MR. DEBASIS BHATTACHARYA, MEMBER

18.09.2015

      Being aggrieved and dissatisfied with the order dated 11.09.2013 passed by the Ld. District Consumer Disputes Redressal Forum (in short, District Forum), Burdwan in CC No.105 2012, the Complainant thereof has preferred this appeal. By the impugned order, the Ld. District Forum has dismissed the complaint.

      The case of the Complainant is that as per advice of Dr.Gopalkrishnan, his wife Dali Chaudhuri, who was suffering from pain in her left leg with swelling and not in a position to work, was admitted at Apollo Hospitals, Chennai and underwent treatment as an indoor patient between the period 12.03.2010 and 16.03.2010 (5 days ), thereafter treated there as an outdoor patient. Further, the said patient was treated between 29.03.2010 and 30.03.2010 (2 days) as per advice of Dr.K.Raghabendra by way of hospitalization and lumber sympathetic nurolysis treatment, and also was rendered further treatment by other physicians. Accordingly, a claim application dated 14.04.2010 of a total claim amount of Rs.1,03,995.80 was submitted in the prescribed forms along with original bills, receipts and discharge certificates, cash memos supported by prescriptions, pathological tests report, surgeon’s certificate, attending doctors reports etc. But, M.D.India health Care Services (TPA) Pvt. Ltd. intimated that the claim is not payable under Clause Nos. 8.1.1 and 7.7. As such, the Insurer and the TPA have deliberately repudiated the genuine claim with falls pretext and thus failed to render services to the insured and it is clearly a case of deficiency of services. So, the case.

      On the other hand, the case of the OP Nos. 1 & 2, i.e., TPA  is that the OP No.3 had issued a Group Insurance mediclaim policy, bearing Policy No.041100/48/09/41/00000318, for the period from 01.01.2010 to 31.12.2010 under Group Medical Scheme for the year 2010, to extend medical benefits to the retired employees of SAIL ( including IISCO) and their spouses . In this case, the patient, Smt. Dali Chaudhuri as spouse the Complainant, retired employee/member of SAIL, who filed a schedule of expenses incurred by her before the OP No.2. From the claim documents, it was observed that for the treatment for nerve root injections and sympathetic neurolysis under local anesthesia, does not require hospitalisation and Insured also hospitalized for less than 24 hours, for which the claim has been repudiated as per Policy Clauses 7.7 and 8.1.1. Accordingly, the complaint petition be dismissed. The case of the OP No.3 is almost on  similar lines of the OP No.1 & 2.

      It is to be considered if the impugned order suffers from any kind of incongruity as to facts and in law, or not.

Decision with reasons

      Ld. Advocate for the Appellant has submitted that Smt. Dali Chaudhuri, for whom the medical expenses have been made, is wife of the Complainant and eligible for the mediclaim benefit as a beneficiary, whereas the Com