State Consumer Disputes Redressal Commission
The New India Assurance Co. Ltd. vs Miss Rita Shaw & Anr. on 23 October, 2017
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION WEST BENGAL 11A, Mirza Ghalib Street, Kolkata - 700087 First Appeal No. FA/654/2014 (Arisen out of Order Dated 02/05/2014 in Case No. CC/459/2013 of District South 24 Parganas) 1. The New India Assurance Co. Ltd. 39, Diamond Harbour Branch, P.O. & P.S. - Thakurpukur, Kolkata -700 008. ...........Appellant(s) Versus 1. Miss Rita Shaw & Anr. 25/9, Sodepur 1st Lane, Post - Haridevpur, P.S. Thakurpukur, Kolkata - 700 082. 2. M/s. Medicare TPA Services India Pvt. Ltd. 6, Bishop Lefroy Road, Kolkata - 700 020. ...........Respondent(s) BEFORE: HON'BLE MR. SHYAMAL GUPTA PRESIDING MEMBER HON'BLE MR. UTPAL KUMAR BHATTACHARYA MEMBER For the Appellant: Sri Nipendra Ranjan Mukherjee, Advocate For the Respondent: Authorised Person., Advocate Dated : 23 Oct 2017 Final Order / Judgement Sri Shyamal Gupta, Member
Present Appeal emanates out of the Order dated 02-05-2014 passed by the Ld. District Forum, South 24 Parganas in C.C. No. 459/2013.
In short, case of the Complainant is that, she submitted a claim form with the OPs seeking reimbursement of her treatment expenses amounting to Rs. 43,469/-. However, the OPs arbitrarily repudiated such claim. Moreover, she was also deprived of cumulative bonus. Hence, the complaint.
OP No. 1 contested the case by filing WV wherein it is stated that on due consideration of the claim papers, in terms of Clause 4.4.6 of the mediclaim policy, the instant claim was adjudicated as 'No Claim' and hence the Complainant's claim was repudiated and the Complainant was duly communicated of such decision of the company.
Decision with reasons Heard both sides and perused the material on record.
It appears from the discharge summary that the Respondent No. 1 underwent treatment for her Obsessive Compulsive Disorder (OCD) and Gastritis. According to the Appellant since treatment related to psychiatric and psychosomatic disorders fell under the ambit of exclusion clause, the instant claim of the Respondent No. 1 was not admissible.
It is indeed surprising that although treatment for Gastritis did not fall under the exempted category, the entire claim was abruptly repudiated by the Appellant. It clearly points out gross deficiency in service on the part of the Appellant, so also that of the Respondent No. 2.
We find that the Ld. Ombudsman allowed 35% of the admissible amount out of its notion that treatment costs for OCD and Gastritis was not separable. We, however, see no logic in such findings. Since the Respondent No. 1 furnished all the bills where details of medicines and pathological/clinical tests were clearly mentioned, had the bills been properly scrutinized, it would certainly not be a Herculean task for the Appellant/Respondent No. 2 to segregate the expenditure meant for psychiatric and psychosomatic treatment.
In any case, the Respondent No. 1 clarified in her petition of complaint that she incurred a sum of Rs. 1,072/- (Doctor's fees Rs. 600/- and medicine Rs. 472/-) for her psychiatric and psychosomatic treatment. The Appellant has not adduced any cogent documentary proof to prove the Respondent No. 1 wrong.
Considering all these aspects, the decision of the Ld. District Forum to direct the Appellant to reimburse 42,397/- after deducting Rs. 1,072/- from the total claim amount of Rs. 43,469/- appears to be perfectly in order.
However, we cannot endorse the decision of the Ld. District Forum whereof it directed the Appellant to disburse the cumulative bonus amount of Rs. 24,500/- to the Respondent No. 1. It is common knowledge that cumulative bonus amount is not disbursed to the Insured directly, but the same is added to the sum insured. We, therefore, feel that there should not be any exception in the present case also.
The Appeal, thus, stands allowed in part.
Hence, O R D E R E D That the Appeal stands allowed on contest in part. The impugned order is modified to the extent that the cumulative bonus amount should be added to the sum insured of the policy in question of the Respondent No. 1. Rest of the order shall remain intact. [HON'BLE MR. SHYAMAL GUPTA] PRESIDING MEMBER [HON'BLE MR. UTPAL KUMAR BHATTACHARYA] MEMBER