Dt. of filing- 15/02/2018
Dt. of Judgement- 11/10/2018
Mrs. Balaka Chatterjee,Member.
This petition of complaint is field u/s. 12 of the Consumer Protection Act, 1986 by Abjhijit Boral alleging deficiency in service on the part o the Opposite Party (referred as OP hereinafter ) namely he Manager, Claim Division, Apollo Munich Health Insurance.
Case of the complainant in brief is that the complainant being suffered with acute sore throat and high fever visited Dr. Monalisha Ghosh on 02.08.2016 who advised the complainant for blood test and for taking medicines mentioned in her prescription but the treatment of said Doctor did not bring expected result and, therefore, the complainant visited Dr. Milan Kr. Chakraborti of CMRI on 05.08.2016 and as per advise of Dr. Milan Kumar Chakraborti the complainant got admitted in the said Hospital on 05.08.2016 and after initial check up he was diagnosed with sore throat, dyspagia, fever, epigastric discomfort and was visited by Dr. T. K. Banerjee. The complainant has stated that during this phase of illness he was covered under medical insurance Policy being No.150300/11001/1000233542-04 vide Member ID No. 110002415958 but the complainant was denied cashless treatment facility and had to bear entire expenditure for treatment on his own and after getting discharged from the Hospital on 13.08.2016 the complainant filed claim with OP vide claim ID 442455 for reimbursement of Rs. 70,111/- towards cost of treatment and accordingly, submitted all original documents relating to his treatment. However, the OP vide letter dt. 14.09.2016 repudiated the claim on the ground that ‘need for hospitalization was not established ‘. ‘The complainant has further stated that this repudiation caused severe mental harassment since the complainant took loan from his friends and the decision taken by him for admission was not his own. Moreover, he had himself got admitted only as per advise of the Doctor and in course of treatment had been administered intravenous medicine through IV Channel and, thereof re, the complainant by filing the instant consumer complaint prayed for direction upon the OPs to reimburse the claim of Rs. 70,111/-, to pay Rs. 1,00,000/- towards compensation, to pay Rs. 20,000/- towards cost of litigation and other reliefs.
The complainant annexed documents including photocopies of prescription dt 2.8.2016 , 5. 8.2016, Receipt dt. 3.08.2016, Pathological test report. Final bill dt.8.12.2016.
The OP contested the case by filing written version denying and disputing all the allegations made out in the petition of complaint stating inter alia, that the complainant had himself insured by obtaining a Mediclaim Insurance Policy under certain terms and conditions mentioned therein the policy document. The OP has stated that the complainant forwarded request for cashless treatment on 13.8.2016 but past history column of pre-authorisation form was remained blank and a query letter as issued from the end of the Insurance company which remained un-replied and due to that reason payer for cashless treatment had not been granted. However, the complainant was intimated that he could file claim for reimbursement annexing all medical and financial records after completion of the treatment which the complainant complied and filed claim on 2.9.2016 for treatment of sore throat, dysphagias, fever, epigastric discomfort for the period of 5.8.2016 to 13.8.2016. It is stated by the OP that during scrutiny and examination of documents it was found that during 8 days span of hospitalization only two pathological tests were done and no justifying ground had been found for hospitalization and treatment with high antibiotics and all related investigations were done 2 days prior to hospitalisation and the Insurance Company. Considering the situation, repudiated the claim of the complaint. The OP Insurance Company placed reliance upon the decision of (1)Hon’ble NCDRC in RP/1173/2007 [ Authority under Yeshasharini Wima Yojna –vs.- Mumtaz Begum ].
(2) Hon’ble Apex Court, reported in (1966) 3 SCR 500 [General Assurance Society Ltd. –vs. – Chandunanll Jain and Another ]
(3) Reported in AIR 1998 SC 3252 [ Oriental Insurance Co. Ltd.-vs.- Sony Cheriyam ]
(4) The Apex Court Indian in Verdict under Appeal No. 6277 of 2004 [ United India Insurance Co. Ltd. –vs.- Harchand Rai Chandan Lal ]
Points for determination :
- Whether repudiation of the claim is justified
- Whether he complainant is entitled to the relief as prayed for.
Decision with reasons
Point No.1 : Admittedly the complainant obtained an Insurance Policy being no 150300/11001/1000233542 - 04 which was in force on and from 19.09.2015 to 18.09.2016 . Admittedly, the complainant had been admitted to CMRI Hospital as indoor patient on 5.8.2016. The complainant put his claim for reimbursement of the amount for his medical expenses during the said period as per provision of the said policy which was repudiated by the OP Insurer vide letter dt.14.09.2016 on the ground/reason “(i) as per the submitted document the need for hospitalization is not established. Hence, we regret to inform you that claim is repudiated u/s. Vi C viii b of the policy terms and conditions”. However, under Section vi C viii b the policy contains medical exclusion runs as “conditions for which treatment could have been done on an OPD basis without any hospitalisation” .
In the written version, e OP also slated that the complainant had suffered from sore throat, dysphgia, fever, epigastric discomfort for which he admitted to the CMRI Hospital. It is further stated in the written version that the OP noticed from the submitted documents that there was no sign and symptoms revealed justifying need of hospitalization and treatment with high end antibiotics. It is further stated in the written version that during eight days of hospitalization only two pathological tests viz. Thyroid and swab culture were done. According to the OP such type of ailment could have been treated as OPD basis and as such as per provision of Section Vi C viii b the claim for reimbursement is not interminable . In support of such repudiation the OP relied upon some decisions of Hon’ble NCDRC and Hon’ble Apex Court but the same are not applicable to the instant case since they are of different context.
On perusal of documents on record it appears that the complainant consulted doctor on 5.8.2016 and the consulting Dr. Milan Kr. Chakraborty by his prescription dt. 5.8.2016 advised admission for parental medicines and Hydration. The complainant has stated that in accordance with such advise he had been admitted to CMR on 5.8.2016 wherein necessary medical treatment administered to him and as per advise of treating Doctor he was discharged therefrom on 13.8.2016. Though the OP has reiterated that there was no necessity on the part of the complainant to get admitted to the hospital as indoor patient since the said ailments could have been treated on the basis of OPD but no authentic document such as opinion of an expert has been brought before us wherefrom it would have been evident that the claim of the OP i.e. the ailment of the complainant could have been treated on the basis of OPD, has validity.
On the other hand prescription dt. 5.8.2016 issued by Dr. Milan Kumar Chakraborty clearly shows that the patient was advised for admission for parental medicine and Hydration Under such circumstances, it is very much evident that the OP miserably failed to substantiate the ground/reason for repudiation of the claim by the complainant. In such view of the matter we think that repudiation of claim is unjustifiable.
Point no.1 is decided accordingly.
Point No.2 :
Admittedly, the complainant obtained a policy from OP being Policy No.150300/11001/000233542 for the period of 29.8.2011 to 28.8.2012 and subsequently renewed from time to time. It appears from the proposal form that assured sum of the said policy was Rs.4,00,000/- and the policy was in force during the period of hospitalisation. The essence of contract for insurance is to indemnify the insured by the insurer from any loss suffered by the insured. Therefore, there is no ground to disallow such innocuous prayer of the complainant for reimbursement of expenses incurred by him during hospitalization period.
The complainant has prayed for compensation. In our considered view we do not find any ground to allow such prayer.
The OP by repudiating claim of the complainant compelled he complainant to file he complaint and, therefore, they are liable to pay cost of litigation.
In the result, the consumer complaint succeeds.
Hence,
ORDERED
That CC/74/2018 and the same is allowed in part on contest with cost.
The OP is directed to reimburse Rs.70,111/- within one month of this order.
The OP is further directed to pay Rs.10,000/- towards cost of litigation within aforesaid period. Failing which the entire amount shall carry interest @7% p.a. from the date of this order.
