(Delivered on 12 /02/2021)

PER SHRI A. Z. KHWAJA, HON’BLE PRESIDING MEMBER.

1.         Appellant-  United India Insurance Company Ltd.  has preferred  the present  appeal  under Section 15 of the Consumer Protection Act, 1986, feeling aggrieved by the impugned judgment and  order dated 06/07/2017 passed by the  learned District Consumer Forum, Bhandara in Consumer Complaint No. 131/2016  whereby learned District Consumer Forum, Bhandara allowed the  consumer  complaint  and directed the  present  appellant  to pay an amount of Rs.1,11,355/-  along with interest  towards medical expenses  and also Rs. 10,000/- towards mental harassment  and Rs. 5,000/- towards litigation cost.  (Appellant hereinafter shall be referred as O.P. and respondent as  complainant for the sake of convenience).

2.         Short facts leading  to the  filing  of the present  appeal  may be narrated as under:-

            Complainant – Dr. Manda Arun Kumbhare  was working  a  Gynecologist and  resident  of Bhandara. The complainant  had taken  Platinum Health Insurance  Policy  from the O.P. in the year 2006 and the last policy  was  renewed  on 14/08/2015 for the period  18/08/2015 to 17/08/2016. The said policy was for Rs.2,00,000/- for husband of the  complainant  and Rs. 1,50,000/- for the complainant.  The complainant  has  come with  a plea that  on 31/06/2015 while she was  walking  her  right  ankle  joint got twisted and  so she went  to  Orthopedic Surgeon Dr. Kukde on 01/07/2015 and she got  admitted  in the Hospital.  After taking X-ray, Dr.Kukde diagnosed  that  there was  a fracture  of right  ankle joint  and so complainant  was advised  to take  injection for 6 months. Complainant  took the said  injection for Rs. 38,245/- and same was  duly  reimbursed. On 28/08/2015 she again  visited Dr. Kukde who advised  her to continue the said injection for 2 years  and also  directed  her to go to Dr. Aurangabadkar  at Nagpur for second opinion.  The complainant  then went to Dr. Aurangabadkar where she had undergone  Dexa Bone Scan on 02/09/2015 and report of the scan revealed that the complainant was suffering  from  Osteoporosis  and Dr. Aurangabadkar  confirmed the  diagnosis of Dr. Kukde and advised  her  to take  injection  for 2 years.  Complainant  has come  with  plea that  she  placed   the order on 28/08/2015 with  Sai Medicals, Nagpur  but  the injections were  not available. However, 18 injections  for Rs. 1,35,000/- were  made available  on 09/09/2015  and so complainant  claimed  an amount of Rs. 1,35,400/- from the  O.P. but the O.P. rejected   the claim on the  ground  that  the claim was not  made within  60 days  from the date of discharge and complainant  was reimbursed  only Rs. 400/-. The complainant  was  left with no option  but to file  the present complaint  before  the learned District Consumer Forum, Bhandara alonging  deficiency  in service  against  the O.P. 

3.         O.P. resisted the complaint by filing detailed reply.  The O.P. has accepted that  the complainant – Dr. Kumbhare had taken  Insurance  Policy  but  has denied  that  the O.P. had  indulged  in any deficiency  in service amounting  to unfair  trade practice. The O.P. has taken  a plea that  the  complaint was  not tenable  in  law and  suffers from non joinder of necessary  party in as much as  Third Party Administrator (TPA) was   a necessary  partly. The O.P. has also taken  a plea that  as per the Insurance  Policy  the claim is  admissible  for medical  expenses  incurred  within 60 days  after the  person  is discharged.  The O.P. has also taken a plea that the claim was rightly repudiated in view of the provisions of Clause 3.31 of the Insurance Policy. The O.P. therefore contended that the complaint filed by the complainant was untenable in law and so deserves to be dismissed with cost.

4.         The learned District Consumer Forum, Bhandara thereafter went through the documents as well as evidence affidavit filed by the complainant as well as O.P. The learned District Consumer Forum, Bhandara also went through written notes of argument filed by both the parties.  The learned District Consumer Forum, Bhandara thereafter gave  findings that the O.P.-Oriental Insurance Company Ltd. had wrongly  repudiated  the genuine  claim of the  complainant on the ground  that  the  post hospitalization  medical  expenses  can be  paid for the  period  60 days  after the  insured  person  is discharged.  Accordingly, the learned District Consumer Forum, Bhandara allowed the complaint  and directed the O.P. namely United India Insurance Co. Ltd.  to pay  the balance sum of Rs. 1,11,355/- along  with interest  at the rate of 9% as well as  Rs. 10,000/- towards mental   harassment  and Rs. 5,000/- towards  litigation  cost. It is against this judgment and order dated 06/07/2017 passed by the learned District Consumer Forum, Bhandara   the present appellant/complainant have come up in appeal.

5.         We have heard Mrs. Anita Mateganokar learned advocate for the appellant and Mr. Shaha, learned advocate for the respondent.  We have also carefully gone through the record as well as documents filed by both the parties and also written notes of argument filed by both the parties on record.  On the  basis  of  facts  stated  above  the only  point  which  emerges  for  our consideration  is as follows  with our finding recorded  against  the  same  and  reasons  thereafter.

Reasons for finding

6.         Prior to turning  to the submission made by the learned advocates for the appellant and respondent it would be pertinent  to set out   certain material  facts. Complainant – Mrs. Manda Kumbhare who was herself  a Gynecologist had taken Platinum Health Insurance Policy in the year 2006 and same was lastly renewed for the period from 18/08/2015 to 17/08/2016. The complainant  had taken a Health  Insurance Policy  for  Rs. 1,500,000/- for her and her  husband  Dr. Arun Kumbhare for Rs. 2,00,000/-.  Complainant  has alleged that  on 31/06/2015  during the valid  period of  insurance  while walking  her   right  ankle  joint got twisted and  so she was  required to go to the Hospital of  Orthopedic Surgeon  Dr. Kukdel when she was admitted. There is no dispute  that  there after  medical treatment  was given  and the claim was made by  the complainant  which had come to be repudiated  by the appellant- United India Insurance Co. Ltd.

7.         Mrs. Anita Mategaonkar, learned advocate for the appellant has challenged the impugned order passed by the learned District Consumer Forum, Bhandara on several counts and we shall deal with them one by one.

8.         At the outset, the learned advocate  for the appellant  has taken a plea that  the complaint  filed by the complainant  was  suffering  from non joinder of necessary  party since  Third Party Administrator (TPA) who was responsible  for settlement  of claims and  resolving  dispute   was not  made party  by the complainant.  It is submitted by the learned advocate  for the appellant  that the Third Party Administrator (TPA) is an authority  designated  to  resolve  the dispute  and  it has already  gone  through  the papers  and thereafter  had allowed the claim partly. However, the learned District Consumer Forum, Bhandara had not taken this aspect and role of Third Party Administrator (TPA) into consideration and therefore, has committed an error in allowing the complaint.

9.         However, the learned advocate  for the  respondent  has strongly opposed  this submission  and has submitted that the  Third Party Administrator (TPA) was not at all necessary party  and  was in fact  an  internal agency  which  was doing   the work of investigation  of claims on behalf of appellant -  United India Insurance Co. Ltd.  and cannot  be  called an  independent  entity or necessary party.

10.       We are also of the clear view that the Third Party Administrator (TPA) was performing the job of investigation of the claims and therefore cannot be termed as a necessary party to the present complaint. We also find that the learned District Consumer Forum, Bhandara has rightly not accepted this contention raised by the appellant. Merely because the Third Party Administrator (TPA) was having   the team of specialized doctors to give expert opinion no inference can be drawn that the Third Party Administrator (TPA) was necessary party.

11.       The next  contention of the learned advocate  for  the appellant  was that  as per  the terms and conditions  of the Insurance  Policy  and more particularly Clause No. 3.31 of the  Insurance Policy  the claim  filed by the Consumer  was admissible  only for  the period  of 60 days  after the patient / insured  person  was discharged from the  Hospital.  But the complainant  though  had agreed to abide  by the terms and conditions  of the  policy  had preferred the claim regarding the purchase  of medicine after the period of 60 days  and so there was a clear breach  of Clause No. 3.31 of the Insurance  Policy .  In this regard the learned advocate for the appellant has drawn our attention to the various documents which were filed on record by the complainant.  The learned advocate  for the appellant  has drawn our attention to the fact that  complainant – Dr. Manda Kumbhare first visited  the Hospital  of Dr. Kukde  on 01/07/2015 and  was also  admitted  in the  Hospital  for one day for fracture.  The complainant also came to be discharged from the Hospital on the next date i.e. on 02/07/2015 and at the time of discharge she was advised  to take Terifrac Injection  daily for  6 months. However, Dr. Kukde also referred the complainant for further examination to Dr. Aurangabadkar and Dr. Aurangabadkar ordered  the Digital  Dexa bone Scan  which came to be performed. The  complainant  has alleged  that  during the Digital  Dexa bone Scan conducted  by Dr. Aurangabadkar it was found that  she was suffering  from  Osteoporosis  and so she was advised  to take  Terifrac injection  for a period of 2 years.  The complainant tried to procure the said injection but it was not available at Bhandara and so she placed an order with Shree Sai Medicals, Nagpur who got the injections procured from Mumbai and supplied the same to the complainant.  Mrs. Anita Mategaonkar, learned advocate  for the appellant  has strenuously  submitted before us  that  the  complainant  had not  placed  on record any documents  which could go to show  that  Shree Sai Medicals, Nagpur  had placed  any order  for the said  injections or that  it  secured the injections from Mumbai. Further Shree Sai Medicals, Nagpur had also not supplied any purchase receipt regarding purchase of injections for the complainant.  Further  the appellant  has also taken a plea that  the receipt shows  that  injections were  purchased  on 09/09/2015 but  expiry date  was in the month of July-2017.  On this aspect  we also  heard the learned advocate for the respondent /complainant and he has drawn our attention  specifically  to the prescription  issued by Dr. Kukde on 02/07/2015 which clearly shows that  Terifrac injection  had come to be prescribed  for the complainant.  Moreover, the discharge card which was issued by Dr. Kukde Nursing Home on 02/07/2015 specifically mentions use of Terifrac Injection daily for 6 months.  It is clear  from the documents  placed  on record by the complainant that  there after Dr. Kukde had referred  the complainant  for further  treatment  to Dr. Aurandabadkar on 28/08/2015.  Not only this but Dr. Kukde has also advised   Dexa Scan for Osteoporosis .The complainant has placed on record the copy of  Rainbow   Medinova Diagnostic Services where the said  Dexa Scan  was conducted . All these  papers  placed  on record by the  complainant  only go to show  that  though  the complainant  was  initially  admitted  for  fracture  subsequently  she was found  to be suffering  from  Osteoporosis  and prescription  also were issued. At this  stage  it is also  necessary  to  turn  to Clause  3.31 of the  Insurance  Policy  which  reads  as under :-

Clause No. 3.31:- POST HOSPITALISATION  MEDICAL  EXPENSES

            Relevant medical expenses incurred immediately 60 days  after the  insured person  is discharged  from the  hospital  provided that :

a.         Such medical  expenses are incurred for the same  condition for which  the  Insured Person’s Hospitalisation was  required and

b.         The in-patient  Hospitalisation claim for such  Hospitalisation is admissible  by the Insurance  Company.

12.       In the light  of the aforesaid clause  it is submitted by the learned advocate for the  appellant  that  the appellant  company  was liable  to pay the medical expenses  incurred  immediately  60 days  after the  insured  person is discharged .  According to the appellant the respondent /complainant got discharged on 02/07/2015 and so the company was not liable to bear expenses of Terifrac Injection for two years.  We find that the learned District Consumer Forum, Bhandara has elaborately dealt with this aspect in para No. 16 of the judgment and has observed that there was no violation of Clause 3.31 of the Insurance Policy. The learned District Consumer Forum, Bhandara has also  observed  that  there were  no documents or material  placed on record  which  could go to point  out that  the  medical bill of Shree Sai Medicals  regarding  purchase of Terifrac Injection was either  false or bogus. We are also of the view that the appellant had not placed on record any such material to draw such inference. So far as this aspect relating to Clause 3.31 of the Insurance Policy  is concerned though  injections  were  prescribed for  2 years. We are of the view that  no hyper technical  approach  can be adopted  while  dealing  with  the Consumer Complaint under  the beneficial provision  of the Consumer Protection Act.  The learned advocate for the  respondent  has submitted that  in case the appellant  was having  any doubts  it could  have  asked  the complainant  to produce  this  injection  but  no such  step was  taken. Further, the learned advocate  for the respondent  has also  argued  that there was  no question  of doubting  the bona-fides of the complainant regarding purchase of injection  who was not only the Consumer but also  Gynecologist herself and more particularly  when the said Terifrac Injections were  duly prescribed  by Dr. Kukde on 02/07/2015 and subsequently also.  We find considerable force in this contention of the learned advocate for the respondent.  We also find that appellant – United India Insurance Co. Ltd. had wrongly repudiated the claim of the complainant.  The respondent  has  also pointed out  during  the argument  that  the appellant  had taken  narrow and hyper technical view  and same was  not  permissible.  We find that  the learned District Consumer Forum, Bhandara has  elaborately  dealt with  these  aspects  and had rightly  come to the  conclusion  that  the appellant /O.P. had  indulged  in deficiency  in service  by not allowing  the  reasonable  claim of the  complainant.

13.       After  going through  the papers  placed  on record and after hearing  the submissions  advanced  by the learned  advocate  for the appellant  and respondent  and on going  through  the judgment  we do not find any reason to  disturb   the  finding  arrived  at  by the learned  District Consumer Forum, Bhandara nor the  same can be  termed as perverse or unwarranted.

14.       In the light of the aforesaid discussion we find that the appeal is devoid of any substance. We therefore answer to point No. 1 is negative and by way of sequel we proceed to pass the following order. 

ORDER

i.          Appeal is hereby dismissed.

ii.          Appellant and respondent shall bear their own costs.

iii.         Copy of order be furnished to both the parties free of cost.