1 shall be responsible and further penalty shall be imposed.