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STATE CONSUMER DISPUTES REDRESSAL COMMISSION, WEST BENGAL
Debasis Bhattacharya, Presiding Member, Jagannath Bag, Member
Regional Manager & Anr. —Appellants
versus
Dr. Santanu Basu —Respondent
First Appeal No.A/922/2015
(Arisen out of Order Dated 31/07/2015 in Case No. CC/607/2013 of District Kolkata-I(North))
Decided on 5.8.2016
Important Points
Mediclaim must be settled according to limits of coverage.
Subject
Insurance - Health Insurance
Act Referred
Headnote
Held: Ld. Forum below having gone through the pleadings of the parties, evidence and documents found that the Complainant was allowed for admission and operation under cashless mediclaim facility, but the TPA of the insurance company harassed the Complainant and made only a part payment of the final bill. The complaint was allowed on contest with cost of Rs. 10,000/-. The OPs were directed to pay the balance amount of Rs. 54,094/- along with compensation of Rs. 65,000/- for causing harassment and mental agony.
The insured was hospitalized on 17.06.2013 and the operation took place on 19.06.13. As the insured was covered by cashless facility, the authorization letter issued by the Insurance Company allowed in writing to extend the cashless facility for the treatment of the Complainant. In their authorization letter, the diagnosis of the ailment has been noted as Grade 2nd degenerative osteoporosis L4-L5 significant compression. But the Patient Visit Report as recorded by Dr. Soumyajit Basu shows that as per X-ray-MRI, the diagnosis was Grade-1 degenerative spondylolisthesis L4-L5 and significant neural compression due to stenosis and PID.
It is important to note that the diagnosis as recorded by the insurance company is not supported by any medical report or prescription. The Respondent / Complainant has repeatedly emphasized that the said two conditions are totally separate ailments and he never suffered from osteoporosis. The attending surgeon was never consulted by the Appellant Insurance Company in the matter of actual ailment of the Respondent / Complainant.
Though the Complainant was not medically proved to have been suffering from Osteoporosis and though his operation is not related to joint replacement due to degenerative condition, age related osteoarthritis, the TPA has vide their letter dated 26.08.13 recorded that as per exclusion clause No. 4 such ailment has been excluded for coverage under the policy schedule. Accordingly, the enhancement sum insured has not been made applicable as the said sum insured was running for the 3rd year.
In fact, the observation of the Insurance Company and that of the TPA does not seem to be substantiated with any medical report. Accordingly, the stipulation as provided under clause 4.3 of the policy schedule does not appear to be applicable. It is again important to note that had it been a case of osteoarthritis and osteoporosis, the treatment could not be made payable for first 4 years of operation of the policy. But, the insurance company allowed part reimbursement of medical expenses accepting the fact that the Complainant was suffering from the ailment as detected through investigation and recorded by Dr. Soumyajit Basu, Spine Surgeon, in his Patient Visit Report dated 02.06.13. The applicability of clause 4.3 as claimed by the Appellant Insurance Co. is, therefore, ruled out.
17. The direction of the Ld. Forum below to pay the balance amount of Rs. 54,094/- appears to be justified. However, both the award of Rs. 65,000/-as compensation for harassment and mental agony and the litigation cost of Rs. 10,000/- as awarded by the Ld. Forum below appear to be on higher side and may be modified. In that view of the matter, the appeal may be allowed in part. Hence,
(Paras 4, 13 to 17)
Result: Appeal Partly allowed.
Counsel for the Parties:
For the Appellants:Mr. Swarajit Dey, Advocate
For the Respondent:In-person, Advocate
Jagannath Bag, Member—The present appeal is directed against the Order, dated 31.07.15, passed by the Ld. District Consumer Disputes Redressal Forum, Unit -I, Kolkata, in CDF/Unit -1 / Case No. 607 / 2013, whereby the complaint was allowed on contest with cost and compensation against the OPs.
2. The complaint case, in brief, was as follows:
The Complainant had taken a Mediclaim policy from the OP Insurance Company in 1995 covering a sum of Rs. 1,00,000/- and the said sum having earned bonus stood at Rs. 1.30 lakh in 2010. The sum insured was enhanced by Rs. 1,00,000/- and in 2012-2013 the total sum insured was Rs. 2,50,000/- including bonus. The Complainant having felt chronic low back pain with radiculopathy and paraethsia visited on 02.06.13 the chamber of Dr. Saumyajit Basu, spine surgeon who advised for operation. He was examined by Dr. T. Sarangi for pre-operative check up. He was admitted at Kothari Medical Centre for operation on 17.06.13. The operation took place on 19.06.2013. After the 5th post operative date the Complainant was discharged on 24.06.2013. Though the final bill stood at Rs. 1,40,289.57, the sponsored amount under cashless facility was Rs. 88,740/- and the balance amount of Rs. 51,550/- was not allowed. The authorized agent, i.e., TPA harassed the petitioner in an inhuman manner. Their final diagnosis was Grade 2nd degenerative osteoporosis L4.L5 significant compression and the Complainant was informed that rest part of the bill will be paid by the party as his applicable sum insured was Rs. 1,40,500/-. The Complainant was bound to pay the balance amount by taking a loan with interest from outside. He sent a letter to the Regional Manager and Senior Divisional Manager-II seeking clarification about their final diagnosis and settlement of claim. In reply he was given a wrong diagnostic criteria. Alleging that the authorized agent of the insurance company was unaware of the subject, the Complainant asserted that he was not suffering from osteoporosis and his operation is not related to joint replacement due to degenerative condition and the case is not barred under clause 4.3 of the Policy Schedule. The Complainant claimed Rs. 54,058/- with interest @ 15 % p.a. and also Rs. 1,00,000/- as compensation for harassment and mental agony and Rs. 20,000/- as litigation cost.
3. The complaint was contested by the OP Insurance Company by filing W.V. wherein all material allegations were denied. It was contended that the authorized TPA, i.e., MD India Health Care Services Pvt. Ltd. who settled the claim of the insured was not made a party and the Complainant was not eligible for reimbursement beyond the amount of Rs. 88,740/- which had already been sanctioned and paid by the TPA. It was further submitted that as per clause 4.3 of the Policy Schedule, the enhancement sum will not be applicable before 4 years from the date of date of such enhancement. As such, the Complainant had no cause of action against the O.P and the complaint was liable to be set aside.
4. Ld. Forum below having gone through the pleadings of the parties, evidence and documents found that the Complainant was allowed for admission and operation under cashless mediclaim facility, but the TPA of the insurance company harassed the Complainant and made only a part payment of the final bill. The complaint was allowed on contest with cost of Rs. 10,000/-. The OPs were directed to pay the balance amount of Rs. 54,094/- along with compensation of Rs. 65,000/- for causing harassment and mental agony.
5. Being aggrieved by and dissatisfied with the order of the Ld. Forum below, the OP Insurance Company has come up with the present appeal seeking direction to set aside the impugned order.
6. Ld. Advocate appearing for the Appellant submitted that the Complainant suppressed material facts and there was material irregularity in the impugned order. As per policy terms, the Insurance Company’s liability in respect of all claims admitted during the pe
