Dt. of filing- 02/08/2017
Dt. of Judgement- 28/09/2018
Mrs. Sashi Kala Basu, President
This is a complaint filed under section 17 of the Consumer Protection Act, 1986 by Mr. Kishore Kumar Das alleging deficiency in service on the par of Opposite Parties namely (1) Branch Manager, National Insurance Company Ltd. and (2) Heritage Health TPA Pvt. Ltd.
The brief facts of the case of the Petitioner/Complainant is that he is a medi claim Policy holder of Opposite Party No.1, having Policy No.101901/48/16/8500000606. Said insurance coverage was for the petitioner, for his wife Alpana Das and son Krishnabhishek Das and sum insured was Rs.75,000/-, Rs.75,000/- and Rs.50,000/- respectively validity period of Policy was from 25.04.2016 to 25.04.2017. Premium price was Rs.16424/-. Policy started from 25.04.2003 (Inception date). Son of the petitioner/complainant namely Krishnabhishek Das felt seriously acute pain in the abdomen and severe headache for the first time and was admitted at IRIS Hospital and treated under Dr. Bhaskar Das ( Proforma OP No.3 ). Patient was admitted on 05.03.2017 and was discharged on 09.03.2017. From the treatment sheet and discharge summary it reveal that patient was diagnostic for (i) Acute colitis (ii) Acute Migrainous attack. As the complainant was holding mediclaim Policy, complainant made an application to OP No.1 through IRIS Hospital for cashless treatment. But OP No.1 did not pay the treatment expenditure of Rs. 47087/-.Petitioner received a letter from OP No.2 dt.09.03.2017 regretting inability to sanction cashless authorization citing clause 4.10 of Policy. OP No.1 vide letter dated 02.05.2017 repudiated the claim of the petitioner with the observation “ As per discharge certificate of IRIS Hospital, patient was suffering from psychiatric disorder accordingly the claim is non-admissible and stands repudiated under exclusion 4.10 of the National Medi claim Policy”.
Complainant again sent the letter with request to settle the claim but OP No.1 did not settle the matter and repudiated the claim of the complainant. Hence, this case is filed for directing OPs to pay and settle the claim amount of Rs.47087/- along with interest @ 12% per annum , compensation of Rs.1,00,000/- for mental agony and harassment and litigation cost of Rs. 5,000/-.
Complainant has annexed with the petition of complaint, documents such as copy of Policy ; copy of discharge summary, copy of letters by OP no.2 dated 09.03.2017 and by OP No.1 dated 02.05.2017.
OP No.1 has only contested the case by filing written version denying and disputing the material allegation made in the petition of complaint contending inter-alia that on examining the claim of the insured/complainant thoroughly and basing upon the opinion given by the specialist /expert doctors of TPA ( OP No.2) , the insurance took the decision of repudiating as per exclusion clause no.4.10 of the Policy and hence, there is no deficiency of service and /or harassment caused to the insured by OP No.1.
OP No.2 and Proforma OP No. 3 have not taken any step on service of the notice. Thus case proceeded ex-parte against them.
Both the parties adduced evidence followed by cross-examination in the form of questionnaire and reply thereto.
Both the parties have filed brief notes of their argument. Ld. Advocate for the complainant has however argued that as per medical science psychiatric disorder comes from genetic in almost in every cases and require treatment under psychiatrist for long time but it is clear from the medical document that the patient suffered for the first time and was suffering from acute infective colitis and acute Migrainous attack.
Ld. Advocate for the OP insurance company by drawing the attention of this Forum to the opinion/report of the TPA/OP No. 2, has argued that OP No.2 denied sanction of cashless authorization to complainant, on through examination of medical documents and found that the “Patient has been admitted for the treatment of LOC with Age, Depressive disorder. Patient is under three drugs – Lithum, Penximine and clonazepam, used to treat manic depressive symptoms, patient was given anti-suicidal prevention. So it is evident that patient is under psychiatric treatment.
So, following points require determination :-
- Whether there is deficiency of service on the part of the OP ?
- Is the complainant entitled to the relief as prayed for ?
Decision with reasons
Point Nos. 1 & 2 :
Both the points are taken up together for discussion for the sake of convenience and to avoid repetition .
At the outset, it may be mentioned that complainant is the holder of ‘Mediclaim Policy’ being the Policy no.101901/48/16/8500000606 with the OP No.1/Insurance Company, for the period from 25.04.2016 to 24.04.2017, is not disputed. It is also an admitted fact that within the period of insurance coverage, son of the complainant was admitted at IRIS Hospital for 04 days. He was admitted on 05.03.2017and was discharged on 09.03.2017.It is also not in dispute that “Psychiatric disorder, intentional self-inflicted injury” fall within the exclusion clause of the policy and the same is statedinclause4.10 of the National Mediclaim Policy. Bone of contention is, according to the complainant, his son ( Patient ) namely Krishnabhishek Das never suffered from any Psychiatric disorder and he was treated only for A cute Infective Colitis and Acute Migrainous Attack. His son did not have any Psychiatric background. Whereas according to OP No.1,as per discharge certificate and other treatment paper of IRIS Hospital , patient was suffering from Psychiatric disorder. So,it is now restricted only to determine whether patient suffered from any Psychiatric disorder or mental illness ?
In the discharge summary annexed with the petition of complaint, it is stated that “Patient admitted with complaint of Left side abdominal pain x 4 Loose stools ( 5 times) severe headache with disturbed sleep, profuse sweating for 3 days,History of LOC 2 day back. Patient treated conservatively with IV fluids& IV antibiotics. Patient is being discharged in hemo dynamically stable condition with following advice”. The medicine has been advised thereafter with diet etc. and also advised to review after 10 days to Dr. Bhaskar ( Med.) and review after 07 days to Dr. Sourav Das(clinical – Psychiatrist ) in OPD.
So, it is evident that patient was treated by Dr. Bhaskar(Medicine)and also by Dr. Sourav Das who is a Psychiatrist. The treatment sheet contains ‘ Doctor’s Referral Sheet ‘ ( running page – 15in the record ) and it indicates that patient was referred to Dr. Sourav Das( Psychiatrist ) who on examination of the patient advised MRI Brain and advised tablets Panazep LS ( 12.5), Lonazep MD ( 0.5 mg)and tablet Lithosum SR. In the bills details names of other drugs& injections have also been mentioned which was given during treatment of the patient.
As per Oxford dictionary a Psychiatrist means ‘A medical Practitioner specializing in the diagnosis and treatment of mental illness’. If that be so than it is for the complainant to establish that the patient did not have any psychiatric disorder. Burden is on him to prove the same.
Complainant has filed a certificate allegedly issued from IRIS Hospital on 23.05.2017.
On perusal of the said certificate, its authenticity becomes doubtful because it is signed “ For Dr. Bhaskar Das” and not signed by Dr. Bhaskar himself. Whereas in the firisty regarding list of document produced bycomplainanton14.09.2018, it is mentioned original certificate issued by Dr. Bhaskar Das was filed. The best document would have been the certificate by Dr. Sourav Das (Psychiatrist ) who had examined and treated the patient but no such document has been filed. However, even accepting the said certificate filed by complainant, it appears that it is stated therein “The treatment was given as per the clinical presentation and basic disease where no psychiatric background was involved”. So by this document complainant intend to emphasize that the patient did not have any history of psychiatric disorder. But in this context, it may be mentioned that the relevant exclusion clause4.10 in the policy specifies that “Treatment for all psychiatric and psychosomatic disorders/ diseases,intentional self –inflicted injury, attempted suicide”. It is evident from the said exclusion clause that any treatment of psychiatric and psychosomatic disorders/diseases will attract the said clause. It is nowhere mentioned that there should be history of psychiatric treatment or there should be psychiatric background. The treatment sheets and the discharge summary discussed above do reflect that the patient was examined by the psychiatrist namely Dr. Sourav Das and he had prescribed certain medicines including Panazep LS and Lithosun SR which is given for Anxiety disorder, depression and panic disorder . It was opined by the heritagehealth TPA Pvt. Ltd that those medicines are used to treat Manic depressive symptoms and patient was given anti suicidal precautions.
The Insurance Policy between the Insurer and the Insured represents a contract between the parties. The terms of the agreement has to be strictly construed to determine the liability of the Insurer. The insured has also to act strictly in accordance with the terms of Policy expressly set out therein.So in view of the exclusion clause4.10 of the policy, no deficiency in service and unfair trade practice has been committed by the Opposite Party Insurance company in this case and thus this consumer complaint is liable to be dismissed.
Hence,
ORDERED
CC/447/2017 is dismissed on contest against O.P. No.1 and ex-parte against O. P. No.2 and Proforma O. P. No.3.
