IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Tuesday the 31st day of May, 2016
Filed on 21.03.2015
Present
1.Smt. Elizabeth George (President)
2.Sri. Antony Xavier (Member)
3.Smt.Jasmine.D. (Member)
in
C.C.No.91/2015
between
Complainant:- Opposite Parties:-
Smt. Rajasree. S. 1. The Divisional Manager
Vaishaghom LIC of India, Divisional Office
Reddyar Compound Jeevan Prakash, M.G. road
Mullackal, Alappuzha Ernakulam
2. The Branch Manager
LIC of India, Branch No. II
Sreevalsom Building
Kidangamparambu, Alappuzha
(By Adv. P.C. Mathew – for
Opposite parties)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
Complainant and her family was holding a Health Protection Plus policy issued by the opposite party. The complainant’s husband sustained injury due to the bike accident on 23.1.2013 and he was admitted to General Hospital, Alappuzha. He was referred to Ernakulam Medical Centre and a major surgery was done on 24.1.2013. The treatment was continued as inpatient till 3.4.2013 and physiotherapy was also done. His claim for the treatment amount was repudiated by the opposite party. Alleging deficiency in service on the part of the opposite parties, hence the complaint is filed.
2. The version of the opposite parties is as follows:-
The complainant has taken Health Protection plus policy on 22.12.2010 from the second opposite party. The complainant’s husband one of the beneficiary of the policy met with an accident on 23.1.2013 and was admitted to Medical Centre, Ernakulam and discharged on 8.2.2013. The claim for the hospital admission on 21.3.2013 and discharged on 3.4.2013 was rejected under rejection code H11 and H16 which pertain to exclusion in respect of hospitalization for the sole purpose of physiotherapy and admission for rehabilitation, Clause 6(1)(xi) clearly excludes, “Convalescence, general debility, nervous or other breakdown, rest cure, congenital disease or defect or anomaly, sterilization or infertility (diagnosis and treatment), and sanatorium, spa or rest cures or long term care of hospitalization undertaken as a preventive or recuperative measure.” Discharge summary from the hospital dated 3.4.2013 clearly shows the reason for admission as rehabilitation. Doctor’s certificate dated 11.7.2013 clearly shows admission was for intense physiotherapy. There is no deficiency in service on the part of the opposite parties.
3. The complainant was examined as PW1. The documents produced were marked as Exts.A1 to A5. The opposite party was examined as RW1. The documents produced were marked as Exts.B1 to B7.
4. The points that arose for consideration are as follows:-
1) Whether there is any deficiency in service on the side of the opposite parties?
3) If so the reliefs and costs?
5. It is an admitted fact that complainant and her family availed an insurance policy (Health Protection Plus policy) from the opposite party. It is also an admitted fact that complainant’s husband sustained injury due to the accident on 23.1.2013 and was admitted Ernakulam Medical Centre on 24.1.2013 and discharged on 8.2.2013. According to the complainant her husband was again admitted to the Medical Centre, Ernakulam from 31.3.2013 to 3.4.2013 for the purpose of physiotherapy and was under the treatment of Orthopedist. The claim for hospitalization was admitted for 16 days from 24.1.2013 to 8.2.2013. But the claim for hospitalization for the period from 21.3.2013 to 3.4.2013 was rejected as the hospitalization was for the sole purpose of intense physiotherapy. According to the opposite party, the complainant is entitled to get Hospital Cash Benefit for the period from 21.3.2013 to 3.4.2013 as per Clause 6 (1) (xi) and Clause 6 (1) (xvi). Clause 6 (1) (xi) excludes, “Convalescence, general debility, nervous or other breakdown, rest cure, congenital disease or defect or anomaly, sterilization or infertility (diagnosis and treatment, and sanatorium, spa or rest cures of long term care or hospitalization undertaken as a preventive or recuperative measure. Clause 6 (1) (xvi) clearly excludes Hospital Cash Benefit in case of “Hospitalization for the sole purpose of physiotherapy or any ailment for which hospitalization is not warranted due to advancement in Medical Technology.” The opposite party again stated that the discharge summary from the hospital dated 3.4.2013 clearly shows that the reason for the admission as rehabilitation. Hence the only point to be considered is whether the complainant is entitled to get Hospital Cash Benefit for the hospital admission for the period from 21.3.2013 to 3.4.2013. Ext.A4 series (2) is the letter dated 11.7.2013 issued by the Dr. C.K. Abdul Salam of Ernakulam Medical Centre. In Ext.A4(2) it is clearly stated that, “Complainant was admitted again for intense physiotherapy on 21.3.2013 and discharged on 3.4.2013. Hospital admission was absolutely necessary since he needed close monitoring. This physiotherapy was done as continuation of treatment for his supra condoler inter condoler fracture ( R) femur.” As per Clause 6 (1) (xvi) of the policy excludes Hospital Cash Benefit in case of hospitalization for the sole purpose of physiotherapy. In the instant case, the patient has undergone physiotherapy as a continuation of treatment for his supra condoler inter condoler fracture ( R) Femur. Hence we are of opinion that complainant is entitled to get Hospital Cash Benefit for the admission from 21.3.2013 to 3.4.2013.
In the result, complaint is allowed. The opposite parties are directed to give Hospital Cash Benefit @ Rs.1100/- (Rupees one thousand and one hundred only) per day for the period from 21.3.2013 to 3.4.2013 to the complainant. The opposite parties are further directed to pay Rs.3000/- (Rupees three thousand only) towards compensation and Rs.1000/- (Rupees one thousand only) towards costs of this proceedings to the complainant. The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in open Forum on this the day 31st of May, 2016.
Sd/- Smt.Elizabeth George (President) :
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt.Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - Rajasree. S. (Witness)
Ext.A1 - Copy of the Policy document
Ext.A2 series - Copy of the documents from General Hospital, Alappuzha
Ext.A3 - Copy of the X-ray films (2 Nos.)
Ext.A4 series - Copy of the documents from Medical Centre, Ernakualm
Ext.A5 - Brochure of Health Policy
Evidence of the opposite parties:-
RW1 - Ganesh. T.R. (Witness)
Ext.B1 - True copy of the brochure of Heal policy
Ext.B2 - True copy of the policy document
Ext.B3 - True copy of the letter dated 20.6.2013
Ext.B4 - True copy of the letter dated 7.8.2013
Ext.B5 - True copy of the letter dated 11.7.2013
Ext.B6 - True copy of the discharge summary
Ext.B7 - True copy of the letter dated 25.9.2013
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
