Consumer Complaint No.166 of 2016
Date of filing: 19.9.2016 Date of disposal: 30.6.2017
Complainant: Swapan Kumar Chakraborty, S/o. Late Sailangshu Bhusan Chakraborty, resident of Flat No. 4D, Chinnamasta Tower, Gouranga Sen Sarani, Radha Nagar Road, PO: Burnpur, Asansol, PS: Hirapur, District: Burdwan, PIN – 713 325.
Opposite Party: 1. United India Insurance Co. Ltd., having its Registered & Head Office at: 24, Whites Road, Chennai – 600 014, represented by its Chairman.
2. E-Meditek (TPA) Services Ltd., at Shri Vishal Plaza No. 123 (N), G.T.Road (East), Murgasol, PS: Asansol (South), District: Burdwan, presently having its Corporate Office at: Plot No. 577, Udyog Vihar, Phase V Gurgaon, Haryana, PIN – 122 016, represented by its Managing Director.
3. Steel Authority of India Ltd., Personnel Department, IISCO Steel Plant, PO: Burnpur, PS: Hirapur, District: Burdwan, PIN - 713 325, represented by its Executive Director (P&A).
4. The Mission Hospital Durgapur, Plot No. 219 (P), Immon Kalyan Sarani, Sector – 2C, Bidhannagar, Durgapur, PS: Bidhannagar, District: Burdwan, PIN – 713 212, represented by its Superintendent. (Proforma OP)
Present: Hon’ble Member: Smt. Silpi Majumder.
Hon’ble Member: Sri Pankaj Kumar Sinha.
Appeared for the Complainant: Ld. Advocate, Debdas Rudra.
Appeared for the Opposite Party No. 1: Ld. Advocate, Shyamal Kr. Ganguli.
Appeared for the Opposite Party No. 2: Mr. Partha Sarkar, Autho. Representative.
Appeared for the Opposite Party No. 3: Sri N. G. Sarkar, Autho. Representative.
Appeared for the Proforma Opposite Party No. 4: Ld. Advocate, Deb Krishna Sinha.
J U D G M E N T
This complaint is filed by the Complainant u/S. 12 of the Consumer Protection Act, 1986 alleging deficiency in service, as well as, unfair trade practice against the OPs as the OP-1 and 2 have repudiated his legitimate insurance claim illegally and arbitrarily.
The brief fact of the case of the Complainant is that being a retired employee of SAIL, ISP, Burnpur he obtained mediclaim policy from the OP-1 for himself and his spouse, which was valid for the period for the period from 01.04.2015 to 31.03.2016. The entire SAIL mediclaim scheme was circulated by the OP-1 and administered by the OP-2. During validity of the said policy on 24.06.2015 the wife of the Complainant was suffering from serious illness. Without any delay the Complainant went to the chamber of Dr. P. Roy at Asansol on the same day. The doctor examined her and prescribed some medicines. But as there was no improvement and the condition of his wife was going deteriorating the Complainant again went to the chamber of the said doctor on 25.06.2015. After examining the patient the doctor referred her to the higher centre for admission and better management. Due to her serious condition she got admission at the OP-4, Durgapur and she was taken therein by ambulance provided by the OP-4 on 25.06.2015 at 12.33 p.m. The doctors of the OP-4 examined the patient and prescribed some clinical tests and after completion of all the tests it was detected that the patient was suffering from Epigastric Discomfort for Pancreatitis, CAD, Acute Gastritis. Considering the serious condition of the patient she was admitted as an indoor patient on 25.06.2015 and after medical treatment she got discharge from the OP-4 on 27.06.2015. For such medical treatment of his wife the Complainant had to incur expenses to the tune of Rs.68, 252=00 from his own pocket. After getting discharge from the OP-4 the Complainant lodged insurance claim to the OP-2 on 22.07.2015 by submitting filled up claim form along with the medical bills and documents towards the treatment of his wife and requested the OP-2 for settlement of the claim as early as possible. Upon receipt of the claim form the OP-2 sent a letter dated 28.08.2015 to the Complainant requesting to submit some additional documents to enable them to process the claim and also to provide justification for delay in intimation as well as non-availing cashless facility. Thereafter correspondences were made by the corporate office of the OP-2. After receipt of the said letter dated 28.08.2015 the Complainant replied regarding justification for delay intimation as well as non-availing of cashless benefit by issuing letter dated 03.09.2015 and also submitted some additional documents as per their requirements to enable them to settle the claim. But very surprisingly the OPs have repudiated the claim lodged by the Complainant by issuing letter dated 04.09.2015 stating that as per investigation report the patient was admitted only for diagnostic purpose and as such the Complainant is not entitled to get the claim because there is a violation of the terms and conditions of the policy. According to the Complainant the ground for repudiation as taken by the OP-1 and 2 is totally illegal, arbitrary and beyond the provisions of law as the patient was not admitted at the OP-4 for any diagnostic purpose, which is evident from the discharge certificate issued by the OP-4. Upon receipt of the repudiation letter the Complainant sent a letter to the MSVP of the OP-4 requesting to issue a medical certificate confirming that the wife of the Complainant was admitted at the OP-4 for the purpose of diagnostic purpose in a serious condition which required hospitalization for effective treatment to save the patient or not. Upon receipt of the said letter the MSVP of the OP-4 certified that the patient was admitted from the Department of Emergency on 25.06.2015 with complaint of Epigastric discomfort and general weakness, which needed evaluation for pancreatitis and CAD for which she was admitted. The OP-4 has also stated that they have to evaluate Epigastric discomfort for pancreatitis, CAD, acute gastritis for which the patient needed admission in the hospital. The Complainant again sent a letter to the OP-2 on 15.10.2015 stating that the patient was not admitted at the OP-4 for diagnostic purpose and request was made by him to look into the matter earnestly and settle the claim as early as possible. But no positive response came from the OP-2, which amounts to deficiency in service as well as unfair trade on the part of the OP-1 and 2. Subsequently several requests was made by the Complainant for settlement of his claim, to no effect. On 07.12.2015 the OP-2 sent a letter to the Complainant informing that the captioned claim has not been considered for payment under clause no-5.6 of the Group Mediclaim Policy as per the claim documents received by the OP-2 from where it was observed that as per the claim papers the patient was admitted only for diagnostic purpose and hence the claim lodged by the Complainant was not payable. Upon receipt of the letter request was made by the Complainant to the OP-2 through e-mail for settlement of his claim, but the OP-2 did not pay any heed to his request. Being aggrieved and dissatisfied with the service of the OPs the Complainant lodged a written complaint before the Additional Director, CA & FBP on 28.01.2016. Mediation was held on 25.02.2016, but no fruitful result yielded. So having no other alternative the Complainant has approached before this Ld. Forum praying for direction upon the OPs to make payment of Rs.68, 252=00 to him towards the reimbursement of the medical expenditure as incurred by him towards the treatment of his insured wife, to pay compensation of Rs.1, 00,000=00 due to harassment, mental pain and agony and litigation cost of Rs.20, 000=00 to him.
The petition of complaint has been contested by the OP-1 by filing written version denying the entire averment/allegation of the complainant and stated that the Complainant has deliberately misled the Ld. Forum by furnishing wrong information. The Complainant hospitalized his wife on 25.06.2015 at the OP-4 under Dr. Balwant Kumar with a complaint of dizziness, nausea, burning sensation but associated with epigastric weakness and the patient is a known case of hypertension on medication and on the request she was discharged on 27.06.2015. From the investigation report it is revealed that the patient got admission at the OP-4 for investigation purpose, so the OP-2 has recommended the claim of the Complainant as ‘No Claim’ under the clause no-5.6 of the terms and the conditions of the policy. According to the OP-1 the motive of the Complainant is no gain money in an unlawful manner. According to the OP-1 there is no deficiency in service on its behalf as the information of repudiation of the insurance claim of the Complainant had been duly informed to him by issuing repudiation letter. So the complaint being frivolous and baseless is liable to be dismissed.
The petition of complaint has been contested by the OP-2 stating that this complaint is not maintainable against this OP as there is no privity of contract by and between the Complainant and the OP-2. No premium was paid to this OP and there is no contract of insurance between them, who is merely a Third party Administrator. As the policy was not issued by this OP, hence there is no financial interest in respect of any claim. This OP only used to process any claim based on the treatment related papers provides by the claimant. The OP-2 has further submitted that as no active line of treatment was done, only investigation done, hence the claim of the Complainant was repudiated by this OP under the clause of 5.6 of the terms and conditions of the policy. According to this OP as there is no deficiency in service on the part of this OP, hence the OP-2 has prayed for dismissal of the complaint with the cost.
The OP-3 has contested the complaint by filing written version stating that the Complainant was an employee of the SAIL-IISCO Steel Plant, Burnpur and had superannuated from service of the Company. As per available records of the Company, the Complainant and his spouse have renewed their mediclaim policy for the period from 01.04.2015 to 31.03.2016 with the OP-1, administered by the OP-2. The OP-3 is the facilitator of the said mediclaim scheme by and between the member and the Insurance Company. As per records of the Company it is evident that the premium on account of the mediclaim has duly been paid by the employee for himself and his spouse. So as the claim was lodged by the Complainant in respect of the mediclaim policy, hence the OP-3 has no role to pay any damage to the Complainant. But the Complainant has made this OP as a party in this complaint unnecessarily. As no allegation has been made out against this OP, the OP-3 has prayed for dismissal of the complaint.
The OP-4 has contested the complaint by filing written version mentioning that the wife of the Complainant got admission at this OP on 25.06.2015 and on evaluation it was found that the patient is also a known case of HTN on medication. The chief complaint of the patient was dizziness and according to the OP-4 such disease can be categorized as neurological and cardiology. The patient was evaluated by the medicine specialist and on further clinical examination it was revealed that the patient had neck pain and ridiculer pain on her right shoulder. The patient was needed emergency admission in view of presenting general weakness, epigastritis, burning sensation which was predominantly in the favour of cardiac disease which needed admission on emergency basis. In the complaint no allegation has been made out by the Complainant against this OP, therefore this OP has been made party in this complaint unnecessarily. As the Complainant did not make any complaint regarding deficiency in service on behalf of this OP, hence prayer is made by the OP-4 for dismissal of the complaint with cost.
The Complainant and the OP-1 have adduced their respective evidences on affidavit along with several papers and documents in support of their contentions.
We have carefully perused the record; papers and documents filed by the contesting parties and heard argument at length advanced by the Ld. Counsel for the parties. It is seen by us that some admitted facts are involved in this complaint i.e. being a retired employee of the OP-3 the Complainant obtained Group Mediclaim insurance policy from the OP-1 through his office for himself and his spouse, the OP-2 is the third party administrator, the policy was valid for the period from 01.04.2015 to 31.03.2016, due premium was paid, during validity of the policy the wife of the Complainant became ill on 24.06.2015, she went to the local doctor on the same day, prescribed some medicines, due to deterioration of her condition she again went to the said doctor on 25.06.2015, the concerned doctor upon examining her referred to the higher centre for admission as well as better management, the patient was taken at the OP-4 on 25.06.2015, the doctors of the OP-4 after examination advised for admission, clinical tests were done, report showed that the patient was suffering from epigastric discomfort for pancreatitis, CAD, acute gastritis, the patient got discharge on 27.06.2015, during the period of treatment at the OP-4 the Complainant had to incur medical expenses amounting to Rs.68,252=00 towards the treatment of his wife, an insurance claim was lodged on 22.07.2015 along with the claim form & other relevant documents with the OP-2, some additional documents was sought for from the Complainant by the OP-2 for processing of the claim, the Complainant submitted the documents as per requirement, as the intimation was given to the OP-2 beyond the statutory period of limitation the Complainant justified the cause for delay in intimation, the Complainant submitted further documents as per the direction of the OP-2, by issuing letter date 04.09.2015 the OP-2 repudiated the claim of the Complainant on the ground that the patient got admission at the OP-4 for diagnostic purpose only, by filing a certificate from the MSVP of the OP-4 the Complainant tried to prove that his wife did not get admission at the OP-4 not for diagnostic purpose, but to effect, several requests was made by the Complainant for settlement of the claim, no fruitful result has been yielded, the OP-2 has further intimated the Complainant that payment could not be made under the clause no-5.6 of the Group Mediclaim Policy, hence this complaint is initiated by the Complainant being dissatisfied and aggrieved with such action of the OP-1 and 2. The allegation of the Complainant is that the OP-1 and 2 have repudiated his legitimate insurance claim illegally, which they cannot do.
The contention of the OP-1 and 2 is that the claim was repudiated as per the terms and conditions of the policy and hence there is no deficiency in service on their part. Therefore the Complainant is not entitled to get any relief as sought for.
At the very outset we are to adjudicate as to whether there is any deficiency in service on behalf of the OP-3 and 4. It is seen by us that the Complainant was an employee of the OP-3 and being retired employee of the OP-3 he obtained the concerned policy from the OP-1 for himself and his spouse. There is no role of the OP-3 either to remit any papers and documents to the OP-1 and 2 or to pay any amount towards the treatment cost of the wife of the insured. Due to avoid the plea of non-joinder of parties and for abundant precaution the OP-3 has been made a party in this proceeding. Moreover no relief has been sought for by the Complainant from this OP. We did not find that there is any deficiency in service on the part of the OP-3 and the Complainant also cannot prove the same and did not make any allegation against this OP, hence in our view that this complaint cannot succeed against the OP-3.
Admittedly, being referred by the local doctor and due to serious condition of the patient the insured wife of the Complainant got admission at the OP-4. The doctor of the OP-4 after examining her and clinical tests advised her for admission. Treatment was provided by the OP-4 successfully as the Complainant did not make any allegation regarding medical treatment as provided by the OP-4 towards the patient. After completion of treatment the patient got discharge from the OP-4. We have noticed that with the four corners of the complaint no allegation is made by the Complainant against this OP and no relief sought for. Therefore in our view this complaint cannot stand against the OP-4.
Now we are to see to whether there was any deficiency in service on behalf of the OP-1 and 2 or not. During argument the Ld. Counsel for the OP-1 has argued that in view of the terms and conditions of the concerned policy the claim was repudiated rightly and legally and as the said repudiation was duly intimated to the Complainant by issuing repudiation letter to the Complainant, there cannot be any deficiency in service on its part. The Op-1 has relied on the clause no-vi of the Important Exclusions as mentioned in the policy copy. We have gone through the same and it is evident that ‘the Hospitalization charges in which Radiological/laboratory investigations/other diagnostic studies have been carried out which are not consistent with or incidental to the diagnosis of treatment of positive existence or presence of any ailment, sickness or injury for which confinement at any Hospital/Nursing Home, has taken place.’ From the aforementioned clause it is clear that the diagnostic studies which are not consistent with the ailment for which the patient was admitted, the cost for the said diagnostic studies falls within the exclusion clause and the insured is not entitled to get any claim for such expenses. But in the case in hand we did not find out from the detailed bill and the treatment related papers that inconsistent diagnostic studies were made by the OP-4 for this patient. Therefore in our view the aforementioned clause of the policy condition does not apply in this present repudiation of the claim of the Complainant. Both parties have placed their reliance on the clause of ‘Hospitalization Benefits’, wherein it is written that under the heading of ‘Reimbursement’ as ‘Reimbursement of actual charges up to Rs.2,00,000=00 per member per policy period (with clubbing facility between employee and spouse) is permissible for expenses incurred towards room rent, IC Unit, nursing expenses, surgeon and anesthesia charges, consultation fee, diagnostic investigations (Laboratory & Radiological) cost of blood/blood components and its transfusion, oxygen/gas, operation theater charges, surgical appliances/implant, medicines and drugs, dialysis, chemotherapy, radiotherapy, cost of pacemaker, artificial limbs and similar other expenses. Claim under Hospitalization benefit shall be admissible only when the patient is admitted in a hospital for a minimum period of 24 hours.’ In the instant case the insured wife of the Complainant got admission at the OP-4 as per the advice of the doctor of the OP-4 who examined the patient clinically on 25.06.2015 and the patient got discharge there from on 27.06.2015. Therefore it is clear that the patient was at the OP-4 for more than 24 hours and during that period several diagnostic investigations was done for detection of her illness. For this purpose the Complainant had to incur expenses to the tune of Rs. 68,252=00 towards the treatment cost of his wife under the mediclaim policy. As the policy condition reveals that the Complainant is entitled to get the cost of the treatment, hence in our view neither the OP-1 nor the OP-2 can debar the insured from getting his legitimate claim, which they did. Moreover the discharge summary issued by the OP-4 on 27.06.2015 reveals that the patient was admitted with in above complaints and as per institutional protocol. She was investigated and treated accordingly. She needs stay in hospital for further treatment but as per patient party’s request, she is being discharged with medical advice. The said observation in the discharge summary denotes that admission of the patient was needed due to her physical condition, so the argument of the OP-1 that the patient got admission therein as per her whims for investigation purpose does not stand. Moreover the treating doctor of the OP-4 namely Dr. Balwant Kumar also issued one certificate stating that ‘the patient named Swapna Chakraborty, a known case of Hypertension, admitted from the department of emergency on 25.06.2015 with complaint of Epigastric discomfort and generalized weakness which needed evaluation for pancreatitis and CAD (ACS), for which she was admitted from emergency. We have evaluated every epigastric discomfort for pancreatitis, CAD, acute gastritis for which she needed admission in the hospital. Though the treating doctor has issued the said certificate, but the OP-1 and 2 did not challenge the same. So the certificate got its finality.
During argument the Ld. Counsel for the OP-1 has submitted that as the patient was suffering from pre-existing disease i.e. Hypertension, which is evident from the discharge summary, hence as per the policy condition the Complainant is not entitled to get any claim for treatment cost of the insured patient. In this respect we are to say that firstly there are several judgments of the upper Forums/Commissions/Courts wherein it has been held that Hypertension is not a disease, rather it is a symptom only and for this reason claim cannot be repudiated on this score and secondly the OPs did not repudiate the claim of the Complainant on this ground. So now the OP-1 cannot go beyond the repudiation letter.
We have noticed that the OP-1 has repudiated the insurance claim of the claim arbitrarily and unnecessarily, which denotes the deficiency in service of the said OP and for this purpose the Complainant is entitled to get compensation from the OP-1 and obviously by filing this complaint the Complainant has to incur some expenses, for which he is also entitled to get litigation cost.
As the Complainant has successfully proved his complaint, hence the complaint is allowed.
Going by the Foregoing discussion, hence it is
O r d e r e d
that the complaint is allowed on contest with cost against the OP-1 and dismissed on contest without any cost against the OP-2, 3 and 4. The OP-1 is directed to pay Rs.68, 252=00 to the complainant towards the treatment cost of his insured wife within 45 days from the date of passing of this award, in default; the awarded amount shall carry penal interest @ 6% p.a. for the default period. The OP-1 is also directed to pay compensation Rs. 2,000=00 to the complainant for his mental pain, agony and harassment and litigation cost of Rs. 500=00 within 45 days from the date of passing of this award. In default, the complainant is at liberty to put the entire order/award in execution as per provisions of law.
Let plain copies of this order be supplied to the parties free of cost as per provisions of Consumer Protection Regulations, 2005.
Dictated and corrected by me.
(Silpi Majumder)
Member
DCDRF, Burdwan
(Pankaj Kumar Sinha) (Silpi Majumder)
Member Member
DCDRF, Burdwan DCDRF, Burdwan
