(आदेश पारीत व्दारा - श्री शेखर पी. मुळे, मा.अध्यक्ष)
(पारीत दिनांक : 26 सप्टेंबर 2016)
All these three complaints are being disposed of by a common judgment as facts and Opposite Party (OP) in all the cases are same and identical. The complaints are filed against Insurance company for refusing to grant medi claim.
The complainants are senior citizens and relatives. Considering their age and health they each took mediclaim policy from the OP. The period of their policies was different. But during subsistence of their policies in January 2013 they suffered some health problem and therefore they decided to go for Ayurvedic treatment. Accordingly doctor advised them to get admitted in hospital for a week. So they got themselves admitted to Madhavbaugh Ayurvedic Cardiac Hospital at Salai (Khurd) Kondhali, Dist. Nagpur from 5.2.2013 to 10.2.2013 and took treatment there. Said treatment and hospital are covered under their policies. They made claim of their medical treatment expenses to the OP. But their claim was rejected on the ground that Ayurvedic treatment was taken in Ayurvedic hospital which was not covered under the policy. Alleging this as deficiency in service they have claimed the treatment expenses with interest along with compensation and cost.
OP filed reply in all the cases which is almost similar. According to it as per the policy terms and conditions the hospital is required to be registered as such with local Authority under the supervision of a registered and qualified medical practitioner of Allopathic system. The complainants were admitted to an Ayurvedic clinic which is not the one defined under the policy and no allopathic treatment was given to them. Therefore the claim was rightly rejected as per the terms of the policy. Hence, it is prayed to dismiss the complaints.
Heard learned counsels for the complainant and OP. Perused the documents of policies along with terms and conditions. We record our findings for the reasons given below.
FINDINGS AND REASONS
The OP has not denied that the complainants had taken mediclaim policies from it and subsequently they had taken Ayurvedic treatment in Madhavbaugh Ayurvedic Cardiac Hospital at Salai (Khurd) Kondhali, Dist. Nagpur. What is disputed is that under the said policy Ayurvedic treatment is not covered and the hospital where treatment was taken is also not covered under the policy. Our attention is invited to the terms and conditions of the said policy. There are two policies and each has somewhat different clauses. As per the exclusion clause 4.13 of one policy filed in C.C. No. 13/564 any treatment other than Allopathic System of medicine is excluded from the cover of the policy. Besides, as per the definition of Hospital given in the policy, it shall be such hospital which is registered with the local authorities and is under the supervision of a registered and qualified medical practitioner of Allopathic system of medicine, or it should be run by govt, or should have atleast 15 inpatient beds, fully equipped OT, nursing staff, etc.
The counsel for the complainants submitted that all the complainants were admitted to the same hospital and taken Ayurvedic treatment. Therefore if this was the reason for repudiating their claim, the reason should have been same in repudiating all the claims. But this is not the case. In one complaint the reason given was an exclusion clause 2.a of the policy, explaining that as per the policy condition the hospital should be registered with the local authority and should be under supervision of a registered and qualified medical practitioner of Allopathic system of medicine. The complainant has filed copy of the certificate of registration which reveals that Dr. Sane has been registered under the Bombay Nursing Homes Registration Act. 1949 in respect of ¨Madhav Baugh Ayurvedic Cardiac Hospital¨. The certificate was issued by Civil Surgeon, Nagpur. That shows that the said hospital was registered with the local authority. But the question is whether Dr. Sane is a registered and qualified Allopathic medical practitioner under whose supervision the said hospital is running.
In second and third complaints (C.C. No. 13/565 & 13/566) the repudiation was on the ground that the patient was taking Ayurvedic treatment, hence under exclusion clause 3.3 of the policy, claim was not recommended. On perusal of exclusion clause 3.3 it can be noticed that it defines medical practitioner, means a person who holds a degree / diploma of a recognized Institution and is registered by Medical council of respective State and such person would include Physician, Specialist, and Surgeon. Dr. Sane is said to be practicing Ayurvedic system of medicine and therefore does not fit in to the catagory as defined in the clause 3.3.
Thus, even though all the complainants had been admitted to same hospital and taken Ayurvedic treatment under an Ayurvedic doctor, repudiation of their claim was on different grounds. This is something inscrutable. It is tried to explain on behalf of the OP that the repudiation letters were written by Third Party Administrator (TPA) on whose recommendation claims were repudiated. It is submitted that in mediclaim policy TPA is appointed to verify and scrutinise mediclaims. Therefore it is urged not to give much weight to this anomaly, but the reasons of repudiation shall be considered in the letter and spirit of policy conditions.
The counsel for the OP contended that as per the policy condition Ayurvedic treatment is excluded from the cover of policy. He submitted that admittedly all the complainants had taken Ayurvedic treatment and that itself is sufficient to dismiss their complaints. Reliance is placed on a decision given by National Commission in National Insurance Co. v/s Abdul Razak in Rev. Pet No. 3725/13 on 7.10.2015. But the decision is on different facts as in that case repudiation was on the ground that some ailments are not payable for first two years of operation of the policy.
Learned counsel for the OP further contended that as per clause 3.3 a person to be a medical practitioner should be registered by Medical council of the State and Dr. Sane is not so registered by Medical council, but by a Civil Surgeon. This is a fact. But we are of the opinion that it is improper to deny the claim on this ground. Because this is not an exclusion to deny policy benefits. In fact, the recommendation for repudiation and clause mentioned in the letters both are self contradictory. We agree with the learned counsel for the complainants that the complainants were not given correct information as to the reason for repudiation, which itself is deficiency in service. Moreover, clause 3.3 is not an exclusion clause to deny the benefits of the mediclaim policy. In the policy attached with the complaint (C.C. No.13/565) Ayurvedic treatment is not excluded, only Naturopathy treatment is excluded. Therefore repudiation on the ground given by the OP in these two complaints does not appear correct. There is thus deficiency in service on its part.
In the complaint (C.C. No. 13/564) the policy reveals that any treatment other than Allopathic System of medicine is excluded. The learned counsel for the complainant submitted that Ayurvedic treatment is not expressly excluded. We do not concur with his submission. The exclusion clause is clear enough to exclude any other interpretation of the said clause. The question is whether on this exclusion clause the claim was repudiated. As said earlier it was repudiated on clause 2.a which does not refer to kind of treatment, but is about the definition of a hospital. Thus the clause and explanation given for repudiation are contradictory and it does not give clear picture to the insured as to the reasons of repudiation of claim.
We feel that the insurance companies after issuing mediclaim policies to their consumers, are taking too much hyper technical stand to repudiate their claims. In our considered view this is deficiency in their service. There is no dispute regarding the medical expenses incurred by the complainants. They have filed receipts of payment on which basis claim was submitted. Therefore, considering the facts and submissions the complainants are held to be entitled to their respective mediclaims. Therefore, we partly allow all the complaints and pass the following order
ORDER
A) All the three complaints are partly allowed as under,
- In C.C. No. 13/564, OP is directed to pay the claim of Rs.34,920/- with 6% p.a. interest from 12.3.2013,
- In C.C. No. 13/565, OP shall pay the claim amount of Rs.36,710/- with 6% p.a. interest from 8.3. 2013,
- In C.C. No. 13/566, OP shall pay the claim amount of Rs. 32,455/- with 6% p.a. interest from 8.3. 2013.
B) In all the complaints OP shall also pay compenation of Rs.15,000/- each to the complainants for mental and physical harassment and shall also pay litigation cost Rs. 3000/- each.
C) Compliance of the order shall be made within 30 days from receipt of the order.
D) Copy of the judgment shall be provided to both the parties free of cost
Nagpur.
Date – 26/09/2016
