OFFICE  OF  THE  DISTRICT  CONSUMER  DISPUTES  REDRESSAL FORUM, KAMRUP,GUWAHATI

C.C.8/2010

Present:-

                             1)Md.Sahadat Hussain, A.J.S.  -   President

                             2)Sri U.N.Deka -                           Member

          Sri Sitangshu Kr.Nandi                                             -Complainant

          S/O Late Sudhangshu Kr.Nandi

           Resident of “Shriniketon”,B.K.Kakati Road       

          Ghty-7.               

 -vs-

         The Manager,                                                         -    Opp.parties

         The Oriental  Insurance Company

         Beltola Branch,Ghty-9

         Appearance-        

                   Learned advocate Sri Gopika Ranjan Dev for the complainant

                   Learned advocate Mrs. Mamoni Choudhury for opp.party

                   Date of argument-                     8.1.2016

      Date of judgment-         4.2.2016

This is a complaint u/s 12 of the Consumer Protection Act, 1986.

1. Complainant’s complaint is admitted on 22.2.10 and notices were issued and served upon the opp.party who also filed their written statement. Then after the complainant filed his affidavit and he was cross examined by the counsel of the opp.party. The opp.party side also filed affidavit of one Sri Balen Sarma, he was also cross examined by the counsel of the complainant. Both sides filed their respective written argument. On 19.1.16 we have heard oral argument of learned counsel of opp.party Mrs. M.Choudhury while the complainant was found absent on that day and on last two occasions without step. We have perused the pleading of the parties, their evidence as well as their written arguments. We have also perused the oral argument of learned advocate Mrs. M.Choudhury who is standing for the opposite party. We are giving our decision as below.
2.            The complainant story in brief is that the complainant purchased mediclaim insurance policy No.321206/2007/84 by payment of premium of Rs.5,085/- for an amount of Rs.2,20,000 (sum assured) against medical expenses for the period from 06.09.06 to 05.09.07. The policy was taken jointly with his wife Smti Sujaya Nandi. As per the terms of the policy, hospitalization expenses in respect of the insured i.e. Shri Sitangshu Kumar Nandy was staying in Bangalore, some problems relating to his heart arose and he had to be admitted at Wockhardt Hospital, Banglore on 11.7.2007. He was discharged from the hospital on 12.7.2007 after treatment. A bill for Rs.18,694.28 (Rupees eighteen thousand six hundred ninety four & twenty eight paisa) relating the treatment was submitted to the office of the respondent under cover of the letter dtd.6^th August,2007 which was received at the office of the respondent on 18.8.2007. As per regulation 9(5) of the Insurance Regulatory and Development Authority (Protection of policy holders interests) Regulations 2002, the insurer is supposed to offer a settlement of claims within a period of 30 days. Even if the insurer decides to reject the claim, it should be communicated in writing within a period of 30 days. Since there was no response from the opposite party, a reminder letter dt.10.12.2007 was submitted to the office to the respondent which was refused to be accepted.

The complainant further stated that he is a senior citizen and suffering from various old age diseases , and therefore could not follow up the matter. Moreover he is a pensioner and facing financial crunch for family maintanance and for and for purchase of medicines and therefore given another lawyers notice dt.24.11.2009 which was received at the office of the opp.party on 4.12.2009.

3.            The gist of the pleading of the opp.party is that there is no cause of action for filing the complaint; the complainant is not a consumer; complainant is guilty of suppression of material fact. The complainant could not placed the claim along with the required documents. They are not guilty of any deficiency of service having the complaint was filed the claim was pending before them. The complainant must prove his allegation.

4.           We have perused the evidence of Opp.Party No.1 (D.W.1) Sri Balen Sarma and found that the opp.party side admitted that the complainant Mr.Sitangshu Kumar Nandi and was admitted in wockhardt Hospital, Bangalore on 11.7.2007 and released on 12.7.2007. From exhibited documents of the complainant the same in reflects . Thus it is established that on 11.7.2007 the complainant had suddenly fallen sick and was admitted at wockhardt Hospital, Bangalore, for immediate medical care and he was released from the hospital on 12.7.2007 after treatment. Thus it is proved that the complainant had been in hospitalized stage in wockhardt Hospital, Bangalore more than 24 hours for treatment as he had suddenly fallen sick at Bangalore. After perusing the evidence of opp.parties it appears to us that the opp.party refused to ignore the claim of the complainant on the ground that the complainant had not taken        treatment in the said hospital rather attended their for health evaluation/diagnostic purposes and hence the case of the complainant is not coverable under policy condition.

5.             It is both sides admitted fact that the complainant did a insurance policy (individual mediclaim) vide policy No. 321206/2007/84 with the opp. party-oriental insurance company ltd. covering the health of complainant and his wife Smti Sujaya Nandi and the policy was effective from 6.9.2006 to 5.9.2007 with yearly premium of Rs.5085/-. As the complainant was admitted in wockhardt Hospital on 11.7.2007 and took treatment there and got discharge their from 12.7.2007. It is found that the complainant got treatment in the said hospital within the coverage of the said policy. In the written argument opp.party side submits that the claim of the complainant fails under exclusion four pointed of the policy which shows that expenses incurred at Hospital or Nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalization period is not payable by the insurer. Now moot question is that whether the complainant had taken active treatment during the hospitalization period. The complainant states that as he had fallen ill he got admitted in the  wockhardt Hospital on 11.7.2007 and took medical care there and discharged from the hospital on 12.7.2007. From the discharge summary of the wockhardt Hospital it is seen that during hospitalization the complainant was treated by Dr.P.Padma Kumar (Cardiology Associates) and on diagnosis it was found that he was suffering from coronary Artery disease, effort angia, mild coronary artery disease with hypertension and during hospitalization test like eco-cardiography, Himatology profile Luxury fax on PRIV and coronary Engiography were done and TMT was also done. The doctors also prescribed some medicines to the complainant which is /stamlo beta one tablet in the evening, Telma-H 40 mg 1 tablet in the morning, deplatt-A-150 mg – 1 tablet in a day and storvas 10 mg (one tablet in the evening) and he was also advised to Dr.Padmakumar after 10 days for evaluation. This it is fact that the doctor prescribed medicines during hospitalization of the complainant and he was also advised to attend the doctor after 10 days for evaluation. This fact proves that the complainant was under the active treatment during hospitalization. Therefore we are constrained to hold that the case of complainant does not fall in the exclusion clause No. 4.0 of the policy. Therefore we hold that the expenditure made  by the complainant in his  said medical treatment is liable to be re-imburse by the insurer(opp.party)

6.   We have perused the bill submitted by the complainant which is Ex-2 and found that the complainant spend Rs.18,694.28/- for his treatment in the said hospital which includes hospitalization charge, the charge of different test and the price of the medicine and it considered on him. Therefore, we hold that the opp.party is liable to pay the said amount to the complainant as cost of treatment.

7.As the opp.parties refused to settle the claim of the complainant and thereby causes harassment to him and for that count the opp.party is liable to pay at least Rs.5,000/- to him as compensation. Moreover for the adamant attitude of the opp.party, the complainant had to filed this complaint and procecute the opp.party by engaging advocate and thereby he had to spending certain amount in paying fees to the complainant and bearing his own transportation cost to this forum. Therefore , the opp.party is liable to pay another amount of Rs.5,000/- as cost of the proceeding.

8.Because of what has been discussed as above, we hold that the complaint has merit. Accordingly, the complaint is allowed on contest and the opp.party is directed to pay Rs.18,694’24paise to the complainant as the cost of his treatment concerned with interest @ 12% per annum and also to pay Rs.5,000/- as compensation for causing harassment to him as well as Rs.5,000/- as cost of the proceeding. The opp.party is directed to pay the amounts within two months, in default their two amount shall also carry interest @ 12% per annum from the date of judgment.

Given under our hands and seal of this forum on this day 4^th Feb,2016.

Free copies of judgment be delivered to the parties.

               (Mr.U.N.Deka)                                               (Md.S.Hussain)

                   Member                                                           President