BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM PRESENT: SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI .A : MEMBER SMT. S.K. SREELA : MEMBER C.C. No. 62/2009 Filed on 16/3/2009 Dated: 16..04..2010 Complainant: C. Omana, Chithira, Karichal, Pulluvila – P.O., Thiruvananthapuram. (Appeared in person)
Opposite parties: Divisional Manager, National Insurance Co. Ltd., St. Joseph Press Building, 11nd Floor, opp. Cotton Hill High School, Vazhuthacaud, Thiruvananthapuram. (By Adv. S. Rajeev) The Manager, Medi Assist India Pvt. Ltd., 106 Chandralayam, Krursuppally Road, Ravipuram, Cochin – 682 015.
This O.P having been heard on 05..02..2010, the Forum on 16..04..2010 delivered the following: ORDER
SHRI.G. SIVAPRASAD, PRESIDENT:
The facts leading to the filing of the complaint are that, complainant along with other insured persons (C. Balakrishnan, husband of the complainant and Prasad, son of the complainant) took an insurance policy vide policy No.570201/48/07/8500001098 from the 1st opposite party, that on 17/07/2008 complainant was admitted to PRS hospital for her treatment and had undergone treatment therein till 19/7/08 for which she had incurred a cost of Rs. 2,403/- and the same was remitted by the complainant to the said hospital on the pretext that she would get reimbursed the said amount on production of the treatment bill along with medical reports from PRS hospital to opposite parties, that complainant produced the medi claim along with the said bills to 2nd opposite party, but opposite parties did not allow it so far. Hence this complaint to direct opposite parties to pay Rs. 2,403/- along with compensation and cost to the complainant.
2. Opposite parties filed version contending that the complaint is not maintainable either in law or on facts, that as per the discharge summary submitted by the complainant, there is no active treatment during the hospitalisation period except the investigation done and oral medicines given to the complainant which does not warrant hospitalisation, and the same falls outside the purview of hospitalisation as per the terms of the policy. Hence the claim was repudiated under exclusion 4.10 of the policy issued to the complainant. Hence opposite parties prayed for dismissal of the complaint.
3. The points that arise for consideration are:
Whether there is deficiency in service on the part of opposite parties? Whether the complainant is entitled to compensation, If so, at what amount? Whether complainant is entitled to get cost?
In support of the complaint, complainant has filed an affidavit of herself as PW1 and has marked Exts. P1 to P16. Complainant has been cross examined by opposite parties. In rebuttal, opposite party has filed affidavit as DW1 and has marked Ext. D1. Opposite party has been cross examined by the complainant.
4. Points (i) to (iii) : It has been the case of the complainant that complainant along with other insured persons took an insurance policy by policy No. 570201/48/07/8500001098, from the 1st opposite party, that on 17/7/2008 complainant was admitted to PRS Hospital for her treatment and had undergone treatment therein till 19/7/08 for which she had incurred a cost of Rs. 2,403/- and the same was remitted by the complainant to the said hospital on the pretext that she would get reimbursed the said amount on production of the treatment bill along with medical reports from PRS hospital to opposite parties, that accordingly complainant produced the medi claim along with said bills to 2nd opposite party, but opposite parties did not allow it so far. Opposite parties resisted the complainant by submitting that there was no active line of treatment during the hospitalisation period except the investigation done and oral medicines given which does not warrant hospitalisation, that the same falls outside the purview of hospitalisation as per the terms of the policy and hence the claim submitted by the complainant was repudiated under exclusion 4.10 of the policy issued to the complainant. Ext. P1 is the copy of the letter dated 18/7/2008 addressed to Administrator/Medical Superintendent PRS Hospital, from Medi Assistant India Ltd informing them to collect hospitalisation expenses from the patient, who in turn, may be advised to submit the bills to medi Assist for a possible re-imbursement subject to the terms, conditions and exclusion of her insurance policy. Ext. P2 is the copy of the PRS Hospital Report dated 17/07/2008 of the Ultrasound of the abdomen of the complainant. Ext. P3 is the copy of the Laboratory Report on Random blood sugar of patient, Mrs. Omana. Ext. P4 is the copy of the Laboratory Report dated 17/07/08 on blood CBC of the complainant. Ext. P5 is the copy of the Laboratory /report dated 18/07/08 on Lipid Profile of the complainant. Ext. P6 is the copy of the Laboratory report dated 18/07/08 on Urine routine of the complainant. Ext. P7 series of PRS pharmacy bills issued by PRS hospital in the name of complainant. Ext. P8 is the copy of the discharge bill details of Mrs. Omana from 17/07/2008 to 19/07/08 for Rs. 2,403. Ext. P9 is the copy of the cash bill for Rs.2,403/-. Ext. P10 is the copy of the discharge summary by PRS Hospital. As per Ext. P10 diagnosis would include Fibroid Uterus and Acute Gastritis. Ext. P11 is the copy of the receipt voucher for Rs. 2,403/-. Ext. P12 is the copy of the medical certificate issued by Dr. P. Rajesh, MD. Ext. P13 is the copy of the claim Form. Ext. P14 is the copy of the letter dated 12/8/08 to Mr. C. Balakrishnan requesting him to furnish some documents. It is further stated in Ext. P14 that on receipt of details of other charges Rs.500/-, Imageology charges Rs. 400/- with reports in main bill, the claim will be processed expeditiously. Ext. P15 is the copy of the letter dated 5/9/08 issued by Medi Asst India Private Ltd., requesting Mr. Balakrishnan to furnish details of other charges Rs.500/-/Imageology charges Rs.400/- with report in main bill. Ext. P16 is the copy of details of break up of Room, other chargs (for two days) Rs.500/- collected from Mrs. Omana, issued by Accounts Manager, PRS Hospital. Ext. P7(b) is the copy of the bill for Rs.400/- for Scan USG – Inpatient. Ext. D1 is the copy of the Hospitalisation and Domiciliary Hospitalisation Benefit Policy issued by the 1st opposite party. As per Ext. D1, policy period is from 1/10/07 to 30/9/08, Net premium comes to Rs. 4,594/-. As per the said policy, there are three insured persons – Mr. C. Balakrishnan, Mrs. C. Omana and Mr. Prasad. B.O., Name of TPA is Medi Assist India Private Ltd. It has been contented by opposite parties that there was no active line of treatment during hospitalisation period except investigation done and oral medicines given, which does not warrant hospitalisation and that the claim submitted by the complainant was repudiated under exclusion 4.10 of the policy. It is argued by the learned counsel on behalf of 1st opposite party that opposite party issued policy subject to the terms and conditions stipulated in the said policy. It is further argued by the opposite parties that, inspite of the letters, reminders issued by opposite parties to complainant to furnish the required papers/documents, the complainant has not complied with the same and so the opposite parties vide letter dated 17/3/09 intimated the complainant the said claim stands closed on account of non submission of requested documents and further that the present claim was towards the primary diagnostic expenses without any active inpatient treatment. According to opposite party medical management under IP treatment there should be 4 drips/4 injection/monitoring of the ailment on hourly basis by the medical staff and such condition where the stay at hospital becomes necessary. On perusal of evidence available on records, complainant was admitted to PRS hospital on 17/7/08 and discharged on 19/7/08. In her cross examination PW1 has deposed that she was admitted to PRS hospital with abdominal pain, giddiness nausea. As per discharge summary (Ext. P10) Mrs. Omana was admitted with H/o abdominal pain and discomfort on and off x 1 month. H/o nausea + and she was treated with Happi D BD, Ulgel liquid, Deomxit 10D etc. Diagnosis = Fibroid Uterus, acute Gastritis. As per Ext. P9, cash bill, the description includes Room Rent Rs. 600/-, Room service Rs. 100/-, Room other charges Rs. 500/-, Doctors visit fee Rs. 100/-, ECG Rs. 100/-, Imageology charges Rs. 400/-, Laboratory Rs. 551/- and medicine charges Rs. 52/-. As per Ext. P14, complainant was requested to furnish details of other charges Rs. 500/-/Imageology charges Rs. 400/- with reports in the main bill. Ext. P16 is the copy of details of other charges Rs. 500/- and Ext. P7(b) is the copy of scan billing Rs. 400/-. As per exclusion clause 4.10, for expenses incurred primarily for evaluation/diagnostic purposes not followed by active treatment during hospitalisation, company shall not be liable to make payament under the policy. It is to be pointed out that the policy itself is a hospitalisation and Domiciliary hospitalisation Benefit Policy. It is not in dispute that complainant was admitted to PRS Hospital and she stayed at hospital for two days. Whether the treatment during hospitalisation was active or not, yet to be established. It is the contention of the complainant that without any disease a person will not be admitted to hsopital. In this context it is worthwhile to mention that a person takes policy with intention to get benefits of it. Herein complainant has taken the policy to get hospitalisation benefit. Nowhere in Ext. P10 is it seen mentioned that expenses incurred primarily for evaluation/diagnostic purposes. Too much technicality would spoil the very purpose of the policy. As per Ext. P9 cash bill complainant was directed to remit Rs.2,403/-, and the same was remitted by complainant by Ext. P11. Taking into consideration of the totality of circumstances, we are of the considered opinion, that it will be expedient and justice will be well met if complaint is allowed the bill amount of Rs. 2,403/-.
In the result, complaint is partly allowed. 1st opposite party is directed to pay Rs. 2,403/- to complainant. There will be no compensation in facts and circumstance of the case. Parties are directed to bear and suffer their costs. 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.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 16th day of April, 2010.
G. SIVAPRASAD PRESIDENT.
BEENA KUMARI. A : MEMBER
S.K. SREELA : MEMBER ad.
C.C.No.62/2009 APPENDIX I. Complainant's witness: PW1 : Omana II. Complainant's documents: P1 : Copy of the letter dated 18/7/08 P2 : " PRS Hospital Report P3 : " Laboratory Report P4 : " Laboratory Report dated 17/07/08 P5 : " Laboratory report dated 18/7/08 on Lipid Profile of the complainant. P6 : " Laboratory report dated 18/7/2008 on Urine routine of the complainant. P7series : PRS Pharmacy bills issued by PRS hospital in the name of complainant. P8 : Copy of the discharge bill details of complainant from 17/7/08 to 19/7/08. P9 : Copy of cash bill for Rs. 2,403/- P10 : " discharge summary P11 : " receipt voucher for Rs. 2,403/-. P12 : " medical certificate P13 : " Claim Form P14 : " letter dated 12/8/08 P15 : " letter dated 5/9/08 P16 : " details of break up of room, other charges. III. Opposite parties' witness: DW1 : Mallika Ganesan IV. Opposite parties' documents: D1 : Copy of the Hospitalisation and Domiciliary Hospitalisation Benefit Policy issued by the 1st opposite party.
PRESIDENT
| | [HONABLE MR. JUSTICE President] President[HONORABLE MR. Sri G. Sivaprasad] PRESIDENT[ Smt. Beena Kumari. A] Member | |
