Ld. Advocate(s)
For Complainant: Pradip Banerjee
For OP/OPs : Raj Kumar Mandal
Date of filing of the case :23.02.2015
Date of Disposal of the case :22.11.2022
Final Order / Judgment dtd.22.11.2022
Complainant Prosenjit Ghosh filed the present complainant against the aforesaid opposite parties under section 12 of the Consumer Protection Act, 1986 alleging deficiency in service and prayed for award amounting to Rs.2,16,253.81(Rupees Two lakhs sixteen thousand two hundred fifty three and eighty one paisa), and compensation amounting to Rs.2,00,000.00(Rupees Two lakh) and cost of the suit.
It is the allegation of the complainant that he had been covered by Insurance Card No. GINI0603497577 valid from 01.08.2012 issued by OP No.1 under OP No.2. As the complainant was seriously fallen in, he went to Narayana Hrudayalaya Hospitals at Bangalore for his treatment and complainant had been suffering from triple vessels disease i.e. heart block. He was admitted there on and from 03.10.2012 till 27.11.2012. For the aforesaid treatment he spent Rs. 2,16,253.81(Rupees Two lakh sixteen thousand two hundred fifty three and eighty one paisa) and furnished a claim before the OPs but they did not pay the same. Thereafter, complainant sent a notice to the OP No.1 on 26.12.2014 through his Ld. Adv. Mr. Pradip Banerjee but in spite of receipt of the said notice OP No.1 did nothing. Thereafter, he lodged a complaint before the SP, GRP, Sealdah through proper channel but no response was found. Hence, the complainant filed this case.
In spite of receipt of the notice, OP No.1not yet appeared in this commission. Case is running ex-parte against him. OP No.2 filed written version before this commission and denied the entire allegations and further stated that there is no deficiency in service. OP No.3 also filed written version before this commission and denied the entire allegations and further stated that there is no deficiency in service.
(3)
Trial
During trial complainant Prosenjit Ghosh filed affidavit in chief. He also submitted answer as per interrogatories of OP No. 2 &3.
OP No. 2 & 3 not yet produced any evidence i.e. affidavit in chief.
Documents
Following documents have been produced viz :
- Letter issued by Genins India TPA Ltd.........(One Sheet)........(Xerox copy)
- Copy of MEMORANDUM OF UNDERSTANDING.......................(six sheets).............(Xerox copy).
- Card issued by Genins India TPA Ltd.............(one sheet)............(Computerised copy)..(Annexed A)
- Discharge Intimation slip issued by Narayana Hrudayalaya Hospitals..........(one sheet)...(Computerised copy)...(Annexed B)
- Hospitalisation Claim Form for Reimbursement............(one sheet)........(xerox copy)..(Annexed C)
- Bill Cum Receipt issued by Narayana Hrudayalaya Hospital..........(four sheets)........(xerox copy)..(Annexed from D to G))
- Receipt issued by Narayana Hrudayalaya Hospitals............(two sheets).............( xerox copy)..(Annexed from H to I)
- Medicine Delivery issued by Hrudayalaya Pharma & General Stores...(two sheets)........(xerox copy)......... ( Annexed from J to K)
- Bill cum Receipt issued by Narayana Hrudayalaya Hospitals........(two sheets)........(xerox copy)..........(Annexed from L to M)
- Receipt issued by Narayana Hrudayalaya Hospitals.............(one sheet).............(xerox copy)..........(Annexed N)
- Receipt issued by Hrudayalaya Pharma & General Stores .............(one sheet)........(xerox copy)........(Annexed O)
- Receipts issued by Suraksha Medical...........(two sheets)........(Xerox copy).........(Annexed from P to Q)
- Letter issued by Pradip Banerjee, Adv. to Genins India TPA Ltd.....(two sheets)........(Xerox copy)........(Annexed from R to S)
- Receipt issued by Hrudayalaya Pharma and General Stores.........(one sheet).........(xerox copy).........(Annexed T)
(4)
- Copy of application from Prosenjit Ghosh to S.P, GRP, Sealdah........(one sheet)........(xerox copy).......(Annexed U)
- Final Bill issued by Narayana Hrudayalaya Hospitals...........(two sheets).........(Computerised copy).........(Annexed 1)
- Patient Ledger issued by Narayana Hrudayalaya Hospitals............(one sheet) ..........(Computerised copy)..........(Annexed 2)
- Final Bill issued by Narayana Hrudayalaya Hospitals...(one sheet)........(Computerised copy)...........(Annexed 3)
- Without Prejudice issued by Narayana Hrudayalaya Hospitals........(One sheet).........(Computerised copy (Annexed 4)
- Payment Receipt issued by GRP, Sealdah, W.B..........(one sheet)..........(xerox copy)..........(Annexed 5)
- Payment received issued by SLD, GRP District...(one sheet)...(Xerox copy)...(Annexed 6)
- Payment received issued by GRP Sealdah District..(One sheet)...(Xerox copy)...(Annexed 7)
- Patient Ledger issued by Narayana Hrudayalaya Hospitals...(One sheet)..(Computerised copy)..(Annexed 8)
OP No.2 also produced certain documents viz:-
- Acknowledgement Form of Penalty issued by DCDRC, Nadia.....(One sheet)....(Original )
- Balance of Bank Pass Book of DCDRC, Nadia.....(one sheet)....(Xerox copy)
- Terms and Condition issued by National Insurance Company Ltd....(Two sheets).....(Original)
Brief Notes of argument.
Complainant in support of his case filed Brief Notes of Argument and OP NO.2 also filed Brief Notes of Argument .
Argument
Ld. Adv. for the complainant argued before this commission that complainant was covered with insurance policy under the OP No.1-3. Complainant relating to his treatment at Narayana Hrudayalaya Hospital at Bangalore spent Rs.216253.81 and claimed the same before the OP NO.2 but they did not give the same. During tendency of the case they without the permission of the complainant transferred an amount of Rs.107000.00 to his bank account. Complainant is entitled to get the rest amount and compensation of Rs.2lakh and cost of the suit.
(5)
In reply Ld. Adv. for the OP NO.2 argued before this court that one memorandum of understanding was executed in between OP No.2 & Mr. Anil Kumar, IPS, Additional Director General and Inspector General of Police (Welfare), West Bengal). He filed the copy of the same and in the said document sanction amount of cost of treatment relating to different type of treatment has mentioned and as per aforesaid specification of cost of treatment complainant was entitled to Rs.107000 as CABG operation has done and they already transferred the said amount in favour of the complainant in his bank account and complainant already withdrew the same. Except the aforesaid amount complainant is not entitled to any other amount. He prays for dismissal of the case.
Decision with Reasons
It is the allegation of the complainant as mentioned in the petition of complaint that OP No.1-3 were negligent to pay the treatment cost in favour of the complainant though they were bound to pay the same as complainant was covered with an insurance policy under them.
He clearly stated in the complaint that due to his treatment at Narayan Hrudlaya Hospital for the period from 03.10.2012 to 27.11.2012, he spent Rs.216253.81 and furnished his claim on 02.01.2013 before the OPs but OP NO.1-3 did not take any attempt to pay the insurance coverage amount. Even they did not respond the Advocate notice.
I have carefully gun through the copy of Memorandum of Understanding which reads as under:-
Clause 3(1) The Sum Insured will be Rs.1,50,000.00 (Rupees One lakh fifty thousand) on family floater basis for medical treatment during hospitalization subject to agreed sub-limits on a floater basis and sum insured of Rs.5,00,000.00(Rupees five lakh) only (on duty) and Rs.2,50,000.00 (Rupees Two lakh fifty thousand) only (off duty) under Add on Personal Accident Insurance benefit for Primary Members only to cover accidental only to cover “accidental death” to serving and enrolled employees.
Clause 3(1) A buffer amount of Rs.2 crores (2,00,00,000/-) will be kept reserved for coverage wherefrom a maximum amount of Rs.2 lakh per family will be allowed (on first come first serve basis) for treatment of 5(five) specific major critical illness namely cerebral stroke, heart surgery, organ transplantation, cancer and major accident to the member’s covered.
Learned Advocate for the OP No.2 argued before the Commission that CABG operation of complainant has done, so as per Memorandum of Understanding complainant is entitled to Rs.1,00,000/- (Rupees One lakh), as per table mentioned after clause 3(xiv). In the said table amount of Rs.1,00,000/- (Rupees One lakh) has clearly mentioned for CABG.
(6)
But Learned Advocate for the OP No.2 could not explained satisfactorily as to why OP No.2 transferred Rs.1,07,000/- (Rupees One lakh seven thousand) where complainant was entitled to Rs.1,00,000/-(Rupees One lakh) as per the table mentioned after clause 3(xiv).
On careful perusal of the said table we find that full form of CABG not yet mentioned in the said table.
On careful perusal of clause 3(ii) we find that OP No.2 was agreed to provide Rs.2,00,000/-(Rupees Two lakhs) per family for heart surgery.
On careful perusal of annex ‘B’ dtd.27.11.2012 which is Discharge Summery bill, we find that in the said document it has mentioned clearly for the complainant, CARDIAC SURGERY and complainant was discharged on 27.11.2012.
O.P. No.2 produced one certificate issued by consulting cardiac surgeon of Narayana Hrudayalaya dtd. 01.12.2012.
On perusal of the said document we find that it has been clearly described therein that complainant was suffering with CORONARY ARTERY DISEASE and in the said hospital on 21.11.2012 ELECTIVE CORONARY ARTERY BY PASS GRAFTING was done.
In view of the aforesaid discussion we are in the considered view that claim of the complainant will considered as “HEART SURGERY” and not as “CABG”.
So it is held that in view of the aforesaid Insurance card and as per clause 3(ii) of Memorandum of Understanding complainant was entitled to reimbursement of cost of heart surgery amounting to Rs.2,00,000/-(Rupees Two lakhs).
It is found from the documents filed by OP No.2 that they already paid Rs.1,07,000/-(Rupees One lakh Seven thousand) to the complainant through the bank account of complainant by way of NEFT.
So it is clear before us that complainant is entitled to Rs.93,000/-(Rupees Ninety three thousand) from the OP No.2 alongwith interest @9% per annum from the date of filling of this case i.e. from 23.02.2015 to till the date of actual payment.
We are also in the opinion that complainant is entitled to Rs.50,000/- (Rupees Fifty thousand) for his harassment, mental pain, agony and complainant is also entitled to Rs.20,000/- (Rupees Twenty thousand) as cost of the suit.
(7)
Hence,
It is
` Ordered
that the present case be and the same
vide No. CC/26/2015 is allowed on contest against the OP No. 2 and 3 and allowed ex-parte against the OP No.1 with cost of Rs.20,000/- (Rupees Twenty thousand) to be paid by the OP No.2 in favour of the complainant.
OP No.2 is hereby directed to pay Rs.93,000/-(Rupees Ninety three thousand) in favour of the complainant alongwith interest @ 9% per annum from the date of filling of this case i.e. from 23.02.2015 to till the date of actual disbursement within a month from the date of this order.
OP No.2 is also directed to pay Rs.50,000/-(Rupees Fifty thousand) in favour of the complainant as compensation for his mental pain, harassment and agony within a month from this order.
Complainant shall have liberty to put this order into execution if OP No.2 will not comply within the aforesaid period.
Let a copy of this Final Order be supplied to the complainant as free of cost.
Let another copy of this Final Order be sent to OP No.2 by post from this Commission for compliance.
