IN THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BANKURA
Consumer Complaint No.15/2021
Date of Filing: 27/09/2021
1. Samiran Dutta Ld. President.
2. Rina Mukherjee Ld. Member.
3. Siddhartha Sankar Bhui Ld. Member.
For the Complainant:Ld. Advocate Jayanta Kumar Mukhopadhyay
For the O.P: Ld. Advocate Ashim Kumar Mondal
1.Mr. Ashis Kumar Mondal, S/O Late Mahadeb Mandal, Vill+P.O.+P.S. Barjora, District- Bankura, PIN- 722 202
2.Mrs. Tapati Mondal, W/O Mr. Ashis Kumar Mondal, Vill+P.O.+P.S. Barjora, District- Bankura, PIN- 722 202
1. Policy Issuing Officer, United India Insurance Co. Ltd., Regional Office at Kolkata, Himalaya House, Door No.38B, Floor No.2, Jawaharlal Nehru Road, Kolkata-700071
2.The Authority, Family Health Plan Insurance TPA Limited, 8-2-269/A/2-1 to 6, 2nd Floor, Srinilaya Cyber Spazio, Banzara Hills, Hyderabad, Talangana, PIN-500034
……..Principal Opposite Parties
(i)The Branch Manager, Punjab National Bank, Erstwhile UBI, Bankura Branch, Bankura-722 101
(ii)Smt. Meena R., Chief Manager, HO-UNI, Nungambakkam, High Road, Chennai, PIN-600034
(iii)Shri Jayanta Chakraborti, Deputy Manager, UNI Customer Care Department, Himalaya House, Door No.38B, Floor No.2, Jawaharlal Nehru Road, Chowringhee, Kolkata-700071
(iv)Dr. Medha Ghugre, Deputy General Manager, Family Health Plan Insurance TPA Limited, 3A Shakespeare Sarani, Corporate House, 7th Floor, Kolkata-700071
(v)Dr. Rita Debsharma, Authorised Signatory, Family Health Plan Insurance TPA Limited, 3A Shakespeare Sarani, Corporate House, 7th Floor, Kolkata-700071 ……..Proforma Opposite Parties
The case is fixed for delivery of judgement.
The Complainant’s case is that Complainant No.1 and his Spouse Complainant No.2 has a Mediclaim Group Insurance Policy No. being 5001002819P112668150 insured with O.P. Insurance Co. valid from 01/11/2019 for consecutive one Calendar Year. On 13/03/2020 the Complainant No.2 was attacked with severe low back pain which made her incapable to work or even stand on her own limb. She was admitted on 16/03/2020 in Medica Super Speciality Hospital and discharged on 21/03/2020 from that hospital having incurred medical expenses of Rs.1,70,323/-. The Complainant accordingly preferred insurance claim before the O.P. Insurance Co. for reimbursement but the same was repudiated. The Complainant has therefore approached this Commission for appropriate relief.
O.P. contested the case by filing a written version contending inter alia that the patient was admitted only for investigation and evaluation purpose without any medical treatment and surgery and as such the Complainant is not entitled to get the claim as prayed for.
-: Decision with reasons:-
Having regard to the facts of the case, contention, submission and documents on both sides the Commission finds from the Discharge Summary dated: 21/03/2020 that the patient was admitted with history of severe low back pain and she was put on analgesia and I.V. medication to control pain with option of surgical treatment in case conservative management fails. The patient therefore underwent a series of investigation and evaluation and the medical bills submitted by the Complainant is based on the expenses for such investigation and diagnostic evaluation. In fact there has been no medical treatment and surgery for which option was left out as per advice of the attending doctor.
Ld. Advocate for the Complainant has referred to the Medical Report dated: 21/03/2020 given by Dr. Sunandan Basu of Medica Super Speciality Hospital but it is a replica of the above mentioned Discharge Summary.
Ld. Advocate for the O.P. Insurance Co. has vehemently opposed the claim on the ground that without surgery/medical treatment the Policy holder has no coverage for such Group Health Policy and he referred to different Clauses of the Policy to justify his stand.
The Commission on perusal of the entire Policy also finds support with the stand of the Ld. Advocate for the O.P. It is a well settled principle for grant of Insurance claim in case of medi-claim Policy that the Insured is not entitled to get any reimbursement for investigation / diagnostic purpose unless medical treatment /surgery is done. In this case performance of medical treatment or surgery is not apparent from any of the documents placed before the Commission for consideration.
The nature of the disease of the Complainant No.2 is so that either she is rendered conservative treatment or surgical operation but the conservative treatment as mentioned in the Discharge Summary is nothing but the avoidance of invasive measures such as surgery usually with the intent to preserve function. Such conservative treatments will not come within the purview of the policy with no scope for reimbursement.
The Complainant is entitled to get the Insurance claim if she is attended with surgical operation as suggested in the Discharge Summary.
Considering the facts and circumstances of the case and the nature of disease and conservative treatment rendered to the patient the Commission is of the view that the Complainant is not entitled to get any Insurance claim as prayed for.
Hence it is ordered…….
That the case be and the same is dismissed on contest but without cost.
Both parties be supplied copy of this Order free of cost.
____________________ _________________ _________________
HON’BLE PRESIDENT HON’BLE MEMBER HON’BLE MEMBER
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