Tamil Nadu

North Chennai

CC/167/2015

Sandeep Kumar Ranka - Complainant(s)

Versus

Apollo Munich Health Insurance Co Ltd - Opp.Party(s)

M/s.Nathan and Association

14 Feb 2018

ORDER

 

                                                            Complaint presented on:  02.11.2015

                                                                Order pronounced on:  14.02.2018

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

    2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

        PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

              THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

 

WEDNESDAY  THE 14^th   DAY OF FEBRUARY 2018

 

C.C.NO.167/2015

 

 

Sandeep Kumar Ranka,

S/o Mangilal,

No.184, Govindappa Naicken Street,

Sowcarpet, Chennai – 600 001.

                                                                                    ….. Complainant

 

..Vs..

1.Apollo Munich Health Insurance Co Ltd.,

Rep by its Authorized Officer,

No.3, Uthamar Gandhi Road,

Seetha Nagar, Nungambakkam,

Chennai – 600 034.

 

2.Apollo Munich Health Insurance Co Ltd.,

Rep by its Authorized Officer,

Central Processing Centre,

2^nd and 3^rd Floor, I labs Centre,

Plot No.404-405, Udyog Vihar,

Phase III Gurgaon, Haryana – 122 016.

 

 

 

.....Opposite Parties

Date of complaint                                 : 24.11.2015

Counsel for Complainant                      : M/s. Nathan and Associates

Counsel for Opposite Parties                   : M/s. Eleveera Ravindran & K.Vinod

 

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant  to refund the cost of Rs.19,088/- towards medical expenses and also to pay a compensation for mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant is a businessman having his electrical shop is in the nature of his family business. He had taken up a medical insurance from the United India Insurance Company before 2012. The complainant has not satisfied with the service of the United Insurance Company, he had ported to the opposite party Insurance Company in March,2012. He requested for renewal of his policy and the 1^st opposite party issued policy dated 03.04.2015 for a sum of Rs.5,00,000/-. The term of the policy was “Optima Restore Floater Two Years”.

          2. On 09.07.2015, the complainant suffered with fever, head ache, vomiting, and giddiness and he had preliminary treatment for next two days  and he was not cured his health condition became worse and due to the advice of the doctors, the complainant father admitted him in the Apollo Hospital-Mint Chennai on 11.07.2015. The complainant sought cashless service for treatment that was not honoured. After treatment he was discharged on 13.07.2015. After discharge the complainant made claim to the opposite parties for his medical expenses and the same was refused by them stating that the treatment not related to illness and for only diagnosis.

          3. The complainant submits that the doctor  at Apollo Hospital stating that the admission of the complainant as inpatient is necessary in lieu of high grade  fever continuously from  09.07.2015. The treatment should be given as inpatient, has to be decided only by the doctors and not by the insurance company. Hence by rejecting the claim of the complainant the opposite parties have committed deficiency in service. Due to rejection of the claim made by the opposite parties the complainant suffered with mental agony, hence the complaint filed this complaint to refund the cost of Rs.19,088/- towards medical expenses and also to pay a compensation for mental agony with cost of the complaint.

4. WRITTEN VERSION OF THE  OPPOSITE PARTIES IN BRIEF:

          The complainant is well aware about the terms and conditions of the policy. The documents submitted by the complainant, it was clearly observed in the internal notes of the hospital that no significant findings in the physical examination. Further in the discharge summary, it was stated that the patient had intermittent fever since two days and the attending doctor certified that the complainant was admitted with two days history of high grade continuous fever. The clinical chart of temperature shows at 98.4º before completion of the dosage given at pre-consultation hospital. The complainant admitted in the Apollo Hospital is not justified. Hence the claim made by the complainant for the diagnostic purpose is not sustainable. The other averments made in the complaint are denied. Hence the opposite parties pray to dismiss the complaint with costs.

5. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what extent?

6. POINT NO :1 

          It is an admitted fact that the complainant is a business man having his electrical shop is in the nature of the family business and he had taken up medical insurance before 2012 from the United Insurance Company and the complainant had ported the said insurance to the opposite parties  in the year 2012 and for the same, he had submitted Ex.B1 proposal form and Ex.A1&Ex.B2 is the Optima Restores Floater policy issued for Two Years policy for the period 03.04.2015 to 02.04.2017 by the opposite parties to the complainant and the complainant had fever, headache, vomiting, and giddiness  on 09.07.2015 and immediately he consulted the doctor at Dhanvantari Daycare & Physiotherapy Centre and the doctor who attended on him prescribed medicines under Ex.A2 and even after two days the fever not reduced and on the other hand his condition worsened, hence on the advice of the Apollo doctors, he was admitted in the hospital on 11.07.2015 and after treatment he was discharged on 13.07.2015 and the said discharge summary is available in Ex.A3 from pages 21 to 26 and the complainant immediately after admission he had applied for cashless treatment that was rejected by the opposite parties and after discharge, he made claim for the expenses incurred in the hospital and that was also rejected under Ex.A2 that

      Admission seems mainly for investigation & evaluation purpose. Hence we regret to inform that your claim is repudiated under Section V) C) Vii) deficiency of the policy

and therefore the complainant filed this complaint.

          7. The complainant would contend that during the period of treatment the medi- claim policy issued by the opposite parties is in force and hence the rejection made by the opposite parties proves that they have committed deficiency in service.

          8. The opposite parties would contend that only for the purpose investigation the complainant was admitted inpatient and treatment for such investigation and evaluation purpose the claim cannot be ordered as per terms and conditions of the policy and therefore prays to reject the complaint.

          9. Admittedly the complainant was an in-patient in the Apollo Hospital from 11.07.2015 to 13.07.2015 for the treatment of fever. Even before admission from 09.07.2015 onwards for two days, the complainant was having high fever and the same was not reduced inspite of that the complainant had treatment as outpatient. Hence on the advice of the doctors only the complainant was admitted as inpatient and investigations were done. A patient could be treated as inpatient or outpatient could be decided only by the doctor and not by the insurance company. The complainant was continuously suffering fever for two days and the same was not controlled and therefore only on the doctor advice he was admitted as inpatient.  The best judge to decide whether the patient was to take treatment as in patient or not is only the doctor. The opposite parties/insurance company merely having the terms and condition that the investigation and evaluation purpose are not required as inpatient treatment is not acceptable. The complainant was admitted as inpatient with high fever. Therefore the complainant rejected the claim quoting unacceptable terms and conditions is not accepted and hence we hold that the opposite parties have committed deficiency in service in this regard.

 

10. POINT NO:2

          The complainant made  claim for a sum of Rs,19,088/- towards medical expenses and the said amount is only very meager. Since, we held in point one that the opposite parties committed deficiency in service, the complainant is entitled for a sum of Rs.19,088/- towards medical expenses and further for mental agony,   it would be appropriate to direct the opposite parties to pay a sum of Rs.20,000/- towards compensation for the same, besides a sum of Rs.5,000/- towards litigation expenses.

          In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally are ordered to refund a sum of Rs.19,088/- (Rupees nineteen thousand  and eighty eight only) towards the medical expenses to the Complainant and also to pay  a sum of Rs. 20,000/- (Rupees twenty  thousand only) towards compensation for mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses.

The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 14^th  day of February 2018.

 

MEMBER – I                                                                PRESIDENT

 

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 03.04.2015	Mediclaim Policy of the complainant
Ex.A2 dated 09.07.2015	Medical Prescription of complainant
Ex.A3 dated 11.07.2015	Case History of complainant
Ex.A4 dated 14.07.2015	Reimbursement claim sent to the opposite party
Ex.A5 dated 28.07.2015	Mail sent to the complainant
Ex.A6 dated 28.07.2015	Reply mail sent to the opposite parties
Ex.A7 dated 29.07.2015	Mail sent to the opposite parties
Ex.A8 dated 30.07.2015	Rejection Letter sent to the complainant
Ex.A9 dated 04.08.2015	Mail repudiating the complainants claim
Ex.A10 dated 05.08.2015	Letter sent to the Insurance Ombudsman along with Annexure VI-A
Ex.A11 dated 07.08.2015	Acknowledgement letter confirming registration of case
Ex.A12 dated 12.08.2015	Second Rejection letter sent to the complainant
Ex.A13 dated 14.08.2015	Summons given insurance ombudsman
Ex.A14 dated 17.08.2015	Certificate of doctor
Ex.A15 dated 11.09.2015	Minutes of Proceedings held before Ombudsman
Ex.A16 dated 12.09.2015	Mail with regards sent by complainant
Ex.A17 dated 30.09.2015	Order of Insurance Ombudsman

 

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTIES :

 

Ex.B1 Dated NIL	Proposal Form along with received documents
Ex.B2 dated NIL	Policy schedule along with policy wordings
Ex.B3 dated NIL	Cashless claim form, query letter dated 13.07.2015 and documents received from the hospital
Ex.B4 dated 13.07.2015	Cashless Rejection Letter
Ex.B5 dated NIL	Claim form along with the relevant medical documents including the discharge summary
Ex.B6 dated 30.07.2015	Repudiation letter
Ex.B7 dated 28.07.2015	Copy of the representation and reply to same
Ex.B8 dated 30.09.2015	Copy of the award assed by the Hon’ble Ombudsman

 

 

 

MEMBER – I                                                               PRESIDENT