BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI Dated this the 30th day of July, 2009
Present: SRI.LAIJU RAMAKRISHNAN PRESIDENT SMT.SHEELA JACOB MEMBER SMT.BINDU SOMAN MEMBER
C.C No.29/2009 Between Complainant : Babu George aged 55 years, Kochuparambil House, Amayapra Bhagam, Udumpanoor P.O. Thodupuzha. (By Adv: Prince J Pananal) And Opposite Parties : 1. The Oriental Insurance Company Ltd., Represented by its Branch Manager, Branch Office, P.B.No:8, Jyothi Super Bazar, Thodupuzha. (By Adv: K. Pradeepkumar) 2. M/s TTK Health care Service (P) Ltd., 1400-B, Mareena Building, 1st floor M.G. Road, Ravipuram, Kochi: 682016.
O R D E R
SRI.LAIJU RAMAKRISHNAN(PRESIDENT)
The complainant availed a Mediclaim policy as No.441701, from the 1st opposite party in the year 1985, which was valid from 04/08/2005 to 03/08/2006, and it was renewed after that. Five family members of the petitioner were also the beneficiaries of the policy. Wife of the complainant, Reena is a diabetic patient. The disease was affected only after the commencement of the policy, and once a claim was settled by the opposite party. On 15/12/2006, she was admitted in M.V. Hospital for Diabetics at Roypuram, Chennai, for chronic toothache and fungal infection in the foot. She was treated there and discharged on 17/12/2006. All the documents regarding the treatment were submitted to the opposite party with claim form. The treatment expense amounts to Rs.11,948/- and Rs.600/- was for the travelling charges. But the opposite party repudiated the claim and hence the petition is filed. The 2nd opposite party is the administrator of the 1st opposite party in connection with enquiry and disposal of claims.
2. As per the written version of the 1st opposite party, it is admitted that the 1st opposite party issued medi-claim insurance policy bearing No.441701/2007/516 for the period 04/08/2006 to 03/08/2007. The petitioner filed a claim form for Rs.12,544.50/-, out of this, Rs.596/- was claimed as travelling expenses, which is not covered by Insurance. One bill for Rs.630/- dated 17/12/06 from Nutrition education services is not medical or treatment bill. As per "clause 04-10" of the contract of Insurance, where the hospitalization is only for the purpose of evaluation, not followed by an active treatment for the ailment diagnosed after the tests, such a claim is not admissible. In this case, when the patient was admitted in the hospital only investigations were carrried out, of these Hepatic profile, renal profile, scan abdomen, eye tests, ECG etc., are not relevant to the context. Insurance policy undertakes to pay the hospitalization expenses for medical surgical treatment, which is reasonably and necessarily incurred. Hospitalization was not necessary for the investigation and tests conducted. So the present claim does not satisfy the conditions of the policy. Second opposite party is the third party administrator of the claim, was appointed to process the claim as per the regulations of the IRDA and government of India. Second opposite party has a team of experts including doctors formed for the purpose of processing medi-claims.
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. The evidence consists of the oral testimony of PW1 and Exts.P1 to P5 marked on the side of the complainant and the oral testimony of DW1 and DW2 and Ext.R1 marked on the side of the opposite parties.
5. The POINT:- The 1st opposite party issued a mediclaim policy to the complainant in which the complainant and his family members were the beneficiaries. Petitioner's wife was treated at M.V.Hospital Chennai, which is specialist for diabetics. But the opposite party repudiated the claim for treatment expenses because the inpatient treatment was not needed for the disease, only certain tests and investigations were conducted in the hospital, which is excluded as per policy condition. Complainant was examined as PW1. PW1 deposed that their son is studying at Chennai and as per the advice of his friends, the hospital was providing advanced treatment in diabetics and so she was admitted there. She was admitted there for 3 days. In the first two days, the blood was testing continuously, after each hour, different medicines were also given, and so the diabetic disease was controlled. Only as per direction of the doctor the patient was admitted there and it was a part of active treatment. Ext.P1 is the discharge summary issued from the hospital and Ext.P5 is the bills for the treatment expenses. Ext.P3 is the copy of the Lawyers Notice issued to the opposite party. The 1st opposite party was examined as DW1. As per DW1, she approached M.V.Hospital Chennai only for further Investigation. So it is excluded as per clause 4.9 of the policy. The policy copy is marked as Ext.R1. DW2 is the Officer, who is working in the claim processing department of OP2. DW2 deposed that the patient was undergone several tests which were not needed for diabetics, Scan, Abdomen scan, ECG etc. Each test is different and not needed for a diabetic patient. The panal of doctors working with 2nd opposite party advised them and so the claim was repudiated. 6. The only dispute is that whether the Inpatient treatment was necessary for the patient. As per PW1, M.V.Hospital is famous hospital in Madras for the treatment of diabetics. The doctors there directed the patient for inpatient treatment. Blood was testing in each hours, when she was admitted there, different medicines were given to control the diabetic disease. As per the complainant, if the diabetics becomes secondary stage, Abdomen scan, ECG, eye test are also needed as the part of treatment. But DW2 answered that the same is not recorded in the discharge summary. Hence we think that the patient was admitted in the hospital as per direction of the doctor and it is the doctor who decides the treatment of the patient. The bills produced by PW1 are only for treatment expenses, not for any other purposes. If the opposite party is having a dispute in the treatment, then it should be proved by a competent doctor. As per DW2 a panal of doctors are advising them in the processing of claim. But not even a single doctor appeared and gave evidence to prove that the treatments were un-necessary. So the repudiation of the claim is a gross deficiency in the part of opposite party. In Ext.P5 bills produced, one bill is for nutrition education services, which is for Rs.630/-. As per opposite party it is not a part of the treatment and Rs.596/- is claimed as travelling expenses, which is also not covered by insurance. The balance amount comes about Rs.11,318.50/-. So we think it is fit to award Rs.11,318.50/- to the complainant as treatment expenses.
Hence the petition allowed. The 1st opposite party is directed to pay Rs.11,318.50/-, which is the medical expenses for the treatment of PW1 as per Ext.P5 bills with 12% interest from the date of this petition. The opposite party is also directed to pay Rs.1,500/- as cost of this petition within one month of a copy of this order.
Pronounced in the Open Forum on this the 30th day of July, 2009. Sd/- SRI.LAIJU RAMAKRISHNAN(PRESIDENT) Sd/- SMT.SHEELA JACOB(MEMBER) Sd/- SMT.BINDU SOMAN(MEMBER)
APPENDIX
Depositions : On the side of Complainant : PW1 - Babu George On the side of Opposite Parties : DW1 - Jimmy Mathew DW2 - Jagadhesh Exhibits: On the side of Complainant: Ext.P1 - Copy of Discharge Summary dated 17/12/2006. Ext.P2 - Copy of Repudiation Letter dated 14/02/2007 Ext.P3 - Lawyers Notice dated 19/03/2007 Ext.P4 - Copy of Reply Notice dated 27/03/2007. Ext.P5 series (a-m) - Copy of Bills issued from M.V. Hospital. On the side of Opposite Parties : Ext.R1 - Policy copy.
| HONORABLE Sheela Jacob, Member | HONORABLE Laiju Ramakrishnan, PRESIDENT | HONORABLE Bindu Soman, Member | |