By. Sri. P. Raveendran, Member:-
Brief of the complaint:- The complainant took a family mediclaim insurance policy from opposite party No.1 in the year 2006 covering himself, his wife Basheerath and their daughter Diya Ismail. Thereafter the complainant renewed the policy periodically. The present policy number is 101601/48/11/97/00000137 for the period 18.05.2011 to 17.05.2012. While so on 27.05.2011 the complainant's wife was admitted at Kasthurba Hospital Manipal for swelling on her left breast. She was treated as impatient and was discharged on 31.05.2011 on
request. The complainant has spent Rs.10,755/- at Kasturba Hospital Manipal for the treatment. Thereafter the complainant's wife continued her treatment at Medical College Hospital Kozhikode. Thereafter the complainant submitted the claim form to the opposite parties for reimbursement of the medical expenses incurred for the treatment of his wife. The complainant enquired about the sanction of the reimbursement on several times to the opposite party. Thereafter the 2nd opposite party vide letter date 13.07.2011 has repudiated the claim of the complainant on the ground that there was no active line of treatment to justify hospitalization. So the act and omission on the part of the opposite parties amount to deficiency of service. Hence it is prayed that to direct the opposite parties to reimburse Rs.10,755/- to the complainant towards medical expenses and Rs.15,000/- as compensation and Rs.1,000/- as cost of this litigation.
2. Notices were served on the opposite parties. The opposite party No.1 appeared and filed his version. Even though time is granted to file the version to opposite party No.2 he is not appeared and filed his version. Hence Opposite Party No.2 is set exparte and proceeded with the case.
3. In the version of opposite party No.1 admitted that insurance policy No.101601/48/11/97/00000137 for the period from 18.05.2011 to 17.05.2012 were issued in favor of the complainant with a coverage including his wife Smt. Basheerath. The claim was processed by 2nd opposite party being a TPA. And after thorough verification of medical records it is observed that the patient was admitted in the hospital on 27.05.2011 and
discharged on 31.05.2011 at Kasturba Hospital Manipal for an ailment lump in left breast. During the hospitalization the patient was investigated and evaluated with no active line of treatment justifying hospitalization. The medical records submitted along with claim form do not indicate the need for hospitalization. The treatment administered did not necessitate any hospitalization. Hence the claim was rejected. There is no deficiency of service on the part of the opposite party. As per clause 4 of policy exclusions this opposite party shall not be liable to make payment order. This policy in respect of any expense without so ever incurred by any insured person with respect of Section 4 (7). The other allegations in the complaint is denied by opposite party No.1. The complainant is not entitled to get Rs.10,755/- towards medical expenses Rs.15,000/- towards compensation and Rs.1,000/- towards cost. Hence it is prayed to disallow petition with cost.
4. Considering the complaint and version the following points are to be considered:-
1. Whether there is any deficiency in service on the part of the opposite parties?
2. Relief and cost.
5. Point No.1: To prove the complainant's case he has filed his proof affidavit and he
was cross examined by opposite party No.1. He has also produced Ext.A1 to A3 documents to prove his case. The case of the opposite party No.1 is that the claim was processed by the 2nd opposite party being a TPA and after thorough verification of medical records it is observed that the patient was admitted in the hospital on 27.05.2011 and discharged on 31.05.2011 for the ailment lump in left breast and the medical records submitted along with claim form do notindicates need for hospitalization. The 2nd opposite party who processed the claim was not appeared before the Forum and adduced any evidence to show that on what basis they came to that conclusion. On perusing Ext.A1 it is clearly stated that Carcinoma left breast. In 2008 underwent breast conservation surgery. Now complaints of swelling since one month and she was admitted with some complaint. Patient was to review at a later date of follow up. She is discharged at request MRI and bone scan reports are awaited. On perusing Ext.A2 series it is clear that the complainant's wife underwent treatment at Medical College Hospital Calicut on 29.06.2011, 02.07.2011, 10.10.2011, 17.10.2011, 25.10.2011, 11.11.2011, 30.11.2011, 05.12.2011, 26.12.2011, 30.12.2011, 09.01.2012, 20.01.2012, 02.02.2012, 10.02.2012, 20.02.2012. In Ext.A2 it is clearly mentioned that she is discharged at request and Ext.A2 series clearly shows that she continue her treatment at Medical College Hospital Calicut. Ext.A1 series also clearly shows that she was admitted in Kasturba Hospital Manipal with some complaint. Hence repudiation of the claim submitted by complainant is a clear deficiency of service on the part of the opposite parties. Point No.1 is decided accordingly.
6. Point No.2:- The complainant is entitled to get Rs.10,775/- which was spent for
medical expenses. He is also entitled to get Rs.3,000/- as compensation and Rs.750/- as cost of this litigation. Point No.2 is decided accordingly.
In the result complaint is partly allowed the opposite parties are directed to pay Rs.10,775/- ( Rupees Ten Thousand Seven Hundred and Seventy Five Only) towards the medical expenses spent by the complainant, Rs.3,000/- (Rupees Three Thousand Only) as compensation and Rs.750/- (Rupees Seven Hundred and Fifty Only) as cost of this litigation to the complainant within 30 days of receipt of this Order.
Pronounced in Open Forum on this the day of 22nd February 2012.
Date of Filing:17.10.2011.
