IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Preethakumari: Member Smt.M.D.Jessy: Member Dated this, the 22nd day of March 2010 C.C.No.68/2009 Baby Mathew, Thannikkal House, P.O.Thondiyil Complainant 1. Manger, New India Assurance co. Branch office, SadhuBuilding, IInd floor, Nr.Municipal Bus stand, Kannur 1. (Rep. by Adv.V.K.Rajeev) 2. The Manager, TTK Health care TPA Private Ltd., No.39-4130,1st floor, Mareena Building, Opposite parties MG.Road, Ravipuram, Ernakulam O R D E R Sri.K.Gopalan, President This is a complaint filed under sectin12 of consumer protection act for an order directing the opposite party to pay the claim amount Rs.5071/- and Rs.3000/- as compensation. In brief, the case of the complainant is that he is a medi claim policy holder of 1st opposite party, the New India Assurance Co.Ltd. from 19.4.2007. He has continued the policy without default till 18.4.09., His wife Lizy Jacob 46 years old, teacher, had been admitted in Dhanaalkshmi Hospital and treated by Dr.Roy.He met an expense of Rs.5071/- for medicine and treatment in the Hospital. He has submitted claim withal the documents in the first week of November. But the office of the company in Kannur responded very irresponsibly. At last on the advice of Sr.Vincent, the Development officer a written complaint was given to the Manger and after 3 months he received a letter of repudiation of his claim. Hence this complaint for the claim amount and compensation. In pursuance of the notice 1st opposite party entered appearance and filed version. 2nd opposite party though served properly remained absent and in consequence declared exparte. The contentions of 1st opposite party in nutshell are as follows.The opposite party admits that the wife of the complainant LizyJacob was the beneficiary of the company. Opposite party denies the liability to pay any amount towards the expense incurred to the complainant's wife since the admission in the hospital was any treatment or for any disease which required any hospitalization. The admission in the hospital were for the evaluation for the reasons for the abdominal pain, which could have been done as a normal out door procedure without getting herself admitted in a hospital. It is seen that there was an outpatient consultation by the complainant. On11.10.08 and it is seen continued the same medicine even on the day when she got admitted in the hospital and thereafter. The doctor had not prescribed any additional medicines or treatment even while the complainant was in the hospital. Moreover, the column No. I of the medical certificate issued by the doctor will also show that the complainant was fully cured. Hence it is appraent that the complainant was admitted in the hospital for the valuation of the reasons for the abdominal pain which does not require the whole body check up as done from the hospital by admitting the complainant as an inpatient. Hence the claim is not within the scope of the Insurance policy. The clause 2.0 of the Janatha Mediclaim policy specificlly exlcudes the opposite party from the liability. As per the clause 2.0 company is liable to reimburse the medical expense only if the treatment is taken in General ward of the hospital. Complainant’s wife has taken treatment admitting her in special room Nol609. Opposite party is also liable to reimburse under clause 4.4.11. As per this clause opposite party is excluded from reimbursing any medical expenses incurred for or arising out of diagnostics, X-ray or laboratory examination not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment sidedness or injury, for which confinement is required at a hospital. The allegation that all the documents submitted, opposite party was irresponsible and the alleggation that the claim was repudiated only after three months etc. are false. Opposite party on receiving the claim 2nd opposite party sent a letter dt.11.12.08 to complainant to furnish details required. But complainant did not comply and thus constrained to repudiate the claim and intimated the reason to complainant on 28.12.08. It is not true that the complainant incurred Rs.5, 071/-. Documents submitted before 2nd opposite party are not properly authenticated and hence are not liable. There is no deficiency in service on the part of opposite party. Hence to dismiss the complaint. On the abvoe pleadings the following issues has been taken for consideration. 1.Whether there is any deficiency on the part of opposite aprties? 2.Whether the complainant is entitled for any remedy as prayed in the complaint/ 3. Releif and cost. The evidence consist of the oral evidence of PW1 and Exts.A1 to A5onthe side of complainant and oral evidence of DW1 and Exts.B1 to B14 on the side of opposite parties. Issue Nos.1 to 3 Admittedly complainant Sri.Baby Mathew was a mediclaim policy holder of 1st opposite party, the New India Insurance Company. The validity of the policy also accepted. But the claim of the complainant repudiated on the exclusion clause 2.0 and 4.4.11 of the policy. Complainant’s case is that his wife was admitted in Dhanalakshmi Hospital and treated by Dr.Joshy. He has spent Rs.5071/- for the medicine and treatment. Claim submitted with all the documents but it is repudiated. Ext.A1 is the Janata Mediclaim policy which shows policy period 19.4.08 to 18.4.09. Ext.A2 is the letter sent by T.K. Health care, 2nd opposite party intimating the complainant that the claim is not admissible. Ext.A3 is the note written by Dr.Roy K.Thomas. Ext.A4 is a paper cutting. Ext.A5 is the terms and conditions of the Janata Medicalaim policy. Ext.A2 stated the reason why the claim has been treated as not admissible. It has stated that the admission is for evaluation of abdominal pain and for routine medical check up which considered to be a normal out door procedure and thus hospital treatment is not found justified in this case as treatment was very well possible without being admitted as inpatient. Ext.A3 issued by Dr.Roy K Thomas who treated the patient stated that she was admitted for evaluation of abdominal pain which was an inpatient complaint as far as the patient is concerned. She was admitted for detailed evaluation. It can be seen that no details of ailment or treatment or the medicines prescribed has not been mentioned in the letter of notes Ext.A3. Even after detailed evaluation the disease was not diagnosed. Complainant filed proof affidavit in tune with this pleadings. He has stated in proof affidavit that his wife was admitted on the advice of doctor for the purpose of diagnosis and treatment. He has also stated that al the examinations have been done as a part of diagnosis and treatment. Complainant also has not adduced evidence details of treatment. Even the result of the diagnosis is not revealed by the complainant in his proof affidavit. Thus the proof affidavit has not challenged the contention of the opposite party that the admission is for routine medical check up which is considered to be normal out door procedure.Ext.a3 notes written by the doctor on 17 June 2009 also does not help to hit the substance of the contention raised by the opposite party. 1st opposite party filed version one month prior to Ext.A3. It means complaint obtained the letter A3 from the doctor after fully knowing well the contentions of 1st opposite party. Ext.B1 is the medical certificate issued by Dr.Roy, which shows that the patient admitted on 13.10.08 and discharged on 14.10.08.The nature of disease given is Abdominal pain and it is also recorded ‘the patient full cured’. Ext, B2 is the prescription for whole body check up and its report is marked as Ext. B3. Ext.B6 is the discharge card and Ext.B7 is cardiograph report. The whole body scan report is marked as Ext.A10. The documents as well as other evidence adduced by complainant do not reveal the ailment of the patient that necessitated the admission. Clause 2.0 of Ext.A5, the terms and conditions specifically states that the company will reimburse cost of treatment taken in general was of the hospital/Nursing Home/D-care centre’. So also permanent exclusion clause 4.4.11 contains thus: “Diagnostics, X-ray or Laboratory examination not consist with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home. Complainant stated in his proof affidavit that”]cn-tim-[-\-I-sf-ÃmT tcmK \nÀW-b-¯n-tâ-bpT NnIn-Õ-bp-tS-bpT Ah-i-y -`m-K-ambn \S-¶-Xm-Wv.” But complainant did not prove the disease for which his wife was admitted, what are the treatment that has been taken, how long the treatment continued why a whole body test necessitate for one day treatment etc. The medical certificate B1 shows patient admitted on 13.10.08 for abdominal pain and discharged on14.10.08 recording “the patient full cured”. The available evidence on record shows that the claim of the complainant comes under the permanent exclusion No.4.4.11 in the terms and conditions of the policy Ext.A5. It also attracted the terms of 2.0 of policy. Hence we find no reason to find fault with opposite party in not admitting the claim. Complainant failed to establish deficiency in service on the part of opposite parties. Thus the issues 1 to 3 are found against complainant. In the result, the complaint is dismissed. No cost. Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the complainant A1.Policy issued by OP A2.Letter sent by OP2 with cover A3.Letter issued by Dr.Roy K Thomas dt.17.6. A4.Manorama daily dt.25.5.09 A5.Policy conditions Exhibits for the opposite parties B1.Medicl certificate issued by Dr.Roy Thomas B2.Whole body check up report of Lizy jacob B3.Copy of the USG of abdomen and pelvis B4.&B5.Lanboratory reports B6.Discharge card issued from Dhanalakshmi Hospital B7.Echo cardiography report issued from Dhanalakshmi Hospitl, Kannur B8 to 10.cash bills B11.copy of the letter dt.11.12.08sent to complainant B12 .Claim form submitted by the complainant B13.Repudiatin letter issued by OP B14.Policy and conditions Witness examined for the complainant PW1.Complainant Witness examined for the opposite parties DW1.Suresh Babu /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Forum, Kannur
| | HONORABLE PREETHAKUMARI.K.P, Member | HONORABLE GOPALAN.K, PRESIDENT | HONORABLE JESSY.M.D, Member | | 
