PER SHRI. S. G. CHABUKSWAR – HON’BLE  MEMBER

1)       This is a consumer complaint under Section 12(1) of the Consumer Protection Act, 1986 for the reliefs of reimbursement of medical expenses Rs.85,948/- with interest @18% p.a. from the date of filing complaint, compensation Rs.3,00,000/- for mental agony and Rs.10,000/- cost of the proceeding.

2)          The case of the Complainant in short is as under –

             The Complainant is the resident of Chinchpokali (E), Mumbai – 12. Opposite Party No.1 is the Insurance Company and Opposite Party No.2 is the Agent of Opposite Party No.1 Opposite Party No.1 issued to the Complainant Individual Mediclaim Policy No.120100/48/09/20/00003396 valid for the period from 30/06/2009 to 29/06/2010 for Rs.2,00,000/-.  The Complainant paid regularly the premium of the policy.

3)        The further case of the Complainant is that on 09/10/2009 the Complainant accidentally slipped on wet floor.  On the same day he was admitted in Navkar Orthopedic Hospital, Bhayandar (W) – 401 101 and was diagnosed that it is a fracture basicervical right femur.  The Complainant was operated upon the said ailment on 12/10/2009 and he was discharged from the hospital on 22/10/2009.  The Complainant incurred medical expenses Rs.85,948/-.  After getting discharge from the hospital the Complainant had telephonic conversation with Mr. Dinesh M. Parekh, agent of Opposite Party No.2 about above hospital surgery and also requested to handover the claim form.  On 23/10/2009 Mr.Dinesh Parekh, agent submitted claim form to the Opposite Party No.2.

4)        The further case of the Complainant is that, Opposite Party No.2 appointed Hi-tech medical service to verify the authenticity of Complainant’s surgery and reports thereof.  According to the Complainant, the report dtd.10/04/2010 given by Hi-tech medical service to the Opposite Parties is baseless and false.  No details or designation of Mr. Iyyer has been specified in the report dtd.10/04/2010.  It has been wrongly mentioned in the said report that the claim of the Complainant is exorbitant.  Opposite Party No.2 rejected the claim of the Complainant by the letter dtd.25/06/2010 under clause 5.7 of the policy on the ground that the claim is supported by fraudulent means/documents. 

5)        The further case of the Complainant is that, the claim of the Complainant was placed before the Review Committee on 28/05/2010. Dr. Manoi of the said Committee reviewed and rejected the claim of the Complainant under clause 5.7 of the policy in question.  According to the Complainant, designation, degree of Dr. Manoi has not been mentioned in the review assessment sheet and therefore, said report cannot be relied. On 30/06/2010 Dr. Benoy who operated the Complainant for fracture of basicervical right femur issued medical certificate stating the details of said surgery.  On 06/07/2010 the Complainant sent letter alongwith connected documents to Opposite Party No.2 and requested for review and re-consideration of the claim. Opposite Party No.2 has rejected the review and claim of the Complainant on 13/07/2010 and 30/07/2010 and informed the said decisions to the Complainant by the letters dtd.14/07/2010 & 03/08/2010 respectively.  On 05/08/2010 Dr. Manoi again reported that the claim cannot be taken into consideration. Thereafter, the Complainant issued notice dtd.10/03/2012 through advocate and called upon the Opposite Parties for re-imbursement of medical expenses Rs.85,948/-. Opposite Parties served with the notice but they neither replied the notice nor paid the amount.  Hence, this complaint for the reliefs mentioned in above para no.1.       

6)        Opposite Party No.1 resisted the claim by filing written version.  The contention of Opposite Party No.1 is that as per report of Hi-tech medical services and on their visit to the Navkar Hospital Bhayandar, the ICPS received from Dr. Benoy Shah after three visits. The said ICPS were hand written at single stretch, there was no detailed clinical notes of the patient and 3-4 days of admission was documented on 1 single paper. As per the investigation report Navkar Hospital is in Bhayandar and the Complainant’s address is Kalachowki, no detail address has been provided neither any contact details has been mentioned in the documents.  The Hi-tech medical services had asked to Dr. Benoy Shah the bill details of the Complainant but he could not provide it with the excuse that the bill book was with the C.A.  This was a mere excuse to conceal the inflated bill charges quoted Rs.85,948/-.  As per the opinion of experts the claimed amount Rs.85,948/- is excessive and exorbitant and not acceptable even in context to the alleged line of treatment been given and also considering the hospital location and standard of hospital.  There is lots of discrepancy in the claim documents submitted by the Complainant.  The Complainant has not submitted x-ray reports to the Opposite Parties which are vital proof of fracture.  Opposite Party No.2 has rightly rejected the claim as per the terms and conditions of the policy under clause no.5.7 by the letter dtd.25/06/2010.

7)        The further contentions of Opposite Party No.1 is that the present complaint involves complicated questions of law and facts, the opinion of experts. The Complainant has filed several voluminous documents on record.  The present dispute can be more conveniently dealt with and tried by a Civil Court. This Forum has no jurisdiction to try and entertain the complaint. Opposite Party No.1 has denied that there is deficiency in service on the part of Opposite Parties.  Opposite Party No.1 has denied all rival contentions of the Complainant and prayed for dismissal of the complaint

8)        Opposite Party No.2 duly served with the notice of the complaint but remained absent hence, complaint proceeded ex-parte against Opposite Party No.2.

9)        The Complainant has submitted his affidavit of evidence.  Opposite Party No.1 has submitted affidavit of Shri. D.S. Tulankar, Sr. Divisional Manager.  Both the parties have submitted their respective written notes of argument.  We have gone through the documents placed on record.  We heard oral arguments of Shri. Digambar Thakare, Ld.Advocate for the Complainant and Smt. Asita Parmar, Ld.Advocate for the Opposite Party No.1. 

10)      Admittedly Opposite Party No.1 issued to the Complainant Individual Mediclaim Policy bearing No.120100/48/09/20/00003396 for the period 30/06/2009 to 29/06/2010 for Rs.2,00,000/-.  The Complainant has submitted with Opposite Party No.2 claim of Rs.85,948/- of the medical treatment, surgery and hospitalization of the period 09/10/2009 to 22/10/2009. Opposite Party No.2 rejected the said claim by the letter dtd.25/06/2010. Thereafter, Opposite Party has also rejected prayers of the Complainant for the review and reconsideration of claim on two occasions i.e. on 13/07/2010 and 30/07/2010. The Opposite Party No.2 has rejected the claim of the Complainant as per the terms and conditions of the policy clause no.5.7.  The copy of said policy has been produced by the Complainant at Exh.A (page Nos.25 to 30) alongwith the complaint.  The clause 5.7 of the policy says that, the Company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on his behalf.  The Opposite Party No.1 comes with the case that, the claim submitted by the Complainant is fraudulent and exorbitant.  The burden lies on the Opposite Party No.1 to prove that the claim in question is fraudulent and exorbitant.  Now we will see the evidence produced by the parties. 

11)      After receipt of the claim the Opposite Party No.1 had appointed Hi-tech Medical Services for the investigation of the claim in question.  The Hi-tech Medical Services visited Navakar Hospital Bhayandar, Dr. Benoy Shah who treated the Complainant.  After investigation the said agency submitted report to Opposite Party No.2 on 10/04/2010.  Opposite Party No.2 has rejected the claim of the Complainant on the basis of report of above investigation agency. The rejection of claim dtd.13/07/2010 is also on the basis of said investigation. The rejection of claim dtd.30/07/2010 is based on the X-ray plats in addition to the investigation report of Hi-tech Medical Services. The last report has been issued by Dr. Manoi on 05/08/2010.  The report of Hi-tech Medical Services dtd.10/04/2010 and Dr. Manoi’s report dtd.05/08/2010 are descriptive and hence, those are material for discussion.  Hi-tech Medical Services has shown the following ground of rejection of the claim –

            i.   The Navkar hospital is in Bhayandar and the patient’ residence address is Kalachowky and no details address has been                                 provided.           

            ii.  The contact detail of the patient has not been mentioned in the treatment record. 

            iii. The ICPS has absolute uniform handwriting and the doctor has single handedly managed to write the line of treatment details.

            iv. Dr. Benoy Shah has not produced billing details by saying that the bill book is with the C.A. only to conceal exorbitant claim.

             v. The alleged fall claimed by the Complainant has no documentation.

            vi. The claim amount Rs.85,948/- is excessive considering the hospital location and standard of the hospital. 

        As per the ground no. i  mentioned above the investigation agency has doubt as to why the Complainant went to Bhayandar Hospital at a long distance from Chinchpokali, Mumbai. It appears the investing agency did not make said enquiry with the Complainant. If the said agency would have made such enquiry to the Complainant then they would have got answer satisfactory or unsatisfactory but it is not done. Opposite Party No.1 or investigating agency has also not produced any document to show that mentioning of contact number of the patient in the medical case papers is mandatory for the hospital. As per ground no. iii there is uniform handwriting of the case papers and doctor has singly handedly to manage to write the line of treatment details.  The Complainant alongwith complaint produced case paper of the period 09/10/2009 to 22/10/2009, Nurses record of the said period, discharge card, letters dtd.09/10/2009 and 16/10/2009 issued by the treating doctor for x-ray reports.  The investigating agency has not made any comments regarding handwriting of discharge card, nurses record and letters dtd.09/10/2009 and 16/10/2009 issued by treating doctor for X-ray reports.  It appears X-ray reports were called on the day of admission of the Complainant in the hospital and after the surgery. The writing of case paper is part of the habit and method of a doctor and it might have been different from person to person.  Only on the above sole ground it cannot be said that there was no any treatment to the Complainant in the Navkar Hospital at Bhayandar. The investigating agency has not mentioned in the report what types of documents agency were expecting from the Complainant regarding fall/slip on the wet floor. The grounds mentioned above at Sr. Nos. i, ii, iii & v are imaginary and not based on medical science and those are shown only on the assumption and presumption.  The grounds nos. iv & vi are discussed in next relevant para. 

12)      The report dtd.05/08/2010 has been produced by the Complainant alongwith the complaint at Exh.M (page No.66).  It has been mentioned in the said report that, the Complainant was examined for surgical marks.  Patient has operation marks on both legs.  Left leg was operated some one year back and right leg now.  The said report shows that the Complainant was previously operated for left leg at the same hospital and his daughter resides at Bhayandar, therefore, the question of ground no. i   raised in the report dtd.10/04/2010 does not arise in the complaint for decision.  The reports shows that the Complainant was operated on the right leg in Navkar Hospital in the month of October, 2009 and there is no contradiction in the case papers regarding surgery of right leg of the Complainant.  It has been mentioned in the report Exh.M dtd.05/08/2010 that patient could not give exact day and date of surgery.  However, the date of admission in the hospital, date of surgery and date of discharge from the hospital have been shown in the discharge card filed alongwith complaint at Exh.B (page No.31) and there is no substance in the ground raised in the report dtd.05/08/2010. 

13)      The Complainant has produced alongwith the complaint at Exh.K (page No.64) claims review committee assessment sheet regarding rejection of the claim dtd.30/07/2010.  It has been mentioned in the said sheet that, no details of patient, date given on X-ray plate.  It has been specifically mentioned in the report dtd.05/08/2010 that the right leg of the Complainant operated now in the Navkar Hospital therefore, the fact of non mentioning the details of the patient and date in the X-ray plate does not go to the root of the case of the Complainant. The fact of right leg surgery has been mentioned in the report dtd.05/08/2010 on verifying the surgical marks of the Complainant therefore, question of verification of X-ray plate does not arise. The grounds raised in the reports dtd.10/04/2010, 30/07/2010 and 05/08/2010, for rejection of the claim cannot be accepted.  considering facts and discharge card, case papers, nurses record, reports of Dr. Baheti Pathology Lab, Bhayandar (W), dtd.09/10/2009, letters for X-ray reports submitted by the Complainant alongwith the complaint at page nos.31 to 53 it cannot be said that those documents are fraudulent.  The Opposite Party No.1 failed to prove that the claim filed by the Complainant is fraudulent or supported by fraudulent means or devices. 

14)      The Hi-tech Medical Services has mentioned in the report dtd.10/04/2010 that Dr. Benoy Shah did not produce the bill book on the ground it is with C.A. only to conceal the exorbitant bills.  It is further mentioned therein that considering the locality and standard of Navkar Hospital bill amount is excessive.  It appears the investigating agency did not ask Dr. Benoy Shah to get xerox copies of the relevant bills from the bill book which was with C.A. and to produce before it for verification.  If it would have been asked to the doctor he would have produced xerox copies of the bills to the investigating agency. The Complainant has submitted alongwith his affidavit of evidence a receipt no.215 of payment of doctor’s bill at Exh.O (page No.10), copy of bill no.215 at page no.11, list of medicine dtd.22/10/09 at page nos.12 & 13, bills of medicine at page nos.14 to 16 total 18 bills.  The receipt no.215, bill no.215 dd.22/10/2009 and other bills page nos.10 to 16 bears the stamp of Opposite Party No.2 and those were submitted to Opposite Party No.2 for granting the claim. The Complainant was admitted in the Navkar Hospital from 09/10/2009 to 22/10/2009 for total 14 days.  As per bill no.215 dtd.22/10/2009 Dr. Benoy Shah has charged consulting fee Rs.200/-, visit fees per day Rs.500 x 14 = Rs.7,000/-, stay in hospital per day Rs.1,700 x 14 = Rs.23,800/-, nursing charges per day Rs.300/- x 14 = Rs.4,200/-, medicine Rs.7,520/-, implants Rs3,200/-, X-ray Rs.200 x2 = Rs.400/-, Operation charges Rs.24,000/-, Operation theater charges Rs.4,500/-, anesthetist charges Rs.3,400/- and dressing charges, etc Rs.200 x 6 = Rs.1,200/- total Rs.79,420/-.  The details of services and its charges have been mentioned in the bill no.215.  The Hi-tech Medical Services has not shown which of the particular services have been charged excessive and by how much amount mentioned in the bill no.215.  The said investigating agency has also not mentioned which of the short comings are noticed to it in the services of Navkar Hospital regarding the sub-standard of said hospital. The investigating agency has also not produced the price rate of services charged by other hospitals situated in Bhayandar near to the Navkar Hospital for the services mentioned in the bill no.215 (page No.11) to prove the excess amount of claim.  Opposite Party No.1 has not lead any evidence to show the sub-standard and excessive rate of service of Nakar Hospital hence, it cannot be said that the claim of the Complainant is exorbitant.  The Complainant has paid to Navkar Hospital bill amount of Rs.79,420/- and the said hospital issued receipt no.215 of payment to the Complainant which is filed at Exh.O page no.10 alongwith affidavit of evidence of the Complainant.  The Complainant has also produced the bills of medicine purchased by him from Swagat Chemists and Ambika Medico, Bhayandar during the period 08/10/2009 to 30/10/2009 total amount of Rs.5,607.50.  It is not the case of Opposite Party No.1 that, the bills of above two medical stores are fraudulent and excessive.  In view of the above evidence, documents and discussion we find that Opposite Party No.1 failed to prove that the claim of the Complainant is fraudulent & exorbitant.  The Complainant is entitled to the reimbursement of medical expenses Rs.85,948/- with interest @ 9% p.a. from the date of filing complaint i.e.31/07/2012 till its realization. The Complainant had thricely requested to Opposite Parties for settlement of the claim but on all times Opposite Parties have rejected his claim and due to which Complainant caused mental harassment and therefore, Complainant is entitled to the compensation Rs.8,000/- for mental agony and Rs.3,000/- towards the cost of the complaint. 

            In the result complaint deserves to be partly allowed with costs.  Hence, we pass following order –

O R D E R

i.     Complaint No.153/2012 is partly allowed with cost.

          ii.      Opposite Parties are directed to pay to the Complainant reimbursement of medical expenses Rs.85,948/- (Rs. Eighty Five

                   Thousand Nine Hundred Forty Eight Only) with interest @ 9% p.a. from the date of filing complaint till realization of the

                    amount.

                iii.      Opposite Parties are directed to pay to the Complainant compensation Rs.8,000/- (Rs. Eight Thousand Only) for mental

                          agony caused to him.

               iv.      Opposite Parties are directed to pay to the Complainant Rs.3,000/- (Rs. Three Thousand Only) towards cost of complaint.                

                v.      Opposite Parties do pay the amount mentioned in above para nos. ii to iv to the complaint within one month from the date

                          of this order.  

         vi.     Certified copies of this order be furnished to the parties.