BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM PRESENT:
SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI. A : MEMBER SMT. S.K. SREELA : MEMBER O.P. No: 52/2003 Dated: 30..05..2009 Complainant:
N.K. Vallikannu, 40,VOC Street, Vadassery, Nagercoil-1.
(By Adv. T. Harikumar)
Opposite party:
National Insurance Company Limited, represented by its Divisional Manager, Divisional Office, Post Box No.434, St.Joseph's Press Building, Vazhuthacaud, Thiruvananthapuram.
(By Adv. M. Nizamudeen)
This O.P having been heard on 15..04..2009, the Forum on 30..05..2009 delivered the following:
ORDER
SMT. S.K.SREELA, MEMBER:
Briefly stated the facts are that the complainant took a medi-claim policy on 23/7/2001 on payment of Rs.722/- as annual premium for a period of one year from the opposite party for a sum of Rs.15,000/-. As per the terms and conditions of the said medi-claim policy the opposite party had agreed to undertake hospitalisation expenses for medical/surgical treatment as an in-patient or domicilliary treatment in India for the period of one year to the insured person, and that the complainant was admitted as an in-patient complaining of severe chest pain to the Sree Chitra Thirunal Institute for Medical Science and Technology, Trivandrum on 20/2/2002 and he was treated there and was discharged on 22/2/2002. The complainant had spent an amount of Rs.10,678/- towards the medical expenses as he was treated as an in-patient. After discharge the complainant submitted a claim to the opposite party claiming the amount of Rs.10,678/- towards the hospitalisation expenses which he had paid to the Sree Chitra Thirunal Hospital, Trivandrum. Since the opposite party failed to consider the claim of the complainant, he issued a notice through his advocate dated 11/11/2002 calling upon the opposite party to pay the hospitalisation expenses due to the complainant under the medi-claim policy. The opposite party by its letter dated 12/11/2002 disowned its liability to incur the hospitalisation expenses met by the complainant. The act of the opposite party to disown its liability under the medi-claim policy is clear violation of the terms and conditions of the policy and amounts to deficiency in service. Hence the complaint.
2. The opposite party has filed their version contending as follows: The complaint is not maintainable. The amount of Rs.10,678/- claimed by the complainant is the amount allegedly spent by the complainant for "Coronary Angiograph" which is a diagnostic test for detecting coronary diseases, and towards medicines and other tests related to the said diagnostic test. As per the Exclusion No. 4.10 of the Medi-claim policy issued by the opposite party to the complainant "charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home" is specifically excluded from payment to the insured/complainant. The case summary and discharge record issued from Sree Chitra Thirunal Institute for Medical Sciences and Technology, Thiruvananthapuram where the complainant was admitted on 20/2/2002 clearly reveals the fact that earlier, a Tread Mill Test (TMT) was done in August 1998 which was found negative and that Coronary Angiography (CAG) which is a diagnostic test was done on 21/2/2002, which revealed "normal coronaries" and "Good LV function" which again reveals that the complainant was not admitted for any disease and solely for diagnosis whether he suffers from any coronary disease. The complainant was admitted as an in-patient complaining severe chest pain to Sree Chitra Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram on 20/2/2002 and he was treated there are false and hence denied. The averments that the opposite party has not considered the claim of the complainant within a reasonable time and that the complainant repeatedly requested the opposite party to consider the claim and pay the hospitalisation expenses as provided in the policy are absolutely false, baseless and hence vehemently denied. The opposite party has not committed any deficiency in service or unfair trade practice on the part of the opposite party. Hence the Hon'ble Forum has no jurisdiction to entertain the complaint and the complaint is liable to be dismissed with compensatory cost of the opposite party.
3. The complainant has filed affidavit and marked Exts.P1 to P7 on his side. PW1 was also examined on the part of the complainant. The opposite party has also filed affidavit and marked Exts.D1 to D7. 4. From the contentions raised, following issues arise for consideration: Whether the act of the opposite party in repudiating the claim is justifiable? Whether the complainant is entitled for any of the reliefs claimed?
5. Points (i) & (ii): The complainant has been issued with a medi-claim policy by the opposite party for the period commencing from 23/7/2001 to 22/7/2002 as per Ext.P1. The grievance of the complainant is that his claim for Rs.10,678/- towards the hospitalisation expenses which he had paid to the Sree Chitra Thirunal Hospital has been repudiated by the opposite party which is a clear violation of the terms and conditions of the policy and amounts to deficiency in service. The contention of the Insurance Company is that they could not honour the claim since on perusal of the documents submitted by the complainant, it is found that the claim is in respect of Coronary Angiogram which is a diagnostic examination not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment or sickness for which confinement is required in a hospital and that since it is seen that the CAG revealed normal coronaries and good LV function and hence excluded as per Exclusion 4.10 of the policy issued to the complainant. Exclusion clause 4.10 of Ext.P1 reads as follows: "Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home". Accordingly, the aspect for consideration is whether the hospitalisation underwent by the complainant comes under the above exclusionary clause.
6. Ext.P2 is the case summary and discharge record pertaining to the complainant wherein the diagnosis is recorded as ATYPICAL CHEST PAIN TMT (1/2002) POSITIVE CAG NORMAL CORONARIES FCI NS GOOD LV FUNCTION. Besides this under the head procedure it has been recorded as CAG done on 21/2/2002, call No: 27323. The history of the complainant reveals that TMT done on 18/1/2002 was positive. The case summary and discharge record shows that the complainant has been admitted on 20/2/2002 and discharged on 22/2/2002. The in-patient bill, Ext.P3, reveals Rs.6,950/- has been collected from the complainant towards sophisticated investigations Coronary Angiography. The Asst. Professor, Cardiology has deposed as PW1 that 'Coronary Angiography is a diagnostic test for detecting blocks in the blood vessels of the heart'. Hence there is no doubt with regard to the fact that the said investigation done by the complainant is only a diagnostic test but whether that is not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment has to be considered. The medical history of the complainant reveals that, TMT done in September 2000 was mildly positive for inducible ischemia, TMT done on 18/1/2002 was positive at 7 Mets. 1-2mm, Atypical chest pain TMT 1/2002. The complainant has pleaded in the complaint that, he was admitted in Sree Chithra Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram on 20/2/2002 following severe chest pain. Ext.P2 also reveals that he has been admitted with chest pain. The pleadings and the documents on record corroborate the fact that the tests, examination and the treatment which were undergone by the complainant for detecting the blocks in the blood vessels were very well in consistent with the diagnosis and treatment of the positive existence of the ailment. As per Ext.P2, the complainant has been admitted for CAG which, definitely is in consistent with the diagnosis and treatment of the positive existence of the ailment which herein is the chest pain. The learned counsel for the opposite party had contended that the pleadings in the complaint that the complainant was admitted as an in-patient complaining severe chest pain to Sree Chitre Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram on 20/2/2002 and he was treated there are false and hence denied. The learned counsel for the complainant had argued that the two days continuous treatment cannot be considered as a mere test as alleged by the opposite party. In our view, there is enough evidence on record to show that the complainant indeed was having history of chest pain. The complaint, of course, is not a case of medical negligence but what is to be looked into is the nexus between chest pain and coronary angiography, the investigation done on the complainant. In the practice of modern medicine, the said procedure of prescribing CAG for detecting blocks in the blood vessels is a routine procedure which in our view is a part of the treatment.
7. In the light of the above discussions and on the basis of the records on file, we conclude that the complainant has succeeded in establishing his complaint and we are of the view that the investigations done in Sree Chitra Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram are in consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home and the act of the opposite party in repudiating the claim of the complainant is not at all justifiable. Hence the complainant is found eligible for refund of the amount of Rs.9,478/- along with a compensation of Rs.1,000/- and Rs.1,500/- towards costs of the proceedings.
In the result, the complaint is allowed and the opposite party is directed to refund Rs. 9,478/- (Rupees Nine thousand four hundred and seventyeight only) along with a compensation of Rs.1,000/- (Rupees One thousand only) and Rs.1,500/- (Rupees One thousand five hundred only) towards costs of the proceedings to the complainant within a period of one month from the date of receipt of the order, failing which the above amounts shall carry interest @ 9%. 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, on this the 30th day of May, 2009.
S.K. SREELA, MEMBER.
G. SIVAPRASAD, PRESIDENT.
BEENA KUMARI.A, ad. MEMBER.
O.P.No.52/2003 APPENDIX I. Complainant's witness: PW1 : Narayanan Namboothiri II. Complainant's documens: P1 : Mediclaim Policy certificate of policy No.570200/48/01/8500604 P2 : Original case summary and discharge record of MRD No:116158 issued from Sree Chitra Tirunal Institute for Medical Sciences and Techniology, Tvpm. P3 : Copy of in-patient bill No.7077 dt. 22/2/02 P4 : Letter No.570200/misc.d/SA/85/02 dt. 13/6/02 issued to the complainant by the opp. party P5 : Copy of advocate notice dt. 11/11/2002 P6 : Acknowledgment card P7 : Letter dated 12/11/2002 issued to the complainant by opp. Party. III. Opposite party's witness: NIL
IV. Opposite party's documents: D1 : Mediclaim Policy certificate (Duplicate) No.570200/48/2001/8500604 dt. 4/7/2003 D2 : Copy of case summary and discharge record of MRDNo.116158 issued by SCTI for Medical Science and Technology, Tvpm. D3 : Original Mediclaim insurance policy claim Form
D4 : Copy of letter dt. 26/4/2002 issued to the complainant by opp. Party D5 : Copy of letter dated 13/6/2002 issued to the complainant D6 : Admission ticket of No.9806225 D7 : Copy of letter issued to the complainant.
PRESIDENT
ad.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM PRESENT:
SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI. A : MEMBER SMT. S.K. SREELA : MEMBER O.P. No: 52/2003 Dated: 30..05..2009 Complainant:
N.K. Vallikannu, 40,VOC Street, Vadassery, Nagercoil-1.
(By Adv. T. Harikumar)
Opposite party:
National Insurance Company Limited, represented by its Divisional Manager, Divisional Office, Post Box No.434, St.Joseph's Press Building, Vazhuthacaud, Thiruvananthapuram.
(By Adv. M. Nizamudeen)
This O.P having been heard on 15..04..2009, the Forum on 30..05..2009 delivered the following:
ORDER
SMT. S.K.SREELA, MEMBER:
Briefly stated the facts are that the complainant took a medi-claim policy on 23/7/2001 on payment of Rs.722/- as annual premium for a period of one year from the opposite party for a sum of Rs.15,000/-. As per the terms and conditions of the said medi-claim policy the opposite party had agreed to undertake hospitalisation expenses for medical/surgical treatment as an in-patient or domicilliary treatment in India for the period of one year to the insured person, and that the complainant was admitted as an in-patient complaining of severe chest pain to the Sree Chitra Thirunal Institute for Medical Science and Technology, Trivandrum on 20/2/2002 and he was treated there and was discharged on 22/2/2002. The complainant had spent an amount of Rs.10,678/- towards the medical expenses as he was treated as an in-patient. After discharge the complainant submitted a claim to the opposite party claiming the amount of Rs.10,678/- towards the hospitalisation expenses which he had paid to the Sree Chitra Thirunal Hospital, Trivandrum. Since the opposite party failed to consider the claim of the complainant, he issued a notice through his advocate dated 11/11/2002 calling upon the opposite party to pay the hospitalisation expenses due to the complainant under the medi-claim policy. The opposite party by its letter dated 12/11/2002 disowned its liability to incur the hospitalisation expenses met by the complainant. The act of the opposite party to disown its liability under the medi-claim policy is clear violation of the terms and conditions of the policy and amounts to deficiency in service. Hence the complaint.
2. The opposite party has filed their version contending as follows: The complaint is not maintainable. The amount of Rs.10,678/- claimed by the complainant is the amount allegedly spent by the complainant for "Coronary Angiograph" which is a diagnostic test for detecting coronary diseases, and towards medicines and other tests related to the said diagnostic test. As per the Exclusion No. 4.10 of the Medi-claim policy issued by the opposite party to the complainant "charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home" is specifically excluded from payment to the insured/complainant. The case summary and discharge record issued from Sree Chitra Thirunal Institute for Medical Sciences and Technology, Thiruvananthapuram where the complainant was admitted on 20/2/2002 clearly reveals the fact that earlier, a Tread Mill Test (TMT) was done in August 1998 which was found negative and that Coronary Angiography (CAG) which is a diagnostic test was done on 21/2/2002, which revealed "normal coronaries" and "Good LV function" which again reveals that the complainant was not admitted for any disease and solely for diagnosis whether he suffers from any coronary disease. The complainant was admitted as an in-patient complaining severe chest pain to Sree Chitra Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram on 20/2/2002 and he was treated there are false and hence denied. The averments that the opposite party has not considered the claim of the complainant within a reasonable time and that the complainant repeatedly requested the opposite party to consider the claim and pay the hospitalisation expenses as provided in the policy are absolutely false, baseless and hence vehemently denied. The opposite party has not committed any deficiency in service or unfair trade practice on the part of the opposite party. Hence the Hon'ble Forum has no jurisdiction to entertain the complaint and the complaint is liable to be dismissed with compensatory cost of the opposite party.
3. The complainant has filed affidavit and marked Exts.P1 to P7 on his side. PW1 was also examined on the part of the complainant. The opposite party has also filed affidavit and marked Exts.D1 to D7. 4. From the contentions raised, following issues arise for consideration: Whether the act of the opposite party in repudiating the claim is justifiable? Whether the complainant is entitled for any of the reliefs claimed?
5. Points (i) & (ii): The complainant has been issued with a medi-claim policy by the opposite party for the period commencing from 23/7/2001 to 22/7/2002 as per Ext.P1. The grievance of the complainant is that his claim for Rs.10,678/- towards the hospitalisation expenses which he had paid to the Sree Chitra Thirunal Hospital has been repudiated by the opposite party which is a clear violation of the terms and conditions of the policy and amounts to deficiency in service. The contention of the Insurance Company is that they could not honour the claim since on perusal of the documents submitted by the complainant, it is found that the claim is in respect of Coronary Angiogram which is a diagnostic examination not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment or sickness for which confinement is required in a hospital and that since it is seen that the CAG revealed normal coronaries and good LV function and hence excluded as per Exclusion 4.10 of the policy issued to the complainant. Exclusion clause 4.10 of Ext.P1 reads as follows: "Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home". Accordingly, the aspect for consideration is whether the hospitalisation underwent by the complainant comes under the above exclusionary clause.
6. Ext.P2 is the case summary and discharge record pertaining to the complainant wherein the diagnosis is recorded as ATYPICAL CHEST PAIN TMT (1/2002) POSITIVE CAG NORMAL CORONARIES FCI NS GOOD LV FUNCTION. Besides this under the head procedure it has been recorded as CAG done on 21/2/2002, call No: 27323. The history of the complainant reveals that TMT done on 18/1/2002 was positive. The case summary and discharge record shows that the complainant has been admitted on 20/2/2002 and discharged on 22/2/2002. The in-patient bill, Ext.P3, reveals Rs.6,950/- has been collected from the complainant towards sophisticated investigations Coronary Angiography. The Asst. Professor, Cardiology has deposed as PW1 that 'Coronary Angiography is a diagnostic test for detecting blocks in the blood vessels of the heart'. Hence there is no doubt with regard to the fact that the said investigation done by the complainant is only a diagnostic test but whether that is not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment has to be considered. The medical history of the complainant reveals that, TMT done in September 2000 was mildly positive for inducible ischemia, TMT done on 18/1/2002 was positive at 7 Mets. 1-2mm, Atypical chest pain TMT 1/2002. The complainant has pleaded in the complaint that, he was admitted in Sree Chithra Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram on 20/2/2002 following severe chest pain. Ext.P2 also reveals that he has been admitted with chest pain. The pleadings and the documents on record corroborate the fact that the tests, examination and the treatment which were undergone by the complainant for detecting the blocks in the blood vessels were very well in consistent with the diagnosis and treatment of the positive existence of the ailment. As per Ext.P2, the complainant has been admitted for CAG which, definitely is in consistent with the diagnosis and treatment of the positive existence of the ailment which herein is the chest pain. The learned counsel for the opposite party had contended that the pleadings in the complaint that the complainant was admitted as an in-patient complaining severe chest pain to Sree Chitre Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram on 20/2/2002 and he was treated there are false and hence denied. The learned counsel for the complainant had argued that the two days continuous treatment cannot be considered as a mere test as alleged by the opposite party. In our view, there is enough evidence on record to show that the complainant indeed was having history of chest pain. The complaint, of course, is not a case of medical negligence but what is to be looked into is the nexus between chest pain and coronary angiography, the investigation done on the complainant. In the practice of modern medicine, the said procedure of prescribing CAG for detecting blocks in the blood vessels is a routine procedure which in our view is a part of the treatment.
7. In the light of the above discussions and on the basis of the records on file, we conclude that the complainant has succeeded in establishing his complaint and we are of the view that the investigations done in Sree Chitra Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram are in consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home and the act of the opposite party in repudiating the claim of the complainant is not at all justifiable. Hence the complainant is found eligible for refund of the amount of Rs.9,478/- along with a compensation of Rs.1,000/- and Rs.1,500/- towards costs of the proceedings.
In the result, the complaint is allowed and the opposite party is directed to refund Rs. 9,478/- (Rupees Nine thousand four hundred and seventyeight only) along with a compensation of Rs.1,000/- (Rupees One thousand only) and Rs.1,500/- (Rupees One thousand five hundred only) towards costs of the proceedings to the complainant within a period of one month from the date of receipt of the order, failing which the above amounts shall carry interest @ 9%. 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, on this the 30th day of May, 2009.
S.K. SREELA, MEMBER.
G. SIVAPRASAD, PRESIDENT.
BEENA KUMARI.A, ad. MEMBER.
O.P.No.52/2003 APPENDIX I. Complainant's witness: PW1 : Narayanan Namboothiri II. Complainant's documens: P1 : Mediclaim Policy certificate of policy No.570200/48/01/8500604 P2 : Original case summary and discharge record of MRD No:116158 issued from Sree Chitra Tirunal Institute for Medical Sciences and Techniology, Tvpm. P3 : Copy of in-patient bill No.7077 dt. 22/2/02 P4 : Letter No.570200/misc.d/SA/85/02 dt. 13/6/02 issued to the complainant by the opp. party P5 : Copy of advocate notice dt. 11/11/2002 P6 : Acknowledgment card P7 : Letter dated 12/11/2002 issued to the complainant by opp. Party. III. Opposite party's witness: NIL
IV. Opposite party's documents: D1 : Mediclaim Policy certificate (Duplicate) No.570200/48/2001/8500604 dt. 4/7/2003 D2 : Copy of case summary and discharge record of MRDNo.116158 issued by SCTI for Medical Science and Technology, Tvpm. D3 : Original Mediclaim insurance policy claim Form
D4 : Copy of letter dt. 26/4/2002 issued to the complainant by opp. Party D5 : Copy of letter dated 13/6/2002 issued to the complainant D6 : Admission ticket of No.9806225 D7 : Copy of letter issued to the complainant.
PRESIDENT
ad.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM PRESENT:
SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI. A : MEMBER SMT. S.K. SREELA : MEMBER O.P. No: 52/2003 Dated: 30..05..2009 Complainant:
N.K. Vallikannu, 40,VOC Street, Vadassery, Nagercoil-1.
(By Adv. T. Harikumar)
Opposite party:
National Insurance Company Limited, represented by its Divisional Manager, Divisional Office, Post Box No.434, St.Joseph's Press Building, Vazhuthacaud, Thiruvananthapuram.
(By Adv. M. Nizamudeen)
This O.P having been heard on 15..04..2009, the Forum on 30..05..2009 delivered the following:
ORDER
SMT. S.K.SREELA, MEMBER:
Briefly stated the facts are that the complainant took a medi-claim policy on 23/7/2001 on payment of Rs.722/- as annual premium for a period of one year from the opposite party for a sum of Rs.15,000/-. As per the terms and conditions of the said medi-claim policy the opposite party had agreed to undertake hospitalisation expenses for medical/surgical treatment as an in-patient or domicilliary treatment in India for the period of one year to the insured person, and that the complainant was admitted as an in-patient complaining of severe chest pain to the Sree Chitra Thirunal Institute for Medical Science and Technology, Trivandrum on 20/2/2002 and he was treated there and was discharged on 22/2/2002. The complainant had spent an amount of Rs.10,678/- towards the medical expenses as he was treated as an in-patient. After discharge the complainant submitted a claim to the opposite party claiming the amount of Rs.10,678/- towards the hospitalisation expenses which he had paid to the Sree Chitra Thirunal Hospital, Trivandrum. Since the opposite party failed to consider the claim of the complainant, he issued a notice through his advocate dated 11/11/2002 calling upon the opposite party to pay the hospitalisation expenses due to the complainant under the medi-claim policy. The opposite party by its letter dated 12/11/2002 disowned its liability to incur the hospitalisation expenses met by the complainant. The act of the opposite party to disown its liability under the medi-claim policy is clear violation of the terms and conditions of the policy and amounts to deficiency in service. Hence the complaint.
2. The opposite party has filed their version contending as follows: The complaint is not maintainable. The amount of Rs.10,678/- claimed by the complainant is the amount allegedly spent by the complainant for "Coronary Angiograph" which is a diagnostic test for detecting coronary diseases, and towards medicines and other tests related to the said diagnostic test. As per the Exclusion No. 4.10 of the Medi-claim policy issued by the opposite party to the complainant "charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home" is specifically excluded from payment to the insured/complainant. The case summary and discharge record issued from Sree Chitra Thirunal Institute for Medical Sciences and Technology, Thiruvananthapuram where the complainant was admitted on 20/2/2002 clearly reveals the fact that earlier, a Tread Mill Test (TMT) was done in August 1998 which was found negative and that Coronary Angiography (CAG) which is a diagnostic test was done on 21/2/2002, which revealed "normal coronaries" and "Good LV function" which again reveals that the complainant was not admitted for any disease and solely for diagnosis whether he suffers from any coronary disease. The complainant was admitted as an in-patient complaining severe chest pain to Sree Chitra Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram on 20/2/2002 and he was treated there are false and hence denied. The averments that the opposite party has not considered the claim of the complainant within a reasonable time and that the complainant repeatedly requested the opposite party to consider the claim and pay the hospitalisation expenses as provided in the policy are absolutely false, baseless and hence vehemently denied. The opposite party has not committed any deficiency in service or unfair trade practice on the part of the opposite party. Hence the Hon'ble Forum has no jurisdiction to entertain the complaint and the complaint is liable to be dismissed with compensatory cost of the opposite party.
3. The complainant has filed affidavit and marked Exts.P1 to P7 on his side. PW1 was also examined on the part of the complainant. The opposite party has also filed affidavit and marked Exts.D1 to D7. 4. From the contentions raised, following issues arise for consideration: Whether the act of the opposite party in repudiating the claim is justifiable? Whether the complainant is entitled for any of the reliefs claimed?
5. Points (i) & (ii): The complainant has been issued with a medi-claim policy by the opposite party for the period commencing from 23/7/2001 to 22/7/2002 as per Ext.P1. The grievance of the complainant is that his claim for Rs.10,678/- towards the hospitalisation expenses which he had paid to the Sree Chitra Thirunal Hospital has been repudiated by the opposite party which is a clear violation of the terms and conditions of the policy and amounts to deficiency in service. The contention of the Insurance Company is that they could not honour the claim since on perusal of the documents submitted by the complainant, it is found that the claim is in respect of Coronary Angiogram which is a diagnostic examination not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment or sickness for which confinement is required in a hospital and that since it is seen that the CAG revealed normal coronaries and good LV function and hence excluded as per Exclusion 4.10 of the policy issued to the complainant. Exclusion clause 4.10 of Ext.P1 reads as follows: "Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home". Accordingly, the aspect for consideration is whether the hospitalisation underwent by the complainant comes under the above exclusionary clause.
6. Ext.P2 is the case summary and discharge record pertaining to the complainant wherein the diagnosis is recorded as ATYPICAL CHEST PAIN TMT (1/2002) POSITIVE CAG NORMAL CORONARIES FCI NS GOOD LV FUNCTION. Besides this under the head procedure it has been recorded as CAG done on 21/2/2002, call No: 27323. The history of the complainant reveals that TMT done on 18/1/2002 was positive. The case summary and discharge record shows that the complainant has been admitted on 20/2/2002 and discharged on 22/2/2002. The in-patient bill, Ext.P3, reveals Rs.6,950/- has been collected from the complainant towards sophisticated investigations Coronary Angiography. The Asst. Professor, Cardiology has deposed as PW1 that 'Coronary Angiography is a diagnostic test for detecting blocks in the blood vessels of the heart'. Hence there is no doubt with regard to the fact that the said investigation done by the complainant is only a diagnostic test but whether that is not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment has to be considered. The medical history of the complainant reveals that, TMT done in September 2000 was mildly positive for inducible ischemia, TMT done on 18/1/2002 was positive at 7 Mets. 1-2mm, Atypical chest pain TMT 1/2002. The complainant has pleaded in the complaint that, he was admitted in Sree Chithra Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram on 20/2/2002 following severe chest pain. Ext.P2 also reveals that he has been admitted with chest pain. The pleadings and the documents on record corroborate the fact that the tests, examination and the treatment which were undergone by the complainant for detecting the blocks in the blood vessels were very well in consistent with the diagnosis and treatment of the positive existence of the ailment. As per Ext.P2, the complainant has been admitted for CAG which, definitely is in consistent with the diagnosis and treatment of the positive existence of the ailment which herein is the chest pain. The learned counsel for the opposite party had contended that the pleadings in the complaint that the complainant was admitted as an in-patient complaining severe chest pain to Sree Chitre Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram on 20/2/2002 and he was treated there are false and hence denied. The learned counsel for the complainant had argued that the two days continuous treatment cannot be considered as a mere test as alleged by the opposite party. In our view, there is enough evidence on record to show that the complainant indeed was having history of chest pain. The complaint, of course, is not a case of medical negligence but what is to be looked into is the nexus between chest pain and coronary angiography, the investigation done on the complainant. In the practice of modern medicine, the said procedure of prescribing CAG for detecting blocks in the blood vessels is a routine procedure which in our view is a part of the treatment.
7. In the light of the above discussions and on the basis of the records on file, we conclude that the complainant has succeeded in establishing his complaint and we are of the view that the investigations done in Sree Chitra Thirunal Institute for Medical Sciences & Technology, Thiruvananthapuram are in consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home and the act of the opposite party in repudiating the claim of the complainant is not at all justifiable. Hence the complainant is found eligible for refund of the amount of Rs.9,478/- along with a compensation of Rs.1,000/- and Rs.1,500/- towards costs of the proceedings.
In the result, the complaint is allowed and the opposite party is directed to refund Rs. 9,478/- (Rupees Nine thousand four hundred and seventyeight only) along with a compensation of Rs.1,000/- (Rupees One thousand only) and Rs.1,500/- (Rupees One thousand five hundred only) towards costs of the proceedings to the complainant within a period of one month from the date of receipt of the order, failing which the above amounts shall carry interest @ 9%. 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, on this the 30th day of May, 2009.
S.K. SREELA, MEMBER.
G. SIVAPRASAD, PRESIDENT.
BEENA KUMARI.A, ad. MEMBER.
O.P.No.52/2003 APPENDIX I. Complainant's witness: PW1 : Narayanan Namboothiri II. Complainant's documens: P1 : Mediclaim Policy certificate of policy No.570200/48/01/8500604 P2 : Original case summary and discharge record of MRD No:116158 issued from Sree Chitra Tirunal Institute for Medical Sciences and Techniology, Tvpm. P3 : Copy of in-patient bill No.7077 dt. 22/2/02 P4 : Letter No.570200/misc.d/SA/85/02 dt. 13/6/02 issued to the complainant by the opp. party P5 : Copy of advocate notice dt. 11/11/2002 P6 : Acknowledgment card P7 : Letter dated 12/11/2002 issued to the complainant by opp. Party. III. Opposite party's witness: NIL
IV. Opposite party's documents: D1 : Mediclaim Policy certificate (Duplicate) No.570200/48/2001/8500604 dt. 4/7/2003 D2 : Copy of case summary and discharge record of MRDNo.116158 issued by SCTI for Medical Science and Technology, Tvpm. D3 : Original Mediclaim insurance policy claim Form
D4 : Copy of letter dt. 26/4/2002 issued to the complainant by opp. Party D5 : Copy of letter dated 13/6/2002 issued to the complainant D6 : Admission ticket of No.9806225 D7 : Copy of letter issued to the complainant.
PRESIDENT
......................Smt. Beena Kumari. A
......................Smt. S.K.Sreela
......................Sri G. Sivaprasad | | 
