DATE OF FILING : 17.11.2009
BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI Dated this the 31st day of March, 2010
Present: SRI.LAIJU RAMAKRISHNAN PRESIDENT SMT.SHEELA JACOB MEMBER SMT.BINDU SOMAN MEMBER C.C No.217/2009 Between Complainant : T.L.Sebastian, Thannickal House, Moolamattom P.O, Idukki District. And Opposite Parties : 1. The Branch Manager, National Insurance Company Limited, Pulimoottil Shopping Arcade, Thodupuzha, Idukki District. (By Adv: Thomas Sebastian) 2. Medi Assist India TPA Private Limited, 406, Chandralayam, Kurisupally Road, Raviuram, Cochin – 682 015. 3. Jose Joseph, Kunnel House, Moolamattom P.O, Idukki District. O R D E R SMT.BINDU SOMAN(MEMBER)
Complainant had taken a mediclaim policy from the opposite party on 3.02.2009. Complainant belongs to a BPL category. This plan of National insurance is specifically created for BPL. Premium amount is Rs.150/- per month and the insured sum is Rs.30,000/-. The policy offered treatment expenses upto Rs.30,000/- per year. Petitioner availed this policy for his family. After few months, complainant had a stomach ache, he approached many hospitals. At last he was admitted in Lisie Hospital, Ernakulam. There he was undergone an operation for renal calculie and discharged from the hospital on 26.06.2009. After discharge he went to the opposite party’s office for claim form. On 30.06.2009 he had submitted claim form with all bills and other records to opposite party’s Thodupuzha office. After three months the petitioner received a notice from the opposite party for production of original bills. He himself appeared at the opposite party’s office and said that he had already produced the original bills. But because of opposite party’s direction complainant again produced the copy of bills. When he went to Thodupuzha office, they wanted to produce the bills at Ernakulam office, petitioner did it. Next time they informed that one more paper is necessary from hospital. Complainant had given that also. On 9.10.2009 complainant went to Thodupuzha and Ernakulam office. The insurance company informed the complainant for receiving the cheque, complainant went to Thodupuzha office and at that time he knew that the amount was only Rs.4,900/-. He asked about this to the 3rd opposite party, the agent of the 1st opposite party. But no explanation given. Hence he had filed a petition before this Forum. 2. The 1st opposite party filed written version and stated the disputed facts. 2nd and 3rd opposite party had no written version. 1st opposite party admitted the policy, company already given the claim amount and the petitioner received the amount without any protest. Complainant had given medical bill of Rs.16,365/-. Medi Assist India Private Limited verified the claim form and medical bills, approved it to settle for Rs.4,900/-. The opposite party issued a cheque for Rs.4,900/- on 30.10.2009 with settlement advice of the Medi Assist India Private Limited to the complainant. The opposite party had settled the claim as per condition No.1.2 of the policy. As per the Universal Health Insurance Policy, the 1st opposite party is liable to pay the amount of such expenses as would fall under different heads subject to limits mentioned in Section-1, hospitalisation expenses mentioned in condition No.1.2 of Universal Health Insurance Policy issued to the complainant. As per the policy the sum insured for each family is Rs.30,000/-. As per the clause A, in the schedule under section 1 mentioned in the condition No.1.2 of the said policy, for room, boarding expenses the amount payable is limited to 0.5% of sum insured per day, that is Rs.150/day. The complainant underwent IP treatment for 2 days and therefore the amount payable is Rs.300/-. That amount is paid. As per clause B, in the schedule under schedule 1 mentioned in the condition 1.2 of the policy towards surgeon, anaesthetist, consultants, medical practitioner, specialists fees and nursing expenses, the amount payable is limited to 15% of sum insured per illness that is Rs.4,500/-. But as per the medical bills an amount of Rs.60/- for nursing charges and Rs.40/- for professional charge is collected. That amount was paid for surgeon and nursing charges. As per clause C, in the schedule under section 1 mentioned in the condition 1.2 of the policy, for anaesthesia, blood, operation theatre charges, surgical appliances, medicines, diagnostic materials, drugs etc. the amount payable under the policy is limited to 15% of the sum insured per illness that is Rs.4,500/-. The complainant produced bill for Rs.15,761/- for anaesthesia, operation theatre charges, medicine, laboratory charges etc.. As per clause C, in the schedule under section 1 mentioned in the condition 1.2 of the policy the amount payable is Rs.4,500/-. The said Rs.4,500/- was paid against the claim of Rs.15,761/- by the complainant. Therefore subject to limits mentioned in the condition No.1.2 of the said policy, the opposite party is liable to pay Rs.4,900/-. The opposite party paid Rs.4,900/-as per the Policy in full and final settlement of the claim. So there is no deficiency in service on the part of the 1st opposite party.
3. The point for consideration is whether there was any deficiency in service on the part of the opposite parties, and if so, for what relief the complainant is entitled to? 4. Complainant was examined as PW1 and marked Exts.P1 to P8. No oral evidence adduced by the opposite parties. Exts.R1 to R4(series) marked on the side of the opposite parties.
5. The POINT :- This is a Universal Health Insurance policy. It is a plan of Government of India. This is for the well being and welfare of BPL Sector. PW1 is belonged to be a BPL category. The policy was admitted by the opposite party. The sum claimed by the complainant is not according to the provisions of the policy, is the contention of opposite party. Ext.P1 is the application form of Insurance policy. Ext.P2 is the policy copy. Ext.P4 is a letter from the opposite party for the production of original bill. Ext.P5 is the copy of hospitable discharge. Ext.P6 is a receipt of complainant. Ext.P7 is a copy of letter from the opposite party. Ext.P8 is a copy of cheque with a letter from the insurance company. The opposite party had no oral evidence and produced documents Exts.R1 to R4(series). Ext.R1 is the application form of policy. Ext.R2 is the policy copy. Ext.R3 is the claim form. Ext.R4(series) are the bills produced by the complainant. Ext.P3(series) and Ext.R4(series) are the original bills of complainant. These bills show the expenses of the petitioner for his treatment. No separate bill is produced for doctor fees. Because of Income Tax Provision, hospitals are not providing separate bills for doctor fees.
6. As per the complainant, he is entitled to get Rs.15,000/-, the maximum limit of the policy amount, because he produced a bill of Rs.16,365/- as per the Ext.R4 (series). As per the opposite party, it is admitted that the complainant produced the bill of Rs.16,365/- but as per the Ext.R2 policy conditions clause 1.2, section-1 shows that the maximum limit for (a) Room, boarding expenses as provided by the hospital / nursing home is limited up to 0.5% of sum insured per day and if it is in IC Unit, up to 1% of sum insured per day. But the complainant was admitted in the hospital only for 2 days and he is liable for only Rs.300/- for the same. As per clause 1.2, section-1 (b) Surgeon, anaesthetist, medical practitioner, consultants, specialists fees, nursing expenses is up to 15% of sum insured per illness. Here the complainant produced medical bill in which Rs.40/- for professional charges and Rs.60/- for nursing charges. That amount was paid for surgeon and nursing charges. As per clause C, operation theatre charges, surgical appliances, medicines, anaesthesia etc. is limited up to 15% of sum insured per illness. That is Rs.4,500/-. The sum Rs.4,500/- is also paid to the complainant. So a total amount of Rs.4,500/- had paid. As per the opposite party, the complainant paid only Rs.60/- for nursing expenses and Rs.40/- for professional charges. The contention of the opposite party is that Rs.40/- is charged for doctor’s fee and Rs.60/- for nursing charges, so as per the clause 1.2 section -1 B, the amount payable is only Rs.100/-. But we don’t think that in multi speciality hospital like Lisie Hospital, Kochi, the doctor who consulted is a senior professor named Dr. Damodaran Nambiar, M.S., MCH, charged only Rs.40/- for the doctor’s fee for conducting an operation. And for conducting such an operation, Rs.60/- only is charged for nursing fee. In Ext.P3(h) bill, the complainant paid an amount of Rs.15,000/- as advance, and Rs.14,533/- is charged for operation expenses. So an ordinary lay man is not able to collect a separate bill for the doctor’s fees for the operation in order to produce before the opposite party. Whatever bill supplied by the hospital and discharge summary is also produced by the complainant. Ext.P3(series) shows that Rs.1,832/- is charged for medicine and tests conducted at the Hospital.
7. As per Ext.R2 policy, the section III, clause 3.4 states that, expenses on hospitalisation for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, that is dialysis, chemotherapy, radiotherapy, eye surgery, dental surgery, lithotripsy (kidney stone removal), D&C, tonsillectomy taken in the hospital and the insured is discharged on the same day, such treatment will be considered to be taken under hospitalisation benefit. This condition will also not apply in case of stay in hospital of less than 24 hours provided
(a) The treatment is such that it necessitates hospitalisation and the procedure involves specialised infrastructural facilities available in hospitals. (b) Due to technological advances hospitalisation is required for less than 24 hours only. Note: When treatment such as dialysis, chemotherapy, radiotherapy, etc. is taken in the hospital and the insured is discharged on the same day the treatment will be considered to be taken under hospitalisation benefit section.
Liability of the company under this clause is restricted as stated in the schedule attached thereto. 8. So we think that there special provisions provided in the clause 3.4 in the limitation of hospital admission for the above mentioned diseases. Due to technological advances hospitalisation is required for a lesser time for this treatment. But treatment needed inpatient for several days. So in this case, the complainant was admitted for kidney stone removal and a surgery was conducted for the same even though he was admitted in the hospital, for the limited time period. So he is eligible for the special provisions under clause 3.4 and the maximum limit for the same is 15% of the insured sum as per the policy condition. So we think that the complainant is entitled to get a maximum limited amount of Rs.15,000/- for the treatment of the disease. Hence the maximum limited amount for one person as per the policy condition is Rs.15,000/- and the complainant is also eligible for the same. And it is a gross deficiency from the part of the opposite party to reject the claim and limits the claim for Rs.4,900/- only because of the difference in technical terms written as charge from the hospital. Here the complainant received Rs.4,900/- from the opposite party.
Hence the petition allowed. The 1st opposite party is directed to pay the balance amount Rs.10,100/- to the complainant, with 12% interest from the date of this petition and Rs.2,000/- as cost of this petition within one month of receipt of a copy of this order, failing which the amount shall carry 12% interest per annum from the date of default.
Pronounced in the Open Forum on this the 31st day of March, 2010
Sd/- SMT.BINDU SOMAN(MEMBER)
Sd/- I agree SRI.LAIJU RAMAKRISHNAN(PRESIDENT)
Sd/- I agree SMT.SHEELA JACOB(MEMBER)
APPENDIX Depositions : On the side of Complainant : PW1 - P.L.Sebastian On the side of Opposite Parties : Nil Exhibits: On the side of Complainant: Ext.P1 - Application Form of Universal health Insurance Policy Ext.P2(series) - Photocopy of Policy Schedule with Conditions Ext.P3(a) - Photocopy of Medical Certificate to be filled in by the Doctor treating the patient Ext.P3(b) - Photocopy of Claim Form Ext.P3(c) - Photocopy of Cash Bill dated 26.06.2009 for Rs.285/- issued from the Lisie Hospital, Cochin Ext.P3(d) - Photocopy of Lab Report of Blood Tests Ext.P3(e) - Photocopy of Cash Bill dated 24.06.2009 for Rs.336/- issued from the Lisie Hospital, Cochin Ext.P3(f) - Photocopy of Cash Bill dated 24.06.2009 for Rs.649/- issued from the Lisie Hospital, Cochin Ext.P3(g) - Photocopy of Cash Bill dated 25.06.2009 for Rs.562/- issued from the Lisie Hospital, Cochin Ext.P3(h) - Photocopy of Inpatient Bill dated 24.06.2009 for Rs.15,000/- as advance Ext.P3(i) - Photocopy of Cash Bill dated 26.06.2009 for Rs.14,533/-/- issued from the Lisie Hospital, Cochin Ext.P4 - Letter dated 10.09.2009 issued by the 2nd opposite party to the complainant Ext.P5(series) - Photocopy of Discharge Summary issued from the Lisie Hospital, Ernakulam Ext.P6 - Photocopy of Receipt dated 24.09.2009 issued by the 2nd opposite party Ext.P7 - Letter dated 09.10.2009 issued by the 2nd opposite party to the complainant Ext.P8 - Copy of Cheque dated 30.10.2009 for Rs.4,900/- with Settlement Advice dated 31.10.2009 issued by the 2nd opposite party to the complainant On the side of Opposite Parties : Ext.R1 - Photocopy of Application Form of Universal health Insurance Policy Ext.R2 - Policy Copy Ext.R3 - Claim Form Ext.R4(series) - Medical Bills(7 Nos) |
