BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM<br /> VAZHUTHACAUD, THIRUVANANTHAPURAM.<br /> <br /> PRESENT<br /> SRI. G. SIVAPRASAD : PRESIDENT<br /> SMT. BEENAKUMARI. A : MEMBER<br /> SMT. S.K.SREELA : MEMBER<br /> O.P.No. 326/2003<br /> Dated : 30.04.2008<br /> Complainant :<br /> Dr. C. Mathew, “Vishranthi”, T.C 3/665, T.K. Divakaran Road, Muttada P.O, Tvpm – 695 025.<br /> <br /> Opposite parties :<br /> 1.Branch Manager, National Insurance Co. Ltd., Soundarya Buildings, II Floor, Puthenchanthai, M.G. Road, Tvpm – 1.<br /> <br /> 2.Divisional Manager, National Insurance Co. Ltd., St. Joseph's Press Building, Vazhuthacaud, Thiruvananthapuram – 14. <br /> (By adv. K. Sreekumaran Nair) <br /> <br /> This complaint is disposed of after the period so specified under the Consumer Protection Act, 1986. Though the case was taken up for orders by the predecessors of this Forum on 30.07.2004, the order was not prepared accordingly. This Forum assumed office on 08.02.2008 and re-heard the complaint. This O.P having been heard on 18.03.2008, the Forum on 30.04.2008 delivered the following :<br /> <br /> ORDER <br /> <br /> SMT. S.K. SREELA : MEMBER<br /> <br /> The case of the complainant is as follows: Complainant joined the Mediclaim Policy Scheme of the opposite parties which is being renewed the last of which was done in January 2003. The complainant on 14.12.2002, suddenly developed an excruciating pain in his lower back and later a severe attack of rigor and vomiting sensation. On consulting with the family doctor, the complainant, as advised by him, had his urine examined which showed the presence of ureates crystals. Hence as per the doctor's advice, the scan was taken which revealed the presence of a calculus at the lower end of the right ureter. The family doctor hence referred the complainant to Dr. Sashikumar. He prescribed two medicines viz; Zyloric and Citrosoda to facilitate the expulsion of the stone from the ureter. As per Doctor's advice urine was cultured and KUB X-ray was also taken which confirmed the presence of the calculus in the right ureter. The IVP test done reconfirmed the presence of the calculus. Dr. Sashikumar opined that the complainant could wait for sometime to see whether the stone would come out on its own, and had asked the complainant to continue to take the above two medicines. It was further told that in case the stone continues to remain in the ureter, some interventional procedures may have to be employed. But after a month, as suggested by this Doctor, the KUB X-ray and ultra sound scan of the abdomen were done and no calculus was detected in the scan. Since the complainant had no pain or other symptoms, he was advised to contact the doctor, if he again develops any of the earlier symptoms. <br /> <br /> Thereafter, the complainant submitted the medical certificate along with all other relevant medical reports and bills to the 1st opposite party on 14.02.2003 for reimbursement, for which since there was no response the complainant again sent 2 reminders and finally he got a reply on 28.04.2003 stating that the claim by the complainant is not payable mainly because the complainant had undergone domiciliary medical treatment without hospitalisation along with a wrong interpretation of clause 4.10 of the policy which states that the charges incurred for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment will be excluded. Though the complainant had reiterated that there is no justification on the part of the 1st opposite party to deny his claim, and since his claim for medical reimbursement has not been considered, this complaint has been enunciated claiming reimbursement along with interest and for compensation and costs. <br /> <br /> The opposite parties are the Branch Manager and the Divisional Manager of National Insurance Company Ltd. and the 2nd opposite party has filed versions contending as follows: The complaint is not maintainable . Since the complainant has violated the policy conditions, the claim will not come under the purview of Mediclaim policy. The complainant has undergone only outpatient treatment which is not payable as per the terms and conditions of the Mediclaim policy issued to the complainant. Since the complainant has not intimated the claim by notice with full particulars to the company within 7 days as per condition, the claim was repudiated. On the grounds that no hospitalisation mentioned in medical records, the tests conducted are not treatment for a particular disease, but only pathological tests to rule out a possibility, conditions in order to make claim payable under domiciliary hospitalisation not complied with and claim is subjected to exclusions-IV.10 of mediclaim policy. Hence pray for dismissal of the complaint. <br /> <br /> Complainant has been examined as PW1 and Exts. P1 to P8 were marked on his side. Ext. D1 has been marked on the part of the opposite parties.<br /> <br /> The issues to be considered are:-<br /> (i)Whether the repudiation of claim by the Insurance Company justifiable?<br /> (ii)Reliefs and costs.<br /> <br /> Points (i) and (ii):- Admittedly, the complainant is a holder of Mediclaim policy of the opposite parties. The complainant alleges hat since he developed excruciating pain in his lower back and later got a severe attack of rigor and vomiting sensation he contacted his family doctor, and as per his suggestion urine was examined which showed presence of ureates crystals and the scan result revealed presence of calculus at the lower end of the right ureter. As per the advice of the family doctor, the complainant consulted Dr. Sashikumar. As suggested by is doctor urine was cultured and KUB X-ray also taken which confirmed the presence of calculus in the right ureter. The IVP test also revealed the presence of the calculus. The complainant further states that, Dr. Sashikumar prescribed 2 medicines namely Zyloric and Citrosoda to facilitate the expulsion of the stone from the ureter and the complainant was asked to wait for sometime to see whether the stone would come out on its own and if not some interventional procedures have to be done. But after one month, the scan and KUB X-ray revealed that there was no calculus and so he was advised to contact Dr. Sashikumar only if the earlier symptoms developed. <br /> <br /> According to the complainant he had sent all the relevant medical reports, medical certificate and bills to the 1st opposite party on 14.02.2003 with a request to reimburse Rs. 3507.08 incurred by him for the same. Ext. P7 is the letter produced by the complainant in corroboration of the same. On going through Ext. P7, it is seen that all the details are averred in it along with a request for claim form. The opposite parties contend that since the claim form duly filled was not sent to the opposite parties till 27.04.2003, the complainant's claim was repudiated. But Exts. P5 and P6 letters produced by the complainant goes to prove that he has been contacting the opposite parties for the same. Though the acknowledgement card for sending Ext. P5 has been produced, it is not seen marked. Ext. P4 is the repudiation letter. Nowhere it has been mentioned that the complainant has not intimated the claim to the company within 7 days as per condition No. 5.3 of the policy. As per clause 5.3 'upon the happening of any event which may, give rise to a claim under this policy notice with full particulars shall be sent to the company within 7 days from the date of death, injury, hospitalisation, domiciliary hospitalisation'. Ext. P7 dated 14.02.2003 produced by the complainant evidences that the relevant original medical reports and bills along with prescriptions have been sent to the opposite party in time. The 1st opposite party in their version has accepted that they have received the letter dated 14.02.2003 sent by the complainant. Moreover though the opposite party contends that they have asked the complainant to send the claim intimation letter duly filled claim form with final report of the attending doctor, no scrap of paper has been produced in support of the same by the opposite parties to prove that they had requested the complainant for the same. The opposite parties have repudiated the claim on three grounds. The grounds stated are no hospitalisation mentioned and the claim is subjected to exclusion 4.10 of Ext. P8 policy and para 2.4 (i) and (ii) of the policy not complied with in order to make claim payable under domiciliary hospitalisation.<br /> <br /> At this juncture the clause 4.10 of Ext. P8/Ext. D1 has to be gone through. As per 4.10 of the policy 'charges incurred at hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home'. The documents on record and the pleadings corroborate the fact that the complainant had undergone the tests and examinations and treatment for the presence of a stone at the lower end of right ureter which is very well consistent with the diagnosis and treatment of the positive existence of the ailment. The opposite parties have miserably failed to prove otherwise. <br /> <br /> The other ground for repudiation is that no hospitalisation has been mentioned in medical records and the conditions for making claim payable under domiciliary hospitalisation not complied with. But according to the complainant the said clause will not apply in his case and he relies on clause 2.3 of the policy for the same. Clause 2.4 of the policy deals with domiciliary hospitalisation benefit. But, on going through clause 2.3 of the said policy it is stated that, hospitalisation for minimum period of 24 hours time limit will not apply for specific treatments in which Lithotripsy (kidney stone removal) is also included. The opposite parties do not have a case that the complainant has not suffered the ailment of ureter stone. The opposite parties' case is that the complainant had conducted the tests to rule out a possibility and the expenses for medical and diagnostic tests are payable only if hospitalisation is required. The complainant has pleaded that two medicines namely Zyloric and Citrosoda were prescribed to him to facilitate the expulsion of the stone from the ureter and some interventional procedures may have to be employed only if the stone continues to remain. This is a case wherein no calculus was detected after one month of the said prescription and consumption of the medicines. The fact cannot be overlooked that in the practice of modern medicine the said procedure of prescribing medicines for the expulsion of the stone from ureter is almost a routine procedure. In such circumstance, the clause 2.3 of the policy is squarely applicable in this case also. The terms and conditions in the policy which is the basis of the contract of insurance, has to be interpreted correctly. The complainant has taken an insurance policy for medicare wherein for the ailment suffered by him, the time limit for hospitalisation for minimum period of 24 hours is not applicable as per clause 2.3 of Ext. P1/Ext. D1 policy. No evidence has been led by the insurance company to substantiate the facts regarding their allegations. Moreover, the opposite parties have failed to prove that the complainant has conducted only tests for a particular disease and not treatment. In our view, case of the complainant falls within the exemption clause 2.3 of the policy and the act of the opposite parties in repudiating the claim of the complainant is not at all justifiable.<br /> <br /> In the light of the above it is found that there is deficiency in service on the part of the opposite parties in repudiating the claim of the complainant and the complainant has to be compensated for the same. The complainant is found entitled for the refund of Rs. 3507/- detailed in Ext. P7 and an amount of Rs. 1000/- towards compensation and Rs. 500/- towards cost of the proceedings. <br /> <br /> In the result, the complaint is allowed. The opposite parties shall pay an amount of Rs. 3507/- and an amount of Rs. 1500/- towards compensation and costs. Time for compliance one month failing which execution proceedings can be invoked.<br /> <br /> A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.<br /> <br /> Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the day of 30th April , 2008.<br /> <br /> G. SIVAPRASAD <br /> President.<br /> <br /> BEENAKUMARI. A : MEMBER<br /> <br /> S.K.SREELA : MEMBER<br /> <br /> O.P.No. 326/2003<br /> APPENDIX<br /> I COMPLAINANT'S WITNESS : <br /> PW1 - Dr. C. Mathew <br /> II COMPLAINANT'S DOCUMENTS :<br /> P1 - Photocopy of notice issued to the 1st opposite party dated 16.07.2003.<br /> <br /> P2 - Photocopy of advertisement published in Malayala Manorama daily dated 22.06.2003 highlighting some of the rules of the Insurance Regulatory and Development Authority.<br /> <br /> P3 - Photocopy of complainant's letter dated 05.05.2003 to the opposite party.<br /> <br /> P4 - Photocopy of letter dated 28.04.2003 from the 1st opposite party to the complainant. <br /> <br /> P5 - Photocopy of letter dtd. 16.04.2003 from the complainant to the opposite party.<br /> <br /> P6 - Photocopy of complainant's letter dated 07.03.2003 to the opposite party.<br /> <br /> P7 - Photocopy of letter dated 14.02.2003 to the opposite party enclosing all the original relevant prescription, medical reports and bills. <br /> <br /> P8 - Photocopy of Mediclaim Insurance Policy(Revised) issued by National Insurance Company Ltd. <br /> III OPPOSITE PARTIES' WITNESS :<br /> NIL<br /> IV OPPOSITE PARTIES' DOCUMENTS :<br /> D1 - Copy of Policy.<br /> <br /> PRESIDENT