1.     This complaint is filed by the complainant under section 11 and 12 of C. P. Act, 1986 seeking a direction on opposite parties for the payment of Rs.32,000/-  towards hospital treatment charges with  24% p.a. interest from 21-12-2009 to the date of realisation, Rs.20,000/-as compensation for mental agony and Rs.5,000/- towards the cost of the complaint.

2.     The complainant case is that he took hospitalization benefit policy/mediclaim policy from opposite party No.1 covering insurance for him self and his wife Smt.D.Rameswaramma.  The policy bearing No.611500/34/09/11/00000002 covering the insured period                      01-04-2009 to 31-03-2010 was issued to him by opposite party No.1 collecting Rs.13,235/- as total premium.  To the family member the sum insured was Rs.1,00,000/-.  The opposite party No.2 is the TPA of this policy.  Presently the complainant’s wife Smt. D.Rameswaramma was suffering from hip joint pain.  He consulted various specialists at Hyderabad for the treatment of his wife, but she did not recover.  On the advice of specialist he admitted his wife as in patient on                    08-11-2009 in Kairaly Ayurvedic Panchakarma Centre, Hyderabad and got discharged on 05-12-2009.  The complainant paid Rs.32,000/- towards hospital treatment charges and submitted claim form to opposite party No.1 along with relevant documents for the reimbursement of medical expenses incurred.  In reply to the claim application on 29-01-2010, opposite party No.1 requested the complainant to submit case sheet, investigation reports supporting diagnosis and previous consultation letters.  Even after submission of the above said documents to opposite party No.1 by the complainant a letter dated 27-03-2010 was sent to the complainant, stating that as per the policy condition 2.7 expenses incurred for Ayurvedic Treatments are admissible provided the treatment is taken in a Government Hospital, since the treatment was taken in a Private Hospital, the claim has been repudiated.  The complainant avered that, it is no where mentioned in the policy about admissibility or                  non-admissibility of policy.  The opposite party No.1 did not reject           the claim at first instance, but processed it, sought some information from the complainant, after receiving them repudiated the claim.  He was taking the policy for the past ten years, but never claimed any amount.  He also stated that the opposite parties did not provide the list of Hospitals in which the Hospitalization charges are inadmissible.  Hence it is unethical to repudiate the claim. Therefore this case is filed in the forum seeking appropriate reliefs.

3.     Documents marked as Ex.A1 to A8 and sworn affidavit are filed by the complainant to substantiate his claim.

4.     In persuance of the notice of this Forum, opposite party No.1 filed his written version denying his liability to the complainant’s claim.  The summery of written version of opposite party No.1 is that the opposite party No.1 admitted the fact of the complainant taking the Mediclaim policy (2007) from him for the period 01-04-2009 to        31-03-2010 vide policy No.611500/34/09/11/00000002 covering complainant’s wife Smt.D.Rameswaramma.  He said that he was not aware of complainant’s wife suffering from hip joint pain, consulted various specialists in Hyderabad for treatment, but did not recover, there after on the advice of specialists admitted her in Kairraly Ayurvedic Panchakarma Center Hyderabad, took treatment from           08-11-2009 to 05-12-2009 and spent Rs.32,000/-for treatment and all require documentary evidence.  The opposite party No.1 accepted the submission of claim form along with documents for reimbursement of medical expenses incurred and repudiation of the claim through the letter dated 27-02-2010.  He denied that the terms and conditions are not mentioned in the policy and submitted that they are attached to the policy and may be read as part and parcel.  Opposite party No.1 further submitted that the payment of regular premium and renewing of the policy for a period of ten years does not give any right to the complainant in claiming amount under this policy.  The opposite party No.1 avered that as per condition 2.7 of Mediclaim policy (2007), expenses incurred for Ayurvedic/ homeopathic/unani treatment are admissible up to 25% of the sum insured provided the treatment is taken in a Government Hospital.  As the complainant took treatment in as private Ayurvedic Hospital, the claim of the complainant is not maintainable as per the clause 2.7 of the policy conditions.  In the above circumstances the opposite party No.1 prayed that as there is no deficiency in service on his part the petition is liable to be dismissed.

5.     Opposite party No.2 is set exparte.

6.     The opposite party No.1 filed documents marked as Ex.B1, Ex.B2 and sworn affidavit in support of his case.

7.     The complainant and opposite party No.1 submitted their written version and oral arguments.

8.     Hence the points for consideration are:

(i)                  Where the complainant made out any case to prove the deficiency on the part of opposite party No.1?

(ii)                 Whether the complainant is entitled for compensation?

(iii)                  If yes, what is the amount of compensation that can be paid to the complainant?

8.      Point No.1 and 2 :-    Ex.A1/B1 is the Mediclaim policy certificate bearing No.61150034081100000001 dated 01-04-2009 issued by opposite party No.1 to the complainant.  Ex.B2 is the copy of terms and conditions of the policy. As per the policy and clause 8.0 of the terms and conditions, the complainant’s wife Smt.D.Rameswaramma was insured and is entitled for the reimbursement up to Rs.1,30,000/- (Rs.1,00,000/- sum insured plus Rs.30,000/- cumulative bonus) if suffers from any illness, require to incur hospitalization expenses for treatment at a hospital as an in patient under the care of a qualified doctor.  Ex.A7, the letter issued by the doctor Kairaly Hospital, Hyderabad, Reg. class – 42, No.1345790.  As per the Ex.A7 the complainant’s wife was admitted on 08-11-2009 under the care of a qualified doctor, took treatment for hip joint pain and with good relief from pain got discharged on                     05-12-2009.  Ex.A2, the claim form with hospital receipts, claiming Rs32,000/- towards hospitalization charges.  As per the condition 3.2 hospital/Nursing home has to be registed with local authorities, and as per the condition 3.6, the medical practitioner should hold a degree/diploma of a recognized institution and is registered by the medical council.  These two conditions are satisfied in the complainant’s claim, since the genuineness of them was not disputed by opposite party No.1.  The complainant  renewing the policy by paying premium regularly for a period of 10 years with out any claim, may not give him the right to claim, but proves his loyality.  Even then the opposite party No.1 rejected the complainants’ claim under the clause 2.7 of terms and conditions stating that “Expenses incurred for Ayurvedic/Homeopathic/ Unani treatment are admissible up to 25% of sum insured provided the treatment is taken in a Government Hospital”.  The opposite party No.1 saying that in case of entitlement, produced a calculation arriving Rs.8,000/- eligibility.  This was wrongly calculated since he calculated on the amount incurred i.e. 25% of Rs.32,000/-.  If it is calculated on sum insured i.e. 25% of                       Rs.1,30,000/- the eligibility comes to Rs.32,500/- which falls above the complainants’ claim, entitling the complainant  for Rs.32,000/-.   Now the point is how much weightage is to be given to clause 2.7 of terms and conditions of the policy.  The complainant filed citations                IV (2008) CPJ 365 and II (2007) CPJ 320 in support of his contentions.  A copy of order II (2007) CPJ 320 was also sent to all District Fora for information.  The extract of the above orders is that “the predominant aim and object of the Mediclaim insurance policy is to indemnify the expenses incurred by the insured towards hospitalisation and treatment of the disease that has landed the insured in the hospital.  It is heart and soul of the contract of insurance.  Also the general view of the consumer is that when a person is issued a mediclaim policy, he gets impression that he can claim medical expenses as and when he is hospitalized.  The interpretation of terms of the contract should be in consonance with aims and objects of the contract.  The terms and conditions of contract have to be interpreted as a whole and not in isolation and in a manner that the main aim and object is not lost in the way.  Interpretation has to be given in such a manner so that the interests of consumer are not defeated on flimsy, feeble grounds by the service providing agency to defeat the rightful claim of the insured.  It is also viewed that any written contract between parties if not duly signed by the parties has no legal enforcing force”.  The clause 2.7 might have been incorporated with a view that for the tests and medicines availed by the patient out side Government Hospital, that are not available in it, the patient will not get bills from the hospital and the reimbursement of such expenses incurred is limited to 25% of sum insured.  So the rule has scope for interpretation that if the insured takes treatment in private hospital, there is no limit for the claim, only when the treatment is in Government Hospital, the claim of the insured is limited to 25% of the insured amount.  Nowhere in the conditions is it said that the treatment in private hospitals is not allowed for insured.  The condition 2.7 at the most speaks about the restriction of the claim for the treatment in Government Hospitals.  Treatment in private hospitals as such, is not prohibited.  In the present case the fact remains that the complainants’ wife did undergo treatment in a registered hospital as an in patient under the care of a registered medical practitioner.  She was covered by the policy. The doctor received fees and issued a receipt.  If the insurance company means that there is no chance for insured to claim reimbursement for the treatment in private hospitals, the spirit and purpose of Mediclaim is completely lost.  Hence the Forum holds that the claim is with in the scope of policy and so the claim of the complainant is admissible.

10.    Point No.3:-       The complainant claimed Rs.32,000/-.  Under clause 2.1 room service, the expenses should not exceed 1% of sum insured i.e. Rs.1,300/- per day.  For 28 days the complainant paid Rs.14,000/- at the rate of Rs.500/- per day which is admissible, under clause 2.3 consultation charges,  no limit being prescribed. The complainant paid Rs.18,000/- which is also acceptable.  Hence the total claim of Rs.32,000/- by the complainant is allowed.

11.    The opposite party No.1 was negligent in settling the claim and made him to suffer mentally.  So the complainant is entitled compensation for mental agony.

12.    In the result, the complaint is allowed directing the opposite party No.1 to pay Rs.32,000/- towards hospitalization and treatment charges, Rs.5,000/- towards compensation for mental agony and Rs.1,000/- as cost of the case, payable within one month  from the date of receipt of this order.

Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 18^th day of February, 2011.

        Sd/-                                                                     Sd/-

          MALEMEMBER                                                    PRESIDENT

       APPENDIX OF EVIDENCE

Witnesses Examined

For the complainant : Nil            For the opposite parties : Nill

List of exhibits marked for the complainant:-

Ex.A1                Policy certificate No.61150034081100000001

dt. 01-04-2009.

Ex.A2.       Photo copy of claim form dt.21-12-2009 along with enclosures.

Ex.A3                Letter of OP NO.2 dt. 29-01-2010.

Ex.A4                Letter of OP NO.2 dt. 18-02-2010.

Ex.A5                Letter of OP NO.2 dt. 27-03-2010.

Ex.A6                Photo copy of letter of complainant to OP dt. 22-02-2010.

Ex.A7        Photo copy of letter of Kairaly Ayurvedic Panchakarma Centre, dt. 23-02-2010.

Ex.A8                Photo copy of Report of Thyrocare dt. 27-07-2009.

List of exhibits marked for the opposite parties:-   

Ex.B1                Mediclaim Policy No. 61150034081100000001.

Ex.B2                Policy terms and conditions.

                Sd/-                                                                            Sd/-

     MALE MEMBER                                                            PRESIDENT

// Certified free copy communicated under Rule 4 (10) of theA.P.S.C.D.R.C. Rules, 1987//

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